**6. Drug-eluting stents vs coronary artery bypass surgery for the treatment of multivessel coronary disease**

A Chinese study identified 3720 consecutive patients with multivessel disease who un‐ derwent isolated CABG surgery or received drug-eluting stents between April 1, 2004, and December 31, 2005, which compared safety (total mortality, myocardial infarction, and stroke) and efficacy (target-vessel revascularization) during a 3-year follow-up. These outcomes were compared after adjustment for the differences in baseline risk factors. Pa‐ tients who underwent CABG (n=1886) were older and had more comorbidities than pa‐ tients who received drug-eluting stents (n=1834). Patients receiving drug-eluting stents had considerably higher 3-year rates of target-vessel revascularization. Drug-eluting stents were also associated with higher rates of death (adjusted hazard ratio, 1.62; 95% confidence interval, 1.07 to 2.47) and myocardial infarction (adjusted hazard ratio, 1.65; 95% confidence interval, 1.15 to 2.44). The risk adjusted rate of stroke was similar in the 2 groups (hazard ratio, 0.92; 95% confidence interval, 0.69 to 1.51). [15]

In a Korean study, a 5-year clinical follow-up of 395 patients with unprotected LMCA disease who underwent PCI with drug-eluting stents (DES) (n = 176) or CABG (n = 219) was preformed from January 2003 to May 2004. In the 5-year follow-up, cohort of DES and concurrent CABG, there had not been a significant difference in the adjusted risk of death (HR: 0.83; 95% CI: 0.34 to 2.07; p = 0.70) or the risk of the composite outcome (HR: 0.91; 95% CI: 0.45 to 1.83; p = 0.79). The rates of TVR were also higher in the DES group than the CABG group (HR: 6.22; 95% CI: 2.26 to 17.14; p < 0.001), [16].

In an Italian study, 249 patients: 107 of whom were treated with PCI along with DES im‐ plantation and 142 treated with CABG. At 5-year clinical follow-up, no difference was found between PCI and CABG in the occurrence of cardiac death (adjusted odds ratio [OR]: 0.502; 95% confidence interval [CI]: 0.162 to 1.461; p = 0.24). The PCI group showed a trend toward a lower occurrence of the composite end point of cardiac death and MI (adjusted OR: 0.408; 95% CI: 0.146 to 1.061; p = 0.06). Percutaneous coronary intervention was associated with a lower rate of the composite end point of death, MI, and/or stroke (OR: 0.399; 95% CI: 0.151 to 0.989; p = 0.04). Indeed, CABG was correlated with lower target vessel revascularization (adjusted OR: 4.411; 95% CI: 1.825 to 11.371; p = 0.0004). No difference was detected in the occurrence of major adverse cardiac and cerebrovascu‐ lar events (adjusted OR: 1.578; 95% CI: 0.825 to 3.054; p = 0.18) [17].

In a Meta-analysis of clinical studies comparing CABG with DES in patients with unpro‐ tected left main coronary artery narrowing, the analysis included 2,905 patients from 8 clinical studies (2 randomized trials and 6 nonrandomized studies). At 1-year follow-up, there was no significant difference between the CABG and DES groups in the risk for death (odds ratio [OR] 1.12, 95% confidence interval [CI] 0.80 to 1.56) or the composite end point of death, myocardial infarction, or stroke (OR 1.25, 95% CI 0.86 to 1.82). The risk for target vessel revascularization was significantly lower in the CABG group com‐ pared to the PCI group (OR 0.44, 95% CI 0.32 to 0.59). In conclusion, PCI with DES is safe and could represent a good alternative to CABG for selected cases in patients with ULMCA disease, [18].

adjusted OR 1.26; *P* = 0.06). When subgroups matched for severity of disease were compared,

