Is angioplasty as safe as coronary artery bypass grafting in people with left main coronary artery disease?

This study compared the safety of percutaneous coronary intervention (PCI) with drug-eluting stents (DESs) to coronary artery bypass grafting (CABG) in patients with left main coronary artery disease (LMCAD). It determined that PCI and CABG were equally safe, mortality-wise. However, PCI was associated with more non-fatal heart attacks, and the need for another procedure. CABG was associated with more strokes. 

PCI (or angioplasty) is a non-surgical procedure where narrow or blocked arteries are widened or unblocked. In some cases a stent is implanted. A stent is a flexible tube that keeps the artery open. Drug-eluting stents also release medication into the body. These drugs prevent cells from gathering inside the stent and blocking it again.

CABG is a surgical procedure where a healthy blood vessel is taken (usually from the chest wall). This healthy vessel will be connected (‘grafted’) to the blocked artery. This creates a ‘bypass’ around the blocked artery.

The left main coronary artery supplies blood to most of the heart. CABG was formerly considered the main treatment for patients with LMCAD. However, newer research suggests PCI with DESs may be just as effective. However, the safety and effectiveness of PCI with DESs, compared with CABG, for LMCAD remains unclear.

Data from 5 studies comparing PCI with DES to CABG was examined. 4595 adults with LMCAD participated in these studies. 2297 received PCI with DES. 2298 received CABG. They were followed-up at 1 year, 3 years, and 5 years.

There was no significant difference, in terms of death, between the two groups. There were no major differences between the two groups in terms of non-fatal heart attacks at 1 and 3 years. However, after 5 years, those who underwent PCI with DES were more than twice as likely as those in the CABG group to have a non-fatal heart attack.

Repeat revascularization is a second, unplanned, PCI or CABG in the same artery as the first procedure, or in another blood vessel in the heart. PCI was associated with an increased need for repeat revascularization compared with the CABG group. The PCI group was 2.5 times more likely than the CABG group to need repeat revascularization after 1 year, 84% more likely after 3 years, and 86% more likely after 5 years. The need for repeat revascularization was linked with the number of patients in the studies who had diabetes.

The CABG group had a higher risk of stroke after 1 year, but not after 3 and 5 years. 

The study concluded that PCI with DES was as safe as CABG for up to 5 years with in terms of mortality. However, PCI was associated with a higher risk of non-fatal heart attacks after 5 years, and a greater need for revascularization, especially in people with diabetes. CABG was associated with an increased risk of stroke after 1 year.

There were differences between the individual studies that may have made comparisons difficult.

Discuss the risks and benefits of PCI and CABG with your physician.