How do the outcomes of percutaneous coronary intervention (PCI) compare to those of surgical revascularization for treatment of stable angina?

Updated: Nov 27, 2019
  • Author: George A Stouffer, III, MD; Chief Editor: Karlheinz Peter, MD, PhD  more...
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Answer

Two prospective clinical trials evaluated balloon angioplasty against surgery for revascularization of isolated LAD artery disease. [17, 18]

Using a combined endpoint (cardiac death, myocardial infarction, or refractory angina necessitating revascularization by surgery), the MASS (Medicine, Angioplasty, or Surgery Study) trial showed that after 3 years of follow-up, endpoint events occurred in 24% of angioplasty patients, 17% of medical patients, and 3% of surgical patients. [17] However, overall survival rates were similar in the three groups.

The other trial evaluated balloon angioplasty against bypass surgery with an internal thoracic (mammary) artery graft to the LAD artery and also reported no difference in survival during follow-up. [18] Although 94% of angioplasty patients and 95% of bypass patients were free of limiting symptoms, the former required more antianginal drugs. At 2.5 years’ follow-up, 86% of surgery patients were free from late events, compared with 43% of angioplasty patients. This difference was primarily due to restenosis necessitating a second revascularization procedure.

It is important to emphasizing that balloon angioplasty, rather than stent placement, was used in both of these trials; with the almost exclusive use of stenting in the current era, restenosis rates are now lower.

Five large (N > 300) randomized trials comparing balloon angioplasty with bypass surgery in patients with multivessel CAD all showed that in appropriately selected patients, the rates of death or of MI were similar, regardless of which treatment was employed. [19, 20, 21, 22, 23] However, more of the angioplasty-treated patients required a second revascularization procedure. Three of these studies are summarized in Table 1 below.

Table 1. Comparison of Surgical Therapy and Coronary Angioplasty (Open Table in a new window)

Endpoint

Pocock et al*

Pocock et al†

BARI Study‡

CABG

(N=358)

PTCA

(N=374)

CABG

(N=1303)

PTCA

(N=1336)

CABG

(N=914)

PTCA

(N=915)

Death (%)

0.3

1.9

2.8

3.1

10.7

13.7

Death or MI

4.5

7.2

8.5

8.1

11.7

10.9

Repeat CABG

1.4

16.0§

0.8

18.3§

0.7

20.5§

Repeat CABG or PTCA

3.6

30.5§

3.2

34.5§

8.0

54.0§

More than mild angina

6.5

14.6§

12.1

17.8§

...

...

*Meta-analysis of results of 3 trials at 1 year. Patients with single-vessel disease were studied. [23]

†Meta-analysis of results of 3 trials at 1 year. Patients with multivessel disease were studied. [23]

‡Reported results are for 5-year follow-up. Patients with multivessel disease were studied. [22]

§ P < .05.

BARI = Bypass Angioplasty Revascularization Investigation; CABG = coronary artery bypass grafting; MI = myocardial infarction; PTCA = percutaneous transluminal coronary angioplasty.

In the BARI (Bypass Angioplasty Revascularization Investigation) study, 5-year survival was 86.3% for those assigned to angioplasty versus 89.3% for those assigned to surgery, and 5-year freedom from Q-wave MI was 78.7% for the former and 80.4% for the latter. [22] However, after 5 years of follow-up, 54% of those assigned to angioplasty required an additional revascularization procedure, compared with only 8% of those assigned to surgery.

Similarly, the ERACI (Argentine Randomized Trial of Percutaneous Transluminal Coronary Angioplasty Versus Coronary Artery Bypass Surgery in Multivessel Disease) study showed that freedom from combined cardiac events at 3 years was significantly better for bypass surgery than for angioplasty (77% vs 47%), though the groups did not differ in terms of overall and cardiac mortality or frequency of MI. [24] Bypass patients were more often free of angina (79% vs 57%) and had fewer additional revascularization procedures (6% vs 37%).

In most patient subgroups with multivessel CAD, long-term mortality after CABG is comparable to that after PCI; therefore, the choice of treatment should depend on patient preference. In a collaborative analysis of individual patient data from 10 randomized trials, Hlatky et al found CABG to be a superior option for patients with diabetes and patients aged 65 years or older because mortality was lower in these subgroups. [25, 26]


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