**6. Drug-eluting stents vs coronary artery bypass surgery for the treatment**

A Chinese study identified 3720 consecutive patients with multivessel disease who un‐ derwent isolated CABG surgery or received drug-eluting stents between April 1, 2004, and December 31, 2005, which compared safety (total mortality, myocardial infarction, and stroke) and efficacy (target-vessel revascularization) during a 3-year follow-up. These outcomes were compared after adjustment for the differences in baseline risk factors. Pa‐ tients who underwent CABG (n=1886) were older and had more comorbidities than pa‐ tients who received drug-eluting stents (n=1834). Patients receiving drug-eluting stents had considerably higher 3-year rates of target-vessel revascularization. Drug-eluting stents were also associated with higher rates of death (adjusted hazard ratio, 1.62; 95% confidence interval, 1.07 to 2.47) and myocardial infarction (adjusted hazard ratio, 1.65; 95% confidence interval, 1.15 to 2.44). The risk adjusted rate of stroke was similar in the

In a Korean study, a 5-year clinical follow-up of 395 patients with unprotected LMCA disease who underwent PCI with drug-eluting stents (DES) (n = 176) or CABG (n = 219) was preformed from January 2003 to May 2004. In the 5-year follow-up, cohort of DES and concurrent CABG, there had not been a significant difference in the adjusted risk of death (HR: 0.83; 95% CI: 0.34 to 2.07; p = 0.70) or the risk of the composite outcome (HR: 0.91; 95% CI: 0.45 to 1.83; p = 0.79). The rates of TVR were also higher in the DES group than the CABG group (HR: 6.22; 95% CI:

In an Italian study, 249 patients: 107 of whom were treated with PCI along with DES im‐ plantation and 142 treated with CABG. At 5-year clinical follow-up, no difference was found between PCI and CABG in the occurrence of cardiac death (adjusted odds ratio [OR]: 0.502; 95% confidence interval [CI]: 0.162 to 1.461; p = 0.24). The PCI group showed a trend toward a lower occurrence of the composite end point of cardiac death and MI (adjusted OR: 0.408; 95% CI: 0.146 to 1.061; p = 0.06). Percutaneous coronary intervention was associated with a lower rate of the composite end point of death, MI, and/or stroke (OR: 0.399; 95% CI: 0.151 to 0.989; p = 0.04). Indeed, CABG was correlated with lower target vessel revascularization (adjusted OR: 4.411; 95% CI: 1.825 to 11.371; p = 0.0004). No difference was detected in the occurrence of major adverse cardiac and cerebrovascu‐

In a Meta-analysis of clinical studies comparing CABG with DES in patients with unpro‐ tected left main coronary artery narrowing, the analysis included 2,905 patients from 8 clinical studies (2 randomized trials and 6 nonrandomized studies). At 1-year follow-up, there was no significant difference between the CABG and DES groups in the risk for death (odds ratio [OR] 1.12, 95% confidence interval [CI] 0.80 to 1.56) or the composite

2 groups (hazard ratio, 0.92; 95% confidence interval, 0.69 to 1.51). [15]

lar events (adjusted OR: 1.578; 95% CI: 0.825 to 3.054; p = 0.18) [17].

no differences in risk-adjusted survival were seen, [14].

**of multivessel coronary disease**

358 Artery Bypass

2.26 to 17.14; p < 0.001), [16].

In the SYNTAX trial, 1,800 patients with three-vessel and/or LM disease were random‐ ized to either CABG or PCI; of these, 271 LM patients were prospectively assigned to receive a 15-month angiogram. The primary endpoint for the CABG arm was the ratio of ≥50% to <100% obstructed/occluded grafts bypassing LM lesions to the number placed. The primary endpoint for the PCI arm was the proportion of patients with ≤50% diameter stenosis ('patent' stents) of treated LM lesions. Per protocol, no formal comparison between CABG and PCI arms was intended based on the differing primary endpoints. Available 15-month angiograms were analyzed for 114 CABG and 149 PCI patients. At 15 months, 9.9% (26/263) of CABG grafts were 100% occluded and an addi‐ tional 5.7% (15/263) were ≥50% to <100% occluded. Overall, 27.2% (31/114) of patients had ≥1 obstructed/occluded graft. The 15-month CABG MACCE rate was 8.8% (10/114) and MACCE at 15 months was not significantly associated with graft obstruction/occlu‐ sion (p=0.85). In the PCI arm, 92.4% (134/145) of patients had ≤50% diameter LM steno‐ sis at 15 months (89.7% [87/97] distal LM lesions and 97.9% [47/48] non-distal LM lesions). The 15-month PCI MACCE rate was 12.8% (20/156) and this was significantly associated with lack of stent patency at 15 months (p<0.001), mainly due to repeated re‐ vascularization. [19].

