Stent versus Coronary Artery Bypass Surgery in Multi-Vessel and Left Main Coronary Artery Disease: A Meta-Analysis of Randomized Trials with Subgroups Evaluation

Abstract Background: Comparison between percutaneous coronary intervention (PCI) using stents and Coronary Artery Bypass Grafting (CABG) remains controversial. Objective: To conduct a systematic review with meta-analysis of PCI using Stents versus CABG in randomized controlled trials. Methods: Electronic databases were searched to identify randomized trials comparing PCI using Stents versus CABG for multi-vessel and unprotected left main coronary artery disease (LMCAD). 15 trials were found and their results were pooled. Differences between trials were considered significant if p < 0.05. Results: In the pooled data (n = 12,781), 30 days mortality and stroke were lower with PCI (1% versus 1.7%, p = 0.01 and 0.6% versus 1.7% p < 0.0001); There was no difference in one and two year mortality (3.3% versus 3.7%, p = 0.25; 6.3% versus 6.0%, p = 0.5). Long term mortality favored CABG (10.6% versus 9.4%, p = 0.04), particularly in trials of DES era (10.1% versus 8.5%, p = 0.01). In diabetics (n = 3,274) long term mortality favored CABG (13.7% versus 10.3%; p < 0.0001). In six trials of LMCAD (n = 4,700) there was no difference in 30 day mortality (0.6%versus 1.1%, p = 0.15), one year mortality (3% versus 3.7%, p = 0.18), and long term mortality (8.1% versus 8.1%) between PCI and CABG; the incidence of stroke was lower with PCI (0.3% versus 1.5%; p < 0.001). Diabetes and a high SYNTAX score were the subgroups that influenced more adversely the results of PCI. Conclusion: Compared with CABG, PCI using Stents showed lower 30 days mortality, higher late mortality and lower incidence of stroke. Diabetes and a high SYNTAX were the subgroups that influenced more adversely the results of PCI.

摘要 背景：采用支架的经皮冠状动脉介入治疗（percutaneous coronary intervention, PCI）与冠状动脉旁路移植术（Coronary Artery Bypass Grafting, CABG）之间的比较仍存在争议。
目的：针对随机对照试验中采用支架的PCI与CABG的对比开展系统综述与Meta分析。
方法：检索电子数据库，以识别针对多支血管病变及无保护左主干冠状动脉疾病（unprotected left main coronary artery disease, LMCAD）比较采用支架的PCI与CABG的随机试验。最终纳入15项试验并对其结果进行合并分析。若P<0.05，则认为试验间差异具有统计学意义。
结果：合并分析数据（n=12781）显示，PCI组的30天死亡率与卒中发生率更低（1% vs 1.7%，P=0.01；0.6% vs 1.7%，P<0.0001）；两组1年及2年死亡率无显著差异（3.3% vs 3.7%，P=0.25；6.3% vs 6.0%，P=0.5）。长期死亡率方面CABG更具优势（10.6% vs 9.4%，P=0.04），在药物洗脱支架（drug-eluting stent, DES）时代的试验中这一差异更为显著（10.1% vs 8.5%，P=0.01）。在糖尿病患者亚组（n=3274）中，长期死亡率同样以CABG更优（13.7% vs 10.3%；P<0.0001）。在6项针对LMCAD的试验（n=4700）中，PCI与CABG的30天死亡率（0.6% vs 1.1%，P=0.15）、1年死亡率（3% vs 3.7%，P=0.18）及长期死亡率（8.1% vs 8.1%）均无显著差异；但PCI组的卒中发生率更低（0.3% vs 1.5%；P<0.001）。糖尿病及高SYNTAX评分亚组会对PCI的治疗结果产生更不利的影响。
结论：与CABG相比，采用支架的PCI30天死亡率更低，但远期死亡率更高，且卒中发生率更低。糖尿病及高SYNTAX评分亚组会对PCI的治疗结果产生更不利的影响。