CLINICAL RESEARCH: CLINICAL TRIALS
Five-Year Outcomes After Coronary Stenting Versus Bypass Surgery for the Treatment of Multivessel Disease
The Final Analysis of the Arterial Revascularization Therapies Study (ARTS) Randomized Trial
Patrick W. Serruys, MD, PhD, FACC*,*,
Andrew T.L. Ong, MBBS, FRACP*,
Lex A. van Herwerden, MD, PhD*,
J. Eduardo Sousa, MD, PhD, FACC ,
Adib Jatene, MD ,
Johannes J.R.M. Bonnier, MD, PhD ,
Jacques P.M.A. Schönberger, MD, PhD,
Nigel Buller, MBBS, FRCP||,
Robert Bonser, MBChB, FRCP, FRCS||,
Clemens Disco, MSc¶,
Bianca Backx, PhD¶,
Paul G. Hugenholtz, MD, FACC¶,
Brian G. Firth, MD, PhD, FACC# and
Felix Unger, MD, FACC**
* Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands
Instituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil
Hospital do Coracao, Sao Paulo, Brazil
Catharina Ziekenhuis, Eindhoven, the Netherlands
|| The Queen Elisabeth Hospital, Birmingham, United Kingdom
¶ Cardialysis, Rotterdam, the Netherlands
# Cordis, a Johnson & Johnson company, Warren, New Jersey
** the University Klinik für Herzchirurgie, Salzburg, Austria
Manuscript received September 27, 2004;
revised manuscript received December 9, 2004,
accepted December 20, 2004.
* Reprint requests and correspondence: Prof. Patrick W. Serruys, Head of the Interventional Cardiology Department, Ba 583, Thoraxcenter, Erasmus Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
(Email: p.w.j.c.serruys{at}erasmusmc.nl).
OBJECTIVES: The long-term (five-year) comparative results of treatment of multivessel coronary artery disease with stenting or coronary artery bypass grafting (CABG) is at present unknown.
BACKGROUND: The Arterial Revascularization Therapies Study (ARTS) was designed to compare CABG and stenting in patients with multivessel disease.
METHODS: A total of 1,205 patients with the potential for equivalent revascularization were randomly assigned to CABG (n = 605) or stent implantation (n = 600). The primary clinical end point was freedom from major adverse cardiac and cerebrovascular events (MACCE) at one year; MACCE at five-year follow-up constituted the final secondary end point.
RESULTS: At five years, there were 48 and 46 deaths in the stent and CABG groups, respectively (8.0% vs. 7.6%; p = 0.83; relative risk [RR], 1.05; 95% confidence interval [CI], 0.71 to 1.55). Among 208 diabetic patients, mortality was 13.4% in the stent group and 8.3% in the CABG group (p = 0.27; RR, 1.61; 95% CI, 0.71 to 3.63). Overall freedom from death, stroke, or myocardial infarction was not significantly different between groups (18.2% in the stent group vs. 14.9% in the surgical group; p = 0.14; RR, 1.22; 95% CI, 0.95 to 1.58). The incidence of repeat revascularization was significantly higher in the stent group (30.3%) than in the CABG group (8.8%; p < 0.001; RR, 3.46;95% CI, 2.61 to 4.60). The composite event-free survival rate was 58.3% in the stent group and 78.2% in the CABG group (p < 0.0001; RR, 1.91;95% CI, 1.60 to 2.28).
CONCLUSIONS: At five years there was no difference in mortality between stenting and surgery for multivessel disease. Furthermore, the incidence of stroke or myocardial infarction was not significantly different between the two groups. However, overall MACCE was higher in the stent group, driven by the increased need for repeat revascularization.
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Abbreviations and Acronyms
| | ARTS = Arterial Revascularization Therapies Study | | CABG = coronary artery bypass grafting | | CI = confidence interval | | MACCE = major adverse cardiac and cerebral event | | PCI = percutaneous coronary intervention | | RR = relative risk |
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