CABG vs. Stenting in Multi-vessel Procedures: A Synopsis
Mayra Arroyo, Chris Lee, Ivan Yang
Coronary artery disease is caused by atherosclerosis, or the accumulation of fatty deposits, known as plaque, along the innermost layer of the coronary arteries. There are three main coronary arteries: the right coronary artery, circumflex artery, and the left anterior descending artery. Atherosclerosis causes the afflicted coronary artery’s wall to thicken and lose elasticity, ultimately narrowing or blocking the artery. This can reduce the oxygen flow to the myocardium. Treatment of coronary artery disease is complex and depends on several factors, but typically comprises of risk factor management, medication, and interventional techniques, such as coronary artery bypass grafting (CABG) and stenting.
Percutaneous Coronary Intervention (PCI) or Stenting is a minimally invasive process in which a doctor inflates a stent (mesh steel tube) with a balloon to open up a clogged artery. This restores normal blood flow. A catheter is inserted through the groin, neck, or arm to move the stent to the affected area. In recent years, newer types of stents such as drug-eluting stents and biodegradable ones have been developed. Before choosing stenting as a treatment option, one should consider risks involved with stenting such as damage to the vessels or arteries.
CABG is a surgical procedure where a vein or artery (usually from the inner thigh) is used to form a path around a blocked coronary artery. Over the years, there have been changes to the techniques used to carry out CABG. One such example is Totally Endoscopic CABG, which uses a robot equipped with a camera and surgical instruments in its arms. It is important to note that this procedure is highly invasive and risky, which is why it is usually used after more conservative treatments have been attempted.
In the three studies discussed, we compared long-term outcomes of CABG and stenting in multi-vessel disease in diabetics and in combined subgroups by looking at death rates, adverse event rates, and repeat revascularization rates. Multi-vessel disease is defined as the occlusion of two or more of the three main coronary arteries, and revascularization is a procedure that returns blood flow to a low-oxygen area.
In diabetics, we found that CABG ultimately has better long-term outcomes in multi-vessel treatment. Primary outcome (death, heart attack, or stroke) rates and all-cause mortality rates were lower in CABG diabetic patients than in diabetic patients who underwent drug-eluting stent procedures.
A study published in 2001 observed the effects that CABG and stent had on patients one year after treatment. The patients’ quality of life (survival and freedom from stroke, heart attack, or repeat revascularization) was examined after one year. It was found that there were no significant differences between the number of CABG and stent patients who did not die or have heart attacks or strokes. However, CABG patients had lower rates of repeat revascularizations than stent patients. In light of this study, it is important to remember that it was conducted in a time before drug-eluting stents and other newer treatment options.
Another study published in January of 2013 found that, compared to CABG patients, a greater percentage of people who underwent PCI with drug-eluting stents underwent repeat revascularization. The study concluded that in people with less complex disease, it is acceptable to undergo PCI. On the other hand, people with multi-vessel problems should choose CABG.
In conclusion, though CABG has proven to have better long-term outcomes than stenting in multi-vessel disease treatment, better studies should be conducted to verify this. Future studies should include more patients, cover modern CABG and stent techniques, and be extended for several years after revascularization. For now, it appears that CABG does have an advantage over stenting and drug-eluting stents, mostly due to reduced rates of repeat revascularization.