The results of the SYNTAX trial confirm that at 3 years CABG remains the treatment of choice for most patients with three-vessel and LMS disease and especially in those with the most severe disease. SYNTAX will have a profound effect on practice recommendations for the foreseeable future and has already had a major effect on the new European Society for Cardiology/European Association for Cardiothoracic Surgery guidelines for myocardial revascularization, [20].

At four years follow-up of SYNTAX trial which presented at TCT in 2011, there was no difference in MACCE between CABG and PCI in those with a SYNTAX score of 0 to 22, (26.1% vs 28.6%; p=0.57). This is good, and would legitimize the use of PCI in this kind of patient". But for those with an intermediate SYNTAX score of 23 to 32, "You see immediately a highly significant difference" in MACCE rate (21.5% for CABG vs 32% for PCI; p=0.006). For those with a high SYNTAX score (≥33), "mortality is double in the PCI group compared with CABG (16.1% vs 8.4%; p=0.04) in addition to MI is two to three times higher with PCI than with CABG (9.3% vs 3.9%; p=0.01).

In this highest-risk group, even the end point of death/stroke/MI becomes significantly higher with PCI, (22.7% vs 14.6%; p=0.01), and MACCE were much higher (40.1% vs 23.6%; p<0.001), driven in large part by a 17% higher rate of revascularization in this high-risk group at four years. Figures 6& 7

**7. Revascularization for patients with diabetes mellitus and multivessel**

Artery Bypass Versus PCI Using New Generation DES

http://dx.doi.org/10.5772/54029

361

In the BARI 2D trial, the selected revascularization strategy, CABG or PCI, was based on physician discretion, declared independent of randomization to either immediate or deferred revascularization if clinically warranted. They analyzed factors favoring selection of CABG versus PCI in 1,593 diabetic patients with multivessel CAD enrolled between 2001 and 2005. The majority of diabetic patients with multivessel disease were selected for PCI rather than CABG. Preference for CABG over PCI was largely based on angiographic features related to the extent, location, and nature of CAD, as well as geographic, demographic, and clinical

However, with each intervention the benefit is less and the risks and complications are greater than in patients without diabetes. Revascularization for treatment of ST elevation myocardial infarction increases survival. Both interventions relieve symptoms, but neither improves survival except in patients at high risk. In patients with clinically stable chronic coronary disease, survival after CABG or PCI is comparable with that in patients treated with optimal medical therapy alone. Accordingly, evaluation for revascularization can be deferred until signs and symptoms worsen except in patients at high risk. In patients at high risk survival after promptly implemented CABG is greater than that with optimal medical therapy,

Among patients with three-vessel or left main coronary artery disease who were suitable candidates for either PCI using DES or CABG, both strategies resulted in significant relief from angina and improvements in overall health status over the first year of follow-up. At both 6 and 12 months, there was a small but significant reduction in angina frequency with CABG as compared with PCI in the overall population. These symptomatic benefits of CABG were counterbalanced by the more rapid recovery and improved short-term health status achieved

**9. Future study with the second generation des and other bioabsorbable**

EXCEL is a 2600-patient study comparing patients with left main disease randomized to bypass surgery or PCI with the Xience stent and followed for at least three years. The primary end point is death, stroke, and MI; repeat revascularization is a secondary end point. EXCEL results

especially when the diabetes is being treated with insulin sensitizing agents. [22]

**8. Quality of life after PCI with DES or CABG**

**CAD**

factors. [21]

with PCI. [23]

awaited. Figure (8)

**stents**

**Figure 6.** years follow up in Syntax study, demonstrate all cause death/CVA/MI up to 4 years

**Figure 7.** years follow up in Syntax study, demonstrate all cause death up to 4 years
