The Very Different Advantages And Disadvantages Of Pci And Cabg

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*Babapulle MN, Joseph L, Belisle P, et al: A hierarchical Bayesian meta-analysis of randomized clinical trials of drug-eluting stents. Lancet 2004;364:583-591.

'Antonucci D, Valenti R, Migliorini A, et al: Abciximab therapy improves survival in patients with acute myocardial infarction compliated by early cardiogenic shock undergoing coronory artery stent implantation. Am J Cardiol 2002;90:353-357.

'Valgimigli M, Malagutti P, Aoki J, et al: Sirolimus-eluting versus paclitaxel-eluting stent implantation for the percutaneous treatment of left-main coronary artery disease: A combined RESEARCH and T-SEARCH long-term analysis. J Am Coll Cardiol 2006;47:507-514.

BENESTENT, Belgian Netherlands Stent Study; BESMART, Bestent in Small Arteries; C-SIRIUS, Canadian Study of the Sirolimus-Eluting Stent in the Treatment of Patients with Long De Novo Lesions in Small Native Coronary Arteries; CADILLAC, Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications; CHIVAS, Coronary Heart Disease Stenting in Small Vessels Versus Balloon Angioplasty Study; COAST, Heparin-COAted STents in small coronary arteries; COMPASS, Cilostazol or Multilink for Percutaneous coronary Angioplasty of Small vessel Study; EPISTENT, Evaluation of Platelet IIb/IIIa Inhibitor for Stenting; FRESCO, Florence Randomized Elective Stenting in Acute Coronary Occlusions; GISSOC, Gruppo Italiano di tudio sullo Stent nelle Occlusioni Coronariche; GRAMI, Gianturco-Roubin in Acute Myocardial Infarction; ISAR-DESIRE, Intracoronary Stenting or Angioplasty for Restenosis Reduction: Drug-Eluting Stents for In-Stent Restenosis; ISAR-SMART, Intracoronary Stenting or Angioplasty for Restenosis Reduction in Small Arteries; LASMAL, Latin American Small Vessels; NSTEMI, non-ST-segment elevation myocardial infarction; PASTA, Primary Angioplasty versus Stent Implantation in Acute Myocardial Infarction; RAP, Restenosis en Arterias Pequenas; RAVEL, Randomized Study with the Sirolimus-Eluting Velocity Balloon Expandable Stent; RESEARCH, Rapamycin-Eluting Stent Evaluated At Rotterdam Cardiology Hospital; SARECCO, Stent or Angioplasty after Recanalization of Chronic Coronary Occlusions; SAVED, Saphenous Vein De Novo; SICCO, Stenting in Chronic Coronary Occlusion; SIRIUS, Sirolimus-Eluting Bx-Velocity Balloon Expandable Stent in the Treatment of Patients with De Novo Native Coronary Artery Lesions; SISA, Stenting in Small Arteries; SISCA, Stenting in Small Coronary Arteries; SPATCO, Stent versus Percutaneous Angioplasty in Chronic Total Occlusion; STEMI, ST-segment elevation myocardial infarction; Stent-PAMI, Stent Primary Angioplasty in Myocardial Infarction; STRESS, Stent Restenosis Study; SVS, Small Vessel Study; T-SEARCH, Taxus-Stent Evaluated At Rotterdam Cardiology Hospital; TOSCA, Total Occlusion Study of Canada.

Revised from Morrison DA: Multivessel percutaneous coronary intervention (PCI): A new paradigm for a new century. Minerva Cardioangiol 2005;53:361-378, with permission of Minerva Cardioangiologica. Compare with Tables 20 and 28 in Smith SC Jr, Feldman TE, Hirshfeld JW Jr, et al: ACC/AHA/ SCA&I guideline update for percutaneous coronary intervention: Summary article. Cath Cardiovasc Intervent 2006;67:87-112.

Table 4-7. Complex PCI Means Lower Likelihood of Success and/or Higher Likelihood of Complication: How Bare Metal

Stents (BMS) and Drug-Eluting Stents (DES) Have Changed PCI for the Better

Feature

BMS More Helpful than Balloon PCI

DES More Helpful than BMS

Anatomic Feature

2.5-3.5 mm diameter; <20 mm long;

STRESS, BENESTENT

RAVEL, SIRIUS, TAXUS IV, Babapulle

without calcium, thrombus,

et al* meta-analysis of DES, ISAR-

tortuosity, or bifurcation

DESIRE

Diffuse

BENESTENT II

RESEARCH registry, C-SIRIUS

Small caliber

ISAR-SMART, SISCA, BESMART, COMPASS, CHIVAS,

RESEARCH registry

SVS, SISA, COAST, RAP, LASMAL

Osteal

Cohort

Cohort

Bifurcation

Cohorts using T stent, Y stent, V stent, "kissing" stents, or

Cohorts using Crush or "kissing" stents

"culotte"

Heavy calcium

Cohorts including both Rotablator and Excimer laser

Cohort

registries

Saphenous vein

SAVED

Cohort

Chronic total

SICCO, GISSOC, TOSCA, SARECCO, SPATCO

RESEARCH registry

Thrombus-containing

EPISTENT

Clinical Feature

STEMI

Stent-PAMI, PASTA, GRAMI, FRESCO, CADILLAC

RESEARCH registry

NSTEMI

EPISTENT

RESEARCH registry

Shock

Antonucci et al*

Left main coronary artery disease

Valgimigli et al*

CABG, or at least it did before the completion of any trials incorporating drug-eluting stents.2,5,47

A major alternative result is the 2006 cost-effectiveness study from the AWESOME trial.48 Because that trial focused on patients with medically refractory myocardial ischemia and high-risk factors for CABG outcome, its survival trends have always favored PCI. By 5 years of follow-up, the survival difference for the entire trial population reached a P value of .06, which is almost "significant" by conventional standards.48 In addition, by 5 years, the cost difference was still more than $20,000, in favor of PCI.48 Accordingly, in this population of high-risk patients with acute coronary syndromes, including acute MI, hemodynamic instability, severe LV dysfunction, and older age, PCI appears to be economically "dominant."48

These results resonate with the cost-effectiveness results from the Swiss Trial of Invasive versus Medical therapy in Elderly patients with chronic symptomatic coronary-artery disease (TIME), in which a medically refractory, elderly cohort was randomized between contemporary medical therapy and revascu-larization (primarily accomplished by PCI).7,49 The TIME investigators found revascularization to be clinically advantageous, in terms of symptoms and hospitalization, but somewhat more expensive than medical therapy alone.

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