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PCI with complete revascularization yields similar survival to CABG
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PCI with complete revascularization yields similar outcomes to CABG, according to newly published data.
“CABG offers a better survival rate compared with PCI in patients with severe [CAD], multivessel disease, and diabetes. Therefore, CABG has been considered the standard revascularization strategy in the treatment of severe [CAD],” the researchers wrote.
Studies demonstrating better outcomes with CABG vs. PCI, however, were limited by a high prevalence of incomplete revascularization, which has been shown to adversely affect outcomes, they wrote.
“In the present study, we hypothesized that when severe [CAD] was completely revascularized by either revascularization strategy, PCI and CABG would show similar long-term survival,” the researchers wrote.
Median follow-up was 4.9 years, with 81.5% of patients completing 5-year follow-up for clinical outcomes.
In their pooled analysis of data from the randomized SYNTAX, PRECOMBAT and BEST trials, the researchers found a higher risk for the primary endpoint of all-cause death in patients undergoing PCI with incomplete revascularization vs. those undergoing CABG with complete revascularization (adjusted HR = 1.43; 95% CI, 1.03-2). However, results indicated no significant difference in all-cause death between patients undergoing CABG and those undergoing PCI with complete revascularization (aHR = 1.16; 95% CI, 0.83-1.63).
Similarly, the risk for the composite endpoint of death, MI and stroke was higher among patients undergoing PCI with incomplete revascularization vs. CABG with complete revascularization (aHR = 1.48; 95% CI, 1.14-1.92), but the increased risk was not significant among patients undergoing PCI with complete revascularization (adjusted HR = 1.14; 95% CI, 0.87-1.48).
These findings were consistent among patients with multivessel disease, SYNTAX scores greater than 32 and diabetes, according to a subgroup analysis.
The study included 3,212 patients — 1,520 of whom underwent CABG and 1,692 underwent PCI. Complete revascularization, achieved in 61.7% of patients overall, was more often achieved in patients undergoing CABG vs. PCI (66.8% vs. 57.2%) and in those with left main CAD vs. multivessel disease.
Additionally, PCI with incomplete revascularization occurred more frequently among older patients, those with insulin-treated diabetes and hypercholesterolemia, and occurred less frequently among those with left main CAD. Patients who had PCI with incomplete revascularization also had lower SYNTAX scores. Patients who underwent PCI and achieved complete revascularization generally required more stents and longer stents, whereas patients undergoing CABG with complete revascularization required more grafts.
“This pooled analysis of randomized trials comparing CABG and PCI in patients with severe [CAD] showed that PCI with [complete revascularization] was associated with similar long-term survival to CABG. Our findings should be confirmed or refuted in future clinical trials,” the researchers wrote. – by Melissa Foster
Disclosures: The authors report no relevant financial disclosures.
Perspective
Back to TopLloyd W. Klein, MD
This is an excellent study with significant clinical implications. A residual SYNTAX score of less than 8 was predictive of outcomes in SYNTAX. Ahn et al take SYNTAX and add data from BEST and PRECOMBAT to show that incomplete revascularization with either PCI or CABG is associated with worse long-term results than if complete revascularization was achieved. The findings also indicate that being able to and then achieving complete revascularization ought to be a critical decision point in the selection of revascularization strategy. The consensus of current data suggests that if complete revascularization is possible, then one should try to achieve it. However, the study findings do not justify extensive implantation of stents just to achieve complete revascularization. The study was not intended to address that contention.
It is also important to recognize that the study also wasn’t intended to answer the question of what we should do if complete revascularization cannot be achieved. The study highlights the observation that complete revascularization is achievable in only 57% of patients undergoing PCI and 67% patients undergoing CABG. This means that complete revascularization can only be achieved in fewer than two-thirds of patients, which is partly a function of the strategy used, but also a marker of the severity of the underlying disease. We do not know if the inability to achieve complete revascularization by one strategy therefore means that we ought to choose the other strategy, nor do we know if complete revascularization is achievable with the other strategy whether that improves outcomes. For example, we do not know if chronic total occlusions, poor distal runoff or diffuse disease, which are not ideal for either CABG or PCI, ought to make us consider a different approach.
My practice is to consider CABG a preferable strategy in general when the SYNTAX score is greater than 22. If choosing PCI to achieve complete revascularization means implanting five or more stents, I think twice about whether CABG isn’t the preferable choice, since I think that correlates well with complex, extensive disease.
Overall, this is a good study that combines data from three contemporary studies that represent the best, up-to-date data we have on PCI.
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