Drug-Eluting Stent Versus Coronary Artery Bypass Grafting for Diabetic Patients With Multivessel and/or Left Main Coronary Artery Disease: A Meta-Analysis
Restricted accessResearch articleFirst published online September, 2019
Drug-Eluting Stent Versus Coronary Artery Bypass Grafting for Diabetic Patients With Multivessel and/or Left Main Coronary Artery Disease: A Meta-Analysis
With the development of stent design and surgical techniques, the relative benefit of percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) in patients with diabetes and complex coronary artery disease are highly debated. This meta-analysis was conducted to compare the outcomes of drug-eluting stent (DES) implantation and CABG in these cohorts. A comprehensive search of PubMed, Embase, and Cochrane Library up to January 4, 2018, was performed. Only randomized controlled trials (RCTs), subgroup analysis from RCTs, or adjusted observational studies were eligible. Five RCTs and 13 adjusted observational studies involving 17 532 patients were included. Overall, PCI with DES was significantly associated with higher risk of all-cause mortality (hazard ratio [HR]: 1.16, 95% confidence interval [CI]: 1.05-1.29), myocardial infarction (MI; HR: 1.69, 95% CI: 1.43-2.00), and repeat revascularization (HR: 3.77, 95% CI: 2.76-5.16) compared with CABG. Nevertheless, the risk of stroke was significantly lower in the DES group (HR: 0.67, 95% CI: 0.54-0.83). The incidence of the composite end point of death, MI, or stroke was comparable between the 2 groups (HR: 0.99, 95% CI: 0.84-1.17). Despite the higher risk of stroke, CABG was better than PCI with DES for diabetic patients with multivessel and/or left main coronary artery disease.
EleziSKastratiAPacheJet al.Diabetes mellitus and the clinical and angiographic outcome after coronary stent placement. J Am Coll Cardiol. 1998;32(7):1866–73.
2.
HlatkyMABoothroydDBBravataDMet al.Coronary artery bypass surgery compared with percutaneous coronary interventions for multivessel disease: a collaborative analysis of individual patient data from ten randomised trials. Lancet. 2009;373(9670):1190–97.
3.
HakeemAGargNBhattiSet al.Effectiveness of percutaneous coronary intervention with drug-eluting stents compared with bypass surgery in diabetics with multivessel coronary disease: comprehensive systematic review and meta-analysis of randomized clinical data. J Am Heart Assoc. 2013;2(4):e000354.
4.
De LucaGSchafferAVerdoiaMRajpurohitNAhmedZUretskyBF. Meta-analysis of 14 trials comparing bypass grafting vs drug-eluting stents in diabetic patients with multivessel coronary artery disease. Nutr Metab Cardiovasc Dis. 2014;24(4):344–54.
5.
HuangFLaiWChanCet al.Comparison of bypass surgery and drug-eluting stenting in diabetic patients with left main and/or multivessel disease: a systematic review and meta-analysis of randomized and nonrandomized studies. Cardiol J. 2015;22(2):123–34.
6.
StroupDFBerlinJAMortonSCet al.Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA. 2000;283(15):2008–12.
7.
MoherDLiberatiATetzlaffJAltmanDG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009;339:b2535.
8.
LundhAGotzschePC. Recommendations by Cochrane Review Groups for assessment of the risk of bias in studies. BMC Med Res Methodol. 2008;8:22.
9.
StangA. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol. 2010;25(9):603–05.
10.
BriguoriCCondorelliGAiroldiFet al.Comparison of coronary drug-eluting stents versus coronary artery bypass grafting in patients with diabetes mellitus. Am J Cardiol. 2007;99(6):779–84.
11.
Dominguez-FrancoAJJimenez-NavarroMFHernandez-GarciaJMet al.Comparison of medium-term outcomes obtained with drug-eluting stents and coronary artery bypass grafts in an unselected population of diabetic patients with multivessel coronary disease. Propensity score analysis. Rev Esp Cardiol. 2009;62(5):491–500.
12.
KimWJParkDWYunSCet al.Impact of diabetes mellitus on the treatment effect of percutaneous or surgical revascularization for patients with unprotected left main coronary artery disease: a subgroup analysis of the MAIN-COMPARE study. JACC Cardiovasc Interv. 2009;2(10):956–63.
13.
QiaoYMaCNieSet al.Twelve months clinical outcome of drug-eluting stents implantation or coronary artery bypass surgery for the treatment of diabetic patients with multivessel disease. Clin Cardiol. 2009;32(8):E24–30.
14.
OnumaYWykrzykowskaJJGargSet al.5-Year follow-up of coronary revascularization in diabetic patients with multivessel coronary artery disease: insights from ARTS (arterial revascularization therapy study)-II and ARTS-I trials. JACC Cardiovasc Interv. 2011;4(3):317–23.
15.
ZhaoXZhouYSongHet al.Comparison of bypass surgery with drug-eluting stents in diabetic patients with left main coronary stenosis. Yonsei Med J. 2011;52(6):923–32.
16.
