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Thorac Cardiovasc Surg
DOI: 10.1055/s-0044-1787014
Original Cardiovascular

Coronary Artery Bypass Grafting versus Percutaneous Coronary Intervention in Patients with Chronic Total Occlusion

Authors

  • Hristo Kirov   *

    1   Department of Cardiothoracic Surgery, Jena University Hospital, Jena, Germany

  • Johannes Fischer   *

    1   Department of Cardiothoracic Surgery, Jena University Hospital, Jena, Germany

  • Tulio Caldonazo   *

    1   Department of Cardiothoracic Surgery, Jena University Hospital, Jena, Germany

  • Panagiotis Tasoudis

    2   Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, United States

  • Angelique Runkel

    1   Department of Cardiothoracic Surgery, Jena University Hospital, Jena, Germany

  • Giovanni Jr. Soletti

    3   Weill Cornell Medicine, New York, New York, United States

  • Gianmarco Cancelli

    3   Weill Cornell Medicine, New York, New York, United States

  • Michele Dell'Aquila

    3   Weill Cornell Medicine, New York, New York, United States

  • Murat Mukharyamov

    1   Department of Cardiothoracic Surgery, Jena University Hospital, Jena, Germany

  • Torsten Doenst

    1   Department of Cardiothoracic Surgery, Jena University Hospital, Jena, Germany

Funding TC was funded by the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation) Clinician Scientist Program OrganAge funding number 413668513, by the Deutsche Herzstiftung (DHS, German Heart Foundation) funding number S/03/23, and by the Interdisciplinary Center of Clinical Research of the Medical Faculty Jena.
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Abstract

Objectives Mechanisms of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) differ as CABG provides surgical collateralization and may prolong life by preventing future myocardial infarctions (MIs). However, evidence for CABG in patients with chronic total occlusion (CTO) has not been fully elucidated and the impact of PCI is discussed controversially.

Methods We performed a meta-analysis of studies comparing outcomes in patients with/without multivessel disease undergoing CABG or PCI for CTO. The primary outcome was long-term all-cause mortality (≥5 years). Secondary outcomes were MIs, repeat revascularization, cardiac mortality, major adverse cardiovascular events, and stroke, as well as short-term mortality (30 days/in-hospital) and stroke. A pooled Kaplan–Meier survival curve after reconstruction analysis was generated. Random-effects models were used.

Results Six studies totaling 12,504 patients were included. In the pooled Kaplan–Meier analysis, PCI showed a significantly higher risk of death in the follow-up compared with CABG (hazard ratio [HR]: 2.12, 95% confidence interval [CI]: 1.88–2.38, p < 0.01). During the observation period, PCI was also associated with higher rates of MI (odds ratio [OR]: 2.86, 95% CI: 1.82–4.48, p < 0.01) and more repeat revascularization (OR: 4.88, 95% CI: 1.99–11.91, p = 0.0005). The other outcomes did not show significant differences.

Conclusion CABG is associated with superior survival to PCI over time in patients with CTO who are eligible for both PCI and CABG. This survival advantage is associated with fewer events of MI and repeat revascularization.

Keywords

coronary artery bypass grafting - percutaneous coronary intervention - coronary artery disease - chronic total occlusion

Note

This study was accepted for presentation at the DGTHG annual meeting 2024 in Hamburg, Germany. Its abstract was ranked among the top 25 submissions.


Data Availability Statement

The data underlying this article are available in the article and in its online supplementary material.


Authors' Contribution

H.K., J.F., and T.C. designed the study, as well as coordinated and performed the major steps of the work regarding literature review, study selection, data management, and manuscript writing. Due to the fact that a meta-analysis of reconstructed time-to-event data is significantly effort demanding, the authors will share the first authorship. P.T. helped extensively with the statistical approach (especially with the Cox regression model and the proportional hazards assumption tests). A.R., G.S., and G.C. qualified the studies according to the risk of bias, checked the data abstraction, built the tables, and organized the results. M.D. and M.M. analyzed the preliminary data and were involved in the international project registration. T.D. was directly involved with the project supervision, manuscript review, and editing and was also consulted for study accuracy verification together with H.K. in cases of conflict. All the authors read and approved the final version of the manuscript.


* These authors contributed equally.


Supplementary Material



Publication History

Received: 28 December 2023

Accepted: 29 April 2024

Article published online:
17 May 2024

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