Background: CABG is the preferred revascularization strategy for unprotected left main disease. Multiple small scale trials and registry data showed that PCI with Drug Eluting Stents is a non-inferior strategy and is a Class IIa ACC/AHA recommendation in a high surgical risk patient with favorable anatomy. However, two recent large scale randomized trials have shown conflicting evidence. We conducted a meta-analysis of the existing data to compare the long term outcomes of PCI with DES vs CABG for left main stenosis.
Methods: 4 randomized and 8 non-randomized studies involving 10,284 patients were included. The primary endpoint was a composite of death, stroke or MI at three years or longer. Secondary end points were MACCE (death, stroke, MI or repeat revascularization) and it's individual components. Heterogeneity of the studies was analyzed by Cochran’s Q statistics. The Mantel-Haenszel random effects model was used to calculate the combined odds ratio for outcomes. An independent analysis was performed for the randomized data only.
Results: There was no significant difference in the primary composite outcome between PCI and CABG at long term follow up. However the MACCE was significantly higher in PCI, primarily driven by significantly high repeat revascularization. The stroke rate was lower in PCI, although not significant. Analysis of randomized data also yielded similar results. A subgroup analysis stratified by SYNTAX score showed that MACCE and repeat revascularization were not significantly different between PCI and CABG in low to intermediate SYNTAX score (<33) while they were significantly higher in PCI in high SYNTAX score.
Conclusion: There was no significant difference in the primary composite outcome between PCI with DES and CABG at long term follow up. Repeat Revascularization in PCI was also not different from CABG in left main stenosis with low SYNTAX score. PCI with DES can be considered as a reasonable alternate strategy in isolated left main stenosis.