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Felix Unger
Magdi H. Yacoub
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J Thorac Cardiovasc Surg 2003;125:809-820
© 2003 The American Association for Thoracic Surgery

Surgery for Acquired Cardiovascular Disease

Revascularization in multivessel disease: Comparison between two-year outcomes of coronary bypass surgery and stenting

Felix Unger, MD, MDhca, Patrick W. Serruys, MD, PhDb, Magdi H. Yacoub, MB, FRCP, FRCS, FRS, KBEc, Charles Ilsley, MD, MB, FRCP, FRACPc, Peter Kildeberg Paulsen, MD, DMScd, Torsten Toftegaard Nielsen, MD, DMScd, Leon Eysmann, MD, PhDe, Ferdinand Kiemeneij, MD, PhDc

From the Klinik ruer Herzchirurgie, Landeskliniken Salzburg, Austria,a Thoraxcenter, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands,b Harefield Hospital, Uxbridge, Middlesex, United Kingdom,c Skejby Sygehus, Arhus N, Denmark,d and Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands.e

Received for publication July 27, 2001. Revisions requested Sept 10, 2001; revisions received Nov 38, 2001. Accepted for publication Jan 10, 2002. Address for reprints: Professor F. Unger, MD, MDhc, Klinik fuer Herzchirurgie,Landeskliniken, Muellner Hauptstr. 48, A-5020, Salzburg, Austria (E-mail: f.unger{at}lks.at).

Objective: The recent appreciation that stenting has improved the short- and long-term outcomes of patients treated with coronary angioplasty has made it imperative to reconsider the comparison between surgery and percutaneous interventions in patients with multivessel disease.
Methods: One thousand two hundred five patients were randomly assigned to undergo bypass surgery or angioplasty with stent implantation when there was consensus between the cardiac surgeon and interventional cardiologist as to equivalent treatability. The primary clinical end point was freedom from major adverse cardiac and cerebrovascular events at 1 year. Major adverse cardiac and cerebrovascular events at 2 years constituted a secondary end point.
Results: At 2 years, 89.6% of the surgical group and 89.2% of the stent group were free from death, stroke, and myocardial infarction (log-rank test P = .65). Among patients who survived without stroke or myocardial infarction, 19.7% in the stent group underwent a second revascularization, as compared with 4.8% in the surgical group (P < .001). At 2 years, 84.8% of the surgical group and 69.5% of the stent group were event-free survivors (log-rank test P < .001), and 87.2% in the surgical cohort and 79.6 % in the stent group were angina-free survivors (P = .001). In the diabetes subgroup, 82.3% of the surgical group and 56.3% of the stent group were free from any events after 2 years (log-rank test P < .001).
Conclusion: The difference in outcome between surgery and stenting observed at 1 year in patients with multivessel disease remained essentially unchanged at 2 years. Stenting was associated with a greater need for repeat revascularization. In view of the relatively greater difference in outcome in patients with diabetes, surgery clearly seems to be the preferable form of treatment for these patients.




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