Drug-eluting Stent - Alternatives (to Stents in General)

Alternatives (to Stents in General)

Medical therapy for coronary artery disease has also improved since the 1970s, and for many kinds of patients may be as successful as stenting or surgery. For those requiring PCI or surgery, medical therapy and revascularization should be viewed as complementary rather than opposing strategies.

Coronary artery bypass graft surgery is the best treatment for some patients. Differences between outcomes with stenting and with coronary bypass grafting (CABG) are a point of controversy. A recent study comparing the outcomes of all patients in New York state treated with coronary artery bypass surgery (CABG) or percutaneous coronary intervention (PCI) demonstrated CABG was superior to PCI with DES in multivessel (two or more diseased arteries) coronary artery disease (CAD). Patients treated with CABG had lower rates of death and of death or myocardial infarction than treatment with a drug-eluting stent. Patients undergoing CABG also had lower rates of repeat revascularization. The New York State registry included all patients undergoing revascularization for coronary artery disease, but was not a randomized trial, and so may have reflected other factors besides the method of coronary revascularization.

No randomized trial comparing CABG and DES has been completed, although two trials of DES versus CABG are currently enrolling patients - SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) and FREEDOM (Future Revascularization Evaluation in Patients With Diabetes Mellitus—Optimal Management of Multivessel Disease). The registries of the nonrandomized patients screened for these trials may provide as much robust data regarding revascularization outcomes as the randomized analysis.

Other studies, including the ARTS II registry, suggest that drug-eluting stenting is not inferior to coronary bypass for treatment of multivessel coronary disease. The ARTS II registry compared a cohort of patients treated with multi-vessel stenting with DES, to the historical CABG cohort in the ARTS I trial (itself a randomized comparison between multivessel bare metal stenting vs. CABG.) At three-year follow-up, major adverse cardiac events were comparable between the ARTS II DES group and the ARTS I CABG group. Re-intervention was lower in the ARTS I CABG group. In all comparison studies of stenting vs. bypass surgery, it is worth noting that only a small minority of patients with multivessel coronary disease have been eligible for inclusion in the studies, and that for most patients, clinical judgement by experienced operators suggests that one or the other approach is preferred.