Is surgery or percutaneous revascularization the preferred strategy for patients with significant left main coronary stenosis? Surgery, Not Percutaneous Revascularization, Is the Preferred Strategy for Patients With Significant Left Main Coronary Stenosis

The place to begin is with a brief discussion of the general case: percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) for all anatomic varieties of coronary disease. Daemen et al1 pooled 3051 patients from 4 randomized trials comparing CABG with PCI using bare metal stents (BMS). At 5 years, PCI and CABG were similar with respect to death, myocardial infarction (MI), and stroke. Repeat revascularization was significantly more frequent after PCI (29.7% versus 7.9%; P 0.001), which probably accounted for a significantly higher frequency of major adverse cardiac and cerebrovascular events (MACCE) after PCI (39.2% versus 23.0%; P 0.001). Revascularization was considered complete in 89.4% of CABG patients compared with 62% of PCI patients (P 0.001). Bravata et al2 reviewed 23 randomized controlled comparisons of CABG with PCI with the use of BMS in 5019 patients and found significantly greater angina relief with CABG at 1 to 5 years (P 0.001). Repeat revascularization was more frequent after PCI (risk difference 25% at 1 year and 33% at 5 years; P 0.001). Javaid et al3 reviewed their “real world” experience with CABG and PCI using drug-eluting stents (DES) for 2and 3-vessel coronary disease in 1680 patients and found that MACCE were more frequent with PCI (21.2% versus 9.7% for 2-vessel disease; P 0.001; 28.4% versus 10.8% for 3-vessel disease; P 0.001).