Does Prior Coronary Stenting Compromise Future Coronary Surgery?

Lazar Velicki

Disclosures

Interv Cardiol. 2013;5(1):93-100. 

In This Article

Abstract and Introduction

Abstract

There has been a tremendous growth in percutaneous coronary interventions (PCIs) with stent implantation, even in cases where coronary artery bypass grafting (CABG) demonstrates superior long-term results – the cases of multivessel coronary disease. With the number of PCIs on the rise, one may expect a growing population of patients with prior PCI to be ultimately referred to CABG as a result of long-term PCI failure, incomplete revascularization or disease progression. It has been suggested that previous PCI might be considered as a risk factor with a negative impact on subsequent CABG procedure. Several large observational studies found that multiple previous coronary stenting has a negative effect on the outcome of a subsequent surgical revascularization – the higher the stent load the worse the outcome. Nevertheless, no definitive conclusion can be made at this point, as this issue is still a matter of significant controversy.

Introduction

"Change is the law of life. And those who look only to the past or present are certain to miss the future."
– John F Kennedy (1917–1963)

Coronary artery disease (CAD) is currently the leading cause of death globally, and is expected to rise in the near future, despite prevalence decline reported in the developed part of the world. Globally, the proportion of deaths attributed to CAD is expected to grow by 2% between 2004 and 2030.[1] Coronary artery bypass graft (CABG) and percutaneous coronary interventions (PCIs) are alternative revascularization procedures for patients with multivessel CAD.[2] The potential for adverse factors when the CABG procedure follows PCI is an important consideration when choosing therapy for patients with CAD.

CABG continues to be one of the most commonly performed surgical procedures worldwide and certainly the most scrutinized. Significant improvements have been made over the 40-year long history of surgical treatment of CAD, while the root cause and profile of patients undergoing cardiac surgery has profoundy changed.[3,4] Patients submitted to surgery today are older and present with complex comorbidities, usually requiring more than an isolated CABG procedure. Interventional cardiology – a 'younger brother' of cardiac surgery – with a history of 30 years that also underwent significant changes and improvements, both from a technological and philosophical standpoint (when to perform the procedure, how to perform it and what can be expected). PCI has evolved from balloon angioplasty of a single coronary stenosis to multivessel stenting with drug-eluting stents (DES) and treatment of chronic total occlusions with advanced techniques and devices. Coronary stents have evolved from the early concept of providing mechanical support and preventing vessel recoil to becoming ubiquitous devices, and have culminated in the highly sophisticated technology of DES.[5]

It is evident from the recent clinical trials, (Box 1) comparing PCI and CABG in patients with multivessel CAD, that CABG offers significant advantages over PCI in terms of rate of repeated revascularization, major adverse cardiac events (MACE) and long-term survival.[6–11] In the recent randomized prospective SYNTAX trial, comparisons of PCI with CABG in left main disease and/or three vessel disease patients have been performed. At 3 years, major adverse cardiac and cerebrovascular events (death, stroke, myocardial infarction [MI], and repeat revascularization; CABG 20.2% vs PCI 28.0%; p < 0.001), repeat revascularization (10.7 vs 19.7%; p < 0.001) and MI (3.6 vs 7.1%; p = 0.002) were elevated in the PCI arm.[12] Major adverse cardiac and cerebral event rates were not significantly different between arms in the left main subgroup (22.3 vs 26.8%; p = 0.20), but were higher with PCI in the three vessel disease subgroup (18.8 vs 28.8%; p < 0.001).

However, the number of performed procedures shows a dramatic change over time, with CABG declining and reaching steady levels only in the most recent years, while the count of PCIs is increasing and patient scope expanding. Event cases involving complex CAD that, until recently, were considered strictly as CABG patients, are now referred for percutaneous treatment. At the same time, aggressive repeated PCI with multiple stent-graft placement has become more common in the 'stent era'.[13] In many industrialized countries, the ratio of PCI to CABG now exceeds four to one (Figures 1 & 2).[14]

Figure 1.

The ratio of percutaneous coronary intervention to coronary artery bypass grafting procedures in different countries across Europe.
CABG: Coronary artery bypass grafting; PCI: Percutaneous coronary intervention.
Data provided by [51,101,102].

Figure 2.

Kaplan–Meier analysis (mean follow-up 58 ± 43 months) for three distinctive events. (A) Survival curve, (B) freedom from cardiac death and (C) freedom from cardiac event. Each curve compares the event of interest between three groups of patients (1: no prior PCI; 2: single PCI; and 3: multiple PCIs).
PCI: Percutaneous coronary intervention.
Data taken with permission from [13].

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