Surgery results in fewer complications than stenting in coronary artery revascularisation
The stent versus surgery debate is hotting up again. The trend over recent years has been away from bypass surgery and toward coronary stents as the most common method of revascularising diseased coronary arteries. However, a meta-analysis has found that minimally invasive bypass surgery results in fewer mid-term complications than transluminal stenting.
The main aim of the study was to compare the outcomes of minimally invasive left internal thoracic artery bypass surgery (through a small thoracotomy on the beating heart) and percutaneous coronary artery stenting as primary interventions for isolated lesions of the left anterior descending artery.
The analysis looked at 12 papers, with a total population of 1,952 patients. The majority of the studies investigated were randomised trials. Around 67% of all patients underwent transluminal stenting, and 33% underwent a minimally invasive internal thoracic artery bypass.
The analysis considered aspects of study design, patient characteristics, coronary disease burden and outcome measures. The duration of the trials varied from nine months to almost eight years of follow-up.
The investigators found a higher angina recurrence rate, more major coronary and cerebral events and a greater need for revascularisation in the stent group. However, there was no significant difference between the two interventions in the risk of MI, stroke or mortality at maximum follow-up.
It appears that internal mammary artery grafting using a less invasive surgical approach has the edge compared with stenting in terms of recurrent symptoms and further revascularisation, even if there is no mortality benefit.
It is relevant that most of the studies analysed were less than four years in duration, as surgical mortality benefits may become more apparent over time. However, in the absence of a definitive survival advantage, I suspect that most patients with coronary artery disease amenable to either intervention will still opt for the less invasive approach of stenting and accept the higher risk of symptom recurrence and reintervention.
Aziz O, Rao C, Panesar SS et al. Meta-analysis of minimally invasive internal thoracic artery bypass versus percutaneous revascularisation for isolated lesions of the left anterior descending artery. BMJ 2007;334:617-621Reviewer
Dr Peter Savill
GPSI Cardiology, Southampton