Will Stents of New Technology Replace Coronary Artery Bypass Surgery?

Abstract

Coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are commonly used procedures to treat patients with multi-vessel coronary artery disease requiring myocardial revascularization. In the past, several randomized comparisons between bypass surgery and coronary angioplasty were performed but had the limitation of comparing CABG to balloon angioplasty.These studies, performed in the pre-stent era, showed no significant differences in mortality and nonfatal myocardial infarction between patients treated with surgery versus PCI. Surgery had an advantage only in treated diabetic patients. More recently, in the stent era, new randomized comparisons between PCI and bypass surgery have been performed. The long-term follow-up data of the four randomized trials of PCI using bare metal stents versus CABG (Stent or Surgery trial, Artery Revascularization Therapies Study [ARTS], ERACI II, and Medicine, Angioplasty, or Surgery Study [MASS] II) showed similar incidence in the combined death, non-fatal myocardial infarction, and stroke rate with both revascularization techniques. However, contemporary treatment of coronary artery disease with stents has switched to the use of drug eluting stents. In a manner similar to the impact of bare-metal stents compared with non-stent balloon angioplasty, drug-eluting stents further reduce restenosis. Data from ARTS II support further reduction in need for repeat interventions in the stent group. During the time since these studies were initiated, CABG procedures have undergone also progressive improvement. The effects of PCI with drug-eluting stents versus minimally invasive direct coronary artery bypass surgery in the management of patients with proximal left anterior descending coronary artery stenosis were recently reported and drug-eluting stent implantation resulted in lower average number of hospital stays and similar postoperative complications. Ongoing trials should further clarify the divergent information streams in this comparison.