CABG VS
Multi Vessel PCI
Hasanat Sharif MD FRCS
Chief of Cardiorthoracic Surgery
Aga Khan University Hospital
Multivessel
• Definition
– Cardiologist
– Cardiac Surgeon
Treatment of Coronary Artery Disease
• Medical
• Percutaneous Intervention
• Surgical Revascularization
Treatment of Coronary Artery Disease
• Medical
• Advances in medical treatment
– Anti platelet agents– ACEI/ARB– Statins– Aggressive risk factor modification
Treatment of Coronary Artery Disease
• Primary percutaneous intervention
• Role in evolving acute myocardial infarction
• Culprit vessel addressed
Intervention
• Interventionalist’s procedural bias
• Perception
– Clinician– Referring doctors and – Patient
End Point CABG (%) DES (%) p
MACCE 12.1 17.8 0.0015
Death/MI/CVA 7.7 7.6 0.98
Revascularization 5.9 13.7 <0.0001
Stroke 2.2 0.6 0.003
MI 3.2 4.8 0.11
All Cause death 3.5 4.3 0.37
Syntax Trial
End point CABG (%) PCI (%) p
All-cause death 4.9 6.2 0.24All stroke 2.8 1.4 0.03Stroke before 1 y 2.2 0.6 0.003Stroke after 1 y 0.6 0.7 0.82MI 3.3 5.9 0.01MI before 1 y 3.3 4.8 0.11MI after 1 y 0.1 1.2 0.008All-cause death, stroke, MI
9.6 10.8 0.44
Repeat PCI 8.6 17.4 <0.001MACCE 16.3 23.4 <0.001
Two-year outcomes for SYNTAX
Kappetein AP. European Society of Cardiology 2009 Congress; September 2, 2009: Barcelona, Spain.
Approriateness criteria for coronary revascularization
• Refined and extended guidance beyond that provided by evidence based guidelines
• Expert panel of 17 members
• Year long effort to evaluate available evidence and existing guidelines
Appropriateness Criteria
• Inappropriate 1-3• Uncertain 4-6• Appropriate 7-9
• PCI inappropriate for LM CAD• PCI uncertain for 3 VCAD• PCI appropriate for acute myocardial injury• CABG appropriate for 3VCAD and LM CAD
What happens in actual practice?
• Catheterization laboratory cardiologists in hospitals with PCI capability were more likely to recommend patients for PCI
than
• Hospitals in which only catheterization was performed
Adherence to ACC/AHA guidelines
• Indicated
• CABG 13%
• PCI 59%
• Both 17%
• Recommended
• 53% (34% PCI)
• 94%
• 93% PCI
• 5% CABG
Trials
• Justification– ? Economically/industry driven– ? Extending the boundaries of care
• Randomization• Multi centered• Adequate numbers• Long term follow up• End point - survival
Trials
• Ethics
– Informed patient consent– Critical to provide complete disclosure of
risks/benefits– Survival– Stent thrombosis/graft closure– Risk of re intervention/complications
Trials
• Enrolled only 5-10% of the eligible population
• ? Generalizability of results
• Real life situations
Trials
• Propensity analysis is not perfect
• Euroscore over predicts procedural risk
• Cost analysis and impact on healthcare budget
Observational data
• Consistently show a survival advantage for CABG over PCI
• STS database
• Northern New England database
• Duke
• New York
AKU Data
Fifty month data Jan 2006-March 2010
• Total CABG n=2041
• Left main n= 406 (19.9%)
• 1 VCAD n= 69 (3.4%)
• 2 VCAD n= 257 (12.6%)
• 3 VCAD n= 1715 (84%)
AKU Data
• Mean age 58 years (+/-11)
• Males 82%
• LVEF 48% (+/-14)
• IMA usage 90%
• CVA n = 8 (0.4%)
• Mortality n = 32 (1.6%)
Cost Considerations
• CABG package 225K
• One bare metal stent 285K– Additional stent 32K
• One DES 395K– Additional stent 139K
Triple vessel and left main coronary stenosis
• CABG first choice for majority of patients
• Consider PCI for patients with co morbidities that preclude CABG
• Advances – PCI technology and – Surgical techniques/ peri operative care
• Extending the boundaries of cardiovascular care
Treatment of coronary artery disease
• Multidisciplinary team approach– Cardiologist– Interventionalist– Cardiac Surgeon
• Separate diagnosis from treatment!
• Treatment option given on cath table
• Scare tactics
Thank You
