Drug-eluting stents versus coronary artery bypass
grafting for left-main coronary artery disease
Hisato Takagi, MD, PhD
Tomo Ando, MD
Takuya Umemoto, MD, PhD
for the ALICE (All-Literature Investigation of Cardiovascular Evidence) Group
Department of Cardiovascular Surgery,
Shizuoka Medical Center, Shizuoka, Japan
Department of Cardiology, