Effectiveness and Safety of Coronary Artery Bypass Grafting for Unprotected Left Main Coronary Artery: A Systematic Review_Chinese Journal of Evidence-Based Medicine

Authors：

LI Junhong , AIKEBAER ,  MuLaTi , Inamdar KY

The First Department of Cardiac Surgery Division, First Affiliated Hospital of Xinjiang Medical University, Urumqi 830054, China;

Corresponding author：

MuLaTi, Email: muratvkili@hotmail.com

Keywords：

Coronary artery bypass grafting (CABG); Percutaneous coronary stent implantation (PCI); Unprotected

DOI：

10.7507/1672-2531.20130188

Video：

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Objective 　To systematically review the effectiveness and safety of coronary artery bypass grafting (CABG) versus percutaneous coronary stent implantation (PCI) in the treatment of patients with unprotected left main coronary artery disease (ULMCA).
Methods 　Databases including The Cochrane Library (Issue 2, 2012), PubMed, EMbase, CBM, CNKI, WanFang Data and VIP were electronically searched from inception to September 2012 for randomized controlled trials on the effectiveness and safety of coronary artery bypass grafting (CABG) versus percutaneous coronary stent implantation (PCI) for ULMCA; References of the included studies were also retrieved. Two reviewers independently screened literature according to the inclusion and exclusion criteria, extracted data, and assessed the methodological quality of the included studies. Then, meta-analysis was performed using RevMan 5.0.
Results 　Four studies were included involving 1 611 cases, of which, 802 cases are in the CABG group, while 809 cases were in the PCI group. The results of meta-analysis showed that: comparing with PCI, CABG significantly reduced the postoperative repeat revascularization rate (OR=0.45, 95%CI 0.31 to 0.66, P lt;0.000 1), but there was no significant difference between the two groups in reducing the myocardial infarction incidence (OR=1.28, 95%CI 0.47 to 3.48, P=0.63), mortality rate (OR=1.36, 95%CI 0.80 to 2.34, P=0.26), and the incidence of major adverse cardio-cerebral vascular events (OR=0.92, 95%CI 0.66 to 1.28, P=0.61).
Conclusion 　This study indicates that CABG is superior to PCI in reducing postoperative rate of target vessel revascularization. But CABG and PCI are alike in reducing myocardial infarction incidence, mortality rate, and the incidence of major adverse cardio-cerebral vascular events. Due to the limited quantity and quality of the included studies, the above conclusion needs to be verified by more high quality RCTs.

Citation： LI Junhong,AIKEBAER,MuLaTi,Inamdar KY. Effectiveness and Safety of Coronary Artery Bypass Grafting for Unprotected Left Main Coronary Artery: A Systematic Review. Chinese Journal of Evidence-Based Medicine, 2013, 13(9): 1096-1101. doi: 10.7507/1672-2531.20130188 Copy