DohiSKajimotoKMiyauchiKet al.Comparing outcomes after off-pump coronary artery bypass versus drug-eluting stent in diabetic patients. J Cardiol. 2012;59(2):195–201.
17.
FarkouhMEDomanskiMSleeperLAet al.Strategies for multivessel revascularization in patients with diabetes. N Engl J Med. 2012;367(25):2375–84.
18.
KimYGParkDWLeeWSet al.Influence of diabetes mellitus on long-term (five-year) outcomes of drug-eluting stents and coronary artery bypass grafting for multivessel coronary revascularization. Am J Cardiol. 2012;109(11):1548–57.
19.
MoshkovitzYMohrRMedalionBet al.Drug-eluting stents compared with bilateral internal thoracic artery grafts for diabetic patients. Ann Thorac Surg. 2012;94(5):1455–62.
20.
KappeteinAPHeadSJMoriceMCet al.Treatment of complex coronary artery disease in patients with diabetes: 5-year results comparing outcomes of bypass surgery and percutaneous coronary intervention in the SYNTAX trial. Eur J Cardiothorac Surg. 2013;43(5):1006–13.
21.
KamaleshMSharpTGTangXCet al.Percutaneous coronary intervention versus coronary bypass surgery in United States veterans with diabetes. J Am Coll Cardiol. 2013;61(8):808–16.
22.
BangaloreSGuoYSamadashviliZBleckerSXuJHannanEL. Everolimus eluting stents versus coronary artery bypass graft surgery for patients with diabetes mellitus and multivessel disease. Circ Cardiovasc Interv. 2015;8(7):e002626.
23.
ParkSJAhnJMKimYHet al.Trial of everolimus-eluting stents or bypass surgery for coronary disease. N Engl J Med. 2015;372(13):1204–12.
24.
YuXHeJLuoYet al.Influence of diabetes mellitus on long-term outcomes of patients with unprotected left main coronary artery disease treated with either drug-eluting stents or coronary artery bypass grafting. Int Heart J. 2015;56(1):43–8.
25.
StoneGWSabikJFSerruysPWet al.Everolimus-eluting stents or bypass surgery for left main coronary artery disease. N Engl J Med. 2016;375(23):2223–35.
26.
ZhengZXuBZhangHet al.Coronary artery bypass graft surgery and percutaneous coronary interventions in patients with unprotected left main coronary artery disease. JACC Cardiovasc Interv. 2016;9(11):1102–11.
27.
LeePHLeeJYLeeCWet al.Long-term outcomes of bypass grafting versus drug-eluting stenting for left main coronary artery disease: results from the IRIS-MAIN registry. Am Heart J. 2017;193:76–83.
28.
WestNEJ. Clinical and angiographic predictors of restenosis after stent deployment in diabetic patients. Circulation. 2004;109(7):867–73.
29.
HeadSJMilojevicMDaemenJet al.Mortality after coronary artery bypass grafting versus percutaneous coronary intervention with stenting for coronary artery disease: a pooled analysis of individual patient data. Lancet. 2018;391(10124):939–48.
30.
FihnSDBlankenshipJCAlexanderKPet al.2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2014;64(18):1929–49.
31.
WindeckerSKolhPAlfonsoFet al.2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J. 2014;35(37):2541–19.
32.
KuntzRE. Importance of considering atherosclerosis progression when choosing a coronary revascularization strategy: the diabetes-percutaneous transluminal coronary angioplasty dilemma. Circulation. 1999;99(7):847–51.
33.
FarooqVSerruysPWGarcia-GarciaHMet al.The negative impact of incomplete angiographic revascularization on clinical outcomes and its association with total occlusions: the SYNTAX (Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery) trial. J Am Coll Cardiol. 2013;61(3):282–94.
34.
PalmeriniTBenedettoUBiondi-ZoccaiGet al.Long-term safety of drug-eluting and bare-metal stents: evidence from a comprehensive network meta-analysis. J Am Coll Cardiol. 2015;65(23):2496–507.
35.
WiviottSDBraunwaldEAngiolilloDJet al.Greater clinical benefit of more intensive oral antiplatelet therapy with prasugrel in patients with diabetes mellitus in the trial to assess improvement in therapeutic outcomes by optimizing platelet inhibition with prasugrel-Thrombolysis in Myocardial Infarction 38. Circulation. 2008;118(16):1626–36.
36.
NewmanMFMathewJPGrocottHPet al.Central nervous system injury associated with cardiac surgery. Lancet. 2006;368(9536):694–703.
37.
LeeSWLeePHKangSHet al.Determinants and prognostic significance of periprocedural myocardial injury in patients with successful percutaneous chronic total occlusion interventions. JACC Cardiovasc Interv. 2016;9(21):2220–28.
38.
D’AscenzoFBollatiMClementiFet al.Incidence and predictors of coronary stent thrombosis: evidence from an international collaborative meta-analysis including 30 studies, 221,066 patients, and 4276 thromboses. Int J Cardiol. 2013;167(2):575–84.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
