Coronary artery bypass graft versus percutaneous coronary intervention with new generation drug-eluting stents for left main and multivessel disease : an indirect comparison using Bayesian network meta-analysis

Abstract

Background : New generation drug-eluting stents (DES) have improved clinical outcomes as compared with their predecessors. However, there have been few studies comparing the clinical outcomes between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) with new generation DES. Using a Bayesian network meta-analysis, we performed an indirect comparison of the two treatment modalities.

Methods : Randomized trials comparing CABG to PCI (14,059 patients from 21 trials) for treating left main (LM) or multivessel (MV) coronary disease, and those comparing different PCI devices (101,163 patients from 144 trials), were included in the Bayesian network meta-analysis.

Results : Using traditional fixed effect meta-analysis, CABG was superior to PCI with respect to mortality (relative risk [RR] 0.90, 95% confidence interval [CI] 0.83~0.98), MI (RR 0.85, 95% CI 0.75~0.96), and repeated revascularization (RR 0.34, 95% CI 0.31~0.38), despite a higher risk of stroke (RR 1.43, 95% CI 1.08~1.89). In the network meta-analysis, however, the superiority of CABG disappeared when compared with new generation DES (RR 1.34 with Resolute zotarolimus-eluting stent, 95% credible interval [CrI] 0.92~1.95 for mortality; RR 1.39 with platinum-chromium everolimus-eluting stent, 95% CrI 0.72~2.68 for MI). Even the benefits of CABG in revascularization decreased from RR 0.12 (95% CrI 0.10~0.15) with balloon angioplasty to RR 0.65 (95% CrI 0.38~1.09) with platinum-chromium everolimus-eluting stent.

Conclusion : Although CABG has been superior to PCI, the gap appears to have become indiscernible along with the advances in stent technology. This indirect comparisonshould be validated by further trials of direct comparisons.