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CLINICAL STUDY

A prospective randomized trial comparing stenting with off-pump coronary surgery for high-grade stenosis in the proximal left anterior descending coronary artery

three-year follow-up

Derk J. Drenth, MD^*, Nic J. G. M. Veeger, Msc^*, Jobst B. Winter, MD, PhD^*, Jan G. Grandjean, MD, PhD, FECTS, Massimo A. Mariani, MD, PhD, A. d J. Boven van, MD, PhD^* and Piet W. Boonstra, MD, PhD, FECTS^*,*

^* Thoraxcentre of the Groningen University Hospital, Groningen, the Netherlands
Thoraxcentre of the Pisa University Hospital, Pisa, Italy

Manuscript received May 17, 2002; revised manuscript received July 18, 2002, accepted July 24, 2002.

^* Reprint requests and correspondence: Dr. Piet W. Boonstra, Department of Cardiothoracic Surgery, University Hospital Groningen, PO Box 30001, 9700 RB Groningen, the Netherlands.
p.w.boonstra{at}thorax.azg.nl

OBJECTIVES: This study was done to identify the best treatment for an isolated high-grade stenosis of the proximal left anterior descending coronary artery (LAD).

BACKGROUND: Percutaneous transluminal coronary angioplasty with stenting (PCI) and off-pump coronary artery bypass grafting (surgery) are used to treat single-vessel disease of a high-grade stenosis of the proximal LAD. Midterm results of both treatments are compared in this prospective randomized study.

METHODS: In a single-center prospective trial, we randomly assigned 102 patients with a high-grade stenosis of the proximal LAD (American College of Cardiology/American Heart Association classification type B2 or C) to PCI (n = 51) or surgery (n = 51). Primary composite end point was freedom from Major Adverse Cardiac and Cerebrovascular Events (MACCE) at follow-up, including death, myocardial infarction, cerebrovascular accident, and repeat target vessel revascularization (TVR). Secondary end points were angina pectoris class and need for antianginal medication at follow-up. Analysis was by intention-to-treat (ITT) and received treatment (RT).

RESULTS: Mean follow-up time was three years (90% midrange, two to four years). Incidence of MACCE was 23.5% after PCI and 9.8% after surgery; p = 0.07 ITT (24.1% vs. 8.3%; p = 0.04 RT). After surgery a significantly lower angina pectoris class (p = 0.02) and need for antianginal medication (p = 0.01) was found compared to PCI. Target vessel revascularization was 15.7% after PCI and 4.1% after surgery (p = 0.09).

CONCLUSIONS: At three-year follow-up (range, two to four years), a trend in favor of surgery is observed in regard to MACCE-free survival with a significantly lower angina pectoris status and significantly lower need for antianginal medication.

Abbreviations and Acronyms   CABG   coronary artery bypass grafting   Gp   glycoprotein   LAD   left anterior descending coronary artery   MACCE   major adverse cardiac and cerebrovascular events   PCI   percutaneous transluminal coronary angioplasty with stenting   surgery   off-pump coronary artery bypass grafting with a left internal mammary artery to the left anterior descending coronary artery   TVR   repeat target vessel revascularization

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