1.	Eagle KA, Guyton RA, Davidoff R, et al. ACC/AHA 2004 Guideline Update for Coronary Artery Bypass Graft Surgery: Summary Article: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery). Circulation, 2004,110(8): 1168-1176.
2.	无保护左主干病变的选择性支架协作组. 无保护左主干病变的选择性支架术. 中华心血管病杂志, 2000,28(5): 346-348.
3.	Black A, Cortina R, Bossi I, et al. Unprotected left main coronary artery stenting: correlates of midterm survival and impact of patient selection. J Am Coll Cardiol, 2001, 37(3): 832-838.
4.	Taniyasu N, Akiyama K, Hirota J, et al. Newly developed left main coronary artery lesion after coronary stenting. J Cardiovasc Surg (Torino), 2002, 43(1): 55-88.
5.	Morice MC, Serruys PW, Kappetein AP, et al. Outcomes in patients with de novo left main disease treated with either percutaneous coronary intervention using paclitaxel-eluting stents or coronary artery bypass graft treatment in the Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery (SYNTAX) trial. Circulation, 2010, 121(6): 2645-2653.
6.	Boudriot E, Thiele H, Walther T, et al. Randomized comparison of percutaneous coronary intervention with sirolimus-eluting stents versus coronary artery bypass grafting in unprotected left main stem stenosis. J Am Coll Cardiol, 2011, 57(5): 538-545.
7.	Buszman PE, Kiesz SR, Bochenek A, et al. Acute and late outcomes of unprotected left main stenting in comparison with surgical revascularization. J Am Coll Cardiol, 2008, 51(5): 538-545.
8.	Park SJ, Kim YH, Park DW, et al. Randomized trial of stents versus bypass surgery for left main coronary artery disease. N Engl J Med, 2011, 364(18): 1718-1727.
9.	Garg S, Stone GW, Kappetein AP, et al. Clinical and angiographic risk assessment in patients with left main stem lesions. JACC Cardiovasc Interv, 2010, 3(9): 891-901.
10.	Chikwe J, Kim M, Goldstone AB, et al. Current diagnosis and management of left main coronary disease. Eur J Cardiothorac Surg, 2010, 38(10): 420-430.
11.	Kim YH, Park DW, Kim WJ, et al. Impact of the extent of coronary artery disease on outcomes after revascularization for unprotected left main coronary artery stenosis. J Am Coll Cardiol, 2010, 55(23): 2544-2552.
12.	Park DW, Kim YH, Song HG, et al. Long-term comparison of drug-eluting stents and coronary artery bypass grafting for multivessel coronary revascularization: 5-year outcomes from the Asan Medical Center-Multivessel Revascularization Registry. J Am Coll Cardiol, 2011, 57(2): 128-137.
13.	Celik T, Iyisoy A. The emerging role of percutaneous coronary intervention in the management of unprotected left main coronary artery disease: Ongoing debate. Int J Cardiol, 2010, 144(1): 90-91.
14.	Takagi H, Manabe H, Umemoto T. Percutaneous stenting versus bypass surgery for unprotected left main coronary artery disease. Am J Cardiol, 2010, 106(7): 1059.
15.	Lee MS, Bokhoor P, Park SJ, et al. Unprotected left main coronary disease and ST-segment elevation myocardial infarction: a contemporary review and argument for percutaneous coronary intervention. JACC Cardiovasc Interv, 2010, 3(8): 791-795.
16.	Lee MS, Yang T, Dhoot J, et al. Meta-analysis of clinical studies comparing coronary artery bypass grafting with percutaneous coronary intervention and drug-eluting stents in patients with unprotected left main coronary artery narrowings. Am J Cardiol, 2010, 105(8): 1070-1075.
17.	Seung KB, Park DW, Kim YH, et al. Stents Versus coronary artery bypass grafting for left main comnary artery disease. N End J Med, 2008, 358(17): 1781-1792.
18.	White AJ, Kedia G, Mirocha JM, et al, Comparison of coronary artery bypass surgery and percutaneous drug-eluting stent implantation for treatment of left main coronary artery stenosis. JACC Cardiovasc Interv, 2008, 1(3): 236-245.
19.	Ghenim R, Roncalli J, Tidjane AM, et al. One-year follow-up of nonrandomized comparison between coronary artery bypass grafting surgery and drug-eluting stent for the treatment of unprotected left main coronary artery disease in elderly patients (aged >or=75 years). J Interv Cardiol, 2009, 22(6): 520-526.
20.	Shimizu T, Ohno T, Ando J, et al. Mid-term results and costs of coronary artery bypass vs drug-eluting stents for unprotected left main coronary artery disease. Circ J, 2010, 74(3): 449-455.
21.	Serruys PW, Moriee MC, Kappetein AP, et al. Pereutaneous Coronary Intervention versus Coronary-Artery ByPass Grafting for Severe Coronary Artery Disease. N Engl J Med, 2009, 360(10): 961-972.
22.	Naik H, White AJ, Chakravarty T, et al. A meta-analysis of 3,773 patients treated with percutaneous coronary intervention or surgery for unprotected left main coronary artery stenosis. JACC Cardiovasc Interv, 2009, 2(8): 739-747.
23.	Palmerini T, Barlocco F, Santarelli A, et al. A comparison between coronary artery bypass grafting surgery and drug eluting stent for the treatment of unprotected left main coronary artery disease in elderly patients (aged 75 years). Eur. Heart J, 2007, 28(22): 2714-2719.
24.	Mclellan CS, Ghali WA, Labinaz M, et al. Association between completeness of percutaneous coronary revascularization and postprocedure outcomes. Am Heart J, 2005, 150(4): 800-806.

1. Eagle KA, Guyton RA, Davidoff R, et al. ACC/AHA 2004 Guideline Update for Coronary Artery Bypass Graft Surgery: Summary Article: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery). Circulation, 2004,110(8): 1168-1176.
2. 无保护左主干病变的选择性支架协作组. 无保护左主干病变的选择性支架术. 中华心血管病杂志, 2000,28(5): 346-348.
3. Black A, Cortina R, Bossi I, et al. Unprotected left main coronary artery stenting: correlates of midterm survival and impact of patient selection. J Am Coll Cardiol, 2001, 37(3): 832-838.
4. Taniyasu N, Akiyama K, Hirota J, et al. Newly developed left main coronary artery lesion after coronary stenting. J Cardiovasc Surg (Torino), 2002, 43(1): 55-88.
5. Morice MC, Serruys PW, Kappetein AP, et al. Outcomes in patients with de novo left main disease treated with either percutaneous coronary intervention using paclitaxel-eluting stents or coronary artery bypass graft treatment in the Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery (SYNTAX) trial. Circulation, 2010, 121(6): 2645-2653.
6. Boudriot E, Thiele H, Walther T, et al. Randomized comparison of percutaneous coronary intervention with sirolimus-eluting stents versus coronary artery bypass grafting in unprotected left main stem stenosis. J Am Coll Cardiol, 2011, 57(5): 538-545.
7. Buszman PE, Kiesz SR, Bochenek A, et al. Acute and late outcomes of unprotected left main stenting in comparison with surgical revascularization. J Am Coll Cardiol, 2008, 51(5): 538-545.
8. Park SJ, Kim YH, Park DW, et al. Randomized trial of stents versus bypass surgery for left main coronary artery disease. N Engl J Med, 2011, 364(18): 1718-1727.
9. Garg S, Stone GW, Kappetein AP, et al. Clinical and angiographic risk assessment in patients with left main stem lesions. JACC Cardiovasc Interv, 2010, 3(9): 891-901.
10. Chikwe J, Kim M, Goldstone AB, et al. Current diagnosis and management of left main coronary disease. Eur J Cardiothorac Surg, 2010, 38(10): 420-430.
11. Kim YH, Park DW, Kim WJ, et al. Impact of the extent of coronary artery disease on outcomes after revascularization for unprotected left main coronary artery stenosis. J Am Coll Cardiol, 2010, 55(23): 2544-2552.
12. Park DW, Kim YH, Song HG, et al. Long-term comparison of drug-eluting stents and coronary artery bypass grafting for multivessel coronary revascularization: 5-year outcomes from the Asan Medical Center-Multivessel Revascularization Registry. J Am Coll Cardiol, 2011, 57(2): 128-137.
13. Celik T, Iyisoy A. The emerging role of percutaneous coronary intervention in the management of unprotected left main coronary artery disease: Ongoing debate. Int J Cardiol, 2010, 144(1): 90-91.
14. Takagi H, Manabe H, Umemoto T. Percutaneous stenting versus bypass surgery for unprotected left main coronary artery disease. Am J Cardiol, 2010, 106(7): 1059.
15. Lee MS, Bokhoor P, Park SJ, et al. Unprotected left main coronary disease and ST-segment elevation myocardial infarction: a contemporary review and argument for percutaneous coronary intervention. JACC Cardiovasc Interv, 2010, 3(8): 791-795.
16. Lee MS, Yang T, Dhoot J, et al. Meta-analysis of clinical studies comparing coronary artery bypass grafting with percutaneous coronary intervention and drug-eluting stents in patients with unprotected left main coronary artery narrowings. Am J Cardiol, 2010, 105(8): 1070-1075.
17. Seung KB, Park DW, Kim YH, et al. Stents Versus coronary artery bypass grafting for left main comnary artery disease. N End J Med, 2008, 358(17): 1781-1792.
18. White AJ, Kedia G, Mirocha JM, et al, Comparison of coronary artery bypass surgery and percutaneous drug-eluting stent implantation for treatment of left main coronary artery stenosis. JACC Cardiovasc Interv, 2008, 1(3): 236-245.
19. Ghenim R, Roncalli J, Tidjane AM, et al. One-year follow-up of nonrandomized comparison between coronary artery bypass grafting surgery and drug-eluting stent for the treatment of unprotected left main coronary artery disease in elderly patients (aged >or=75 years). J Interv Cardiol, 2009, 22(6): 520-526.
20. Shimizu T, Ohno T, Ando J, et al. Mid-term results and costs of coronary artery bypass vs drug-eluting stents for unprotected left main coronary artery disease. Circ J, 2010, 74(3): 449-455.
21. Serruys PW, Moriee MC, Kappetein AP, et al. Pereutaneous Coronary Intervention versus Coronary-Artery ByPass Grafting for Severe Coronary Artery Disease. N Engl J Med, 2009, 360(10): 961-972.
22. Naik H, White AJ, Chakravarty T, et al. A meta-analysis of 3,773 patients treated with percutaneous coronary intervention or surgery for unprotected left main coronary artery stenosis. JACC Cardiovasc Interv, 2009, 2(8): 739-747.
23. Palmerini T, Barlocco F, Santarelli A, et al. A comparison between coronary artery bypass grafting surgery and drug eluting stent for the treatment of unprotected left main coronary artery disease in elderly patients (aged 75 years). Eur. Heart J, 2007, 28(22): 2714-2719.
24. Mclellan CS, Ghali WA, Labinaz M, et al. Association between completeness of percutaneous coronary revascularization and postprocedure outcomes. Am Heart J, 2005, 150(4): 800-806.

Chinese Journal of Evidence-Based Medicine

Effectiveness and Safety of Coronary Artery Bypass Grafting for Unprotected Left Main Coronary Artery: A Systematic Review

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