What outcomes have been reported for the use of drug-eluting stents (DESs) in percutaneous coronary intervention (PCI)?

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

In the ARTS II trial, a registry comparing the use of sirolimus-eluting stents (SESs) with the PTCA and CABG arms of the ARTS I trial, SESs were associated with an 8% major cardiovascular event (MACE) rate (vs 13% for CABG in ARTS I) and an 8.5% target vessel revascularization rate (vs 4% for CABG and 21% for PTCA in ARTS I). The 1-year MACE rate was 10.5% for SES patients. [33]

The New York Cardiac Registry found that patients who underwent PCI with a DES had a higher rate of target vessel revascularization than those who underwent CABG (30.6% vs 5.2%). [32] They analyzed 17,400 patients who either received a DES (n = 9963) or underwent CABG (n = 7437) and observed them for 18 months. Unadjusted survival curves did not demonstrate a statistical significance in survival for two- or three-vessel disease.

Nevertheless, when adjustments were made for several factors (ie, age; sex; ejection fraction; hemodynamic state; history or no history of MI before the procedure; the presence or absence of cerebrovascular disease, peripheral arterial disease, congestive heart failure, chronic obstructive pulmonary disease [COPD], diabetes, and renal failure; and involvement of the proximal LAD artery), CABG had a statistically significant 18-month survival benefit over PCI with a DES. [32]

The SYNTAX (Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery) study was a large randomized controlled trial that enrolled 1800 patients with multi-vessel CAD to receive either a paclitaxel-eluting stent or CABG. [34]

At 5 years, the major adverse cardiac and cerebrovascular events (MACCE)—a composite of death, stroke, MI, or repeat revascularization—was significantly higher in patients with PCI than in those with CABG (37.5% vs 24.2%). [34] PCI, as opposed to CABG, resulted in significantly higher rates of all-cause death (14.6% vs 9.2%), MI (9.2 vs 4.0%), and repeat revascularization (25.4% vs 12.6%); however, the rate of stroke was similar.

In this trial, the extent of CAD was assessed by using a SYNTAX score that was based on location, severity, and degree of stenosis. [34] In patients with a low (0-22) SYNTAX score, PCI and CABG resulted in similar rates of MACCE (33.3% vs 26.8%) but PCI was associated with significantly more repeat revascularization (25.4% vs 12.6%). In patients with intermediate (23-32) or high (≥33) SYNTAX scores, CABG demonstrated clear superiority, with lower rates of MACCE, all-cause death, MI, and repeat revascularization.

In conclusion, the SYNTAX trial suggested that in patients with multivessel CAD, survival rates with CABG and PCI are comparable in patients with relatively uncomplicated and lesser degrees of CAD. [34] However, in patients with complex and diffuse CAD, CABG appears to be preferable. One caveat to be remembered is that the SYNTAX trial used first-generation paclitaxel-eluting stents. These stents have a higher rate of restenosis than the currently used second-generation DESs.

In summary, in deciding between PCI and CABG in patients with complex multivessel CAD, a Heart Team approach is recommended.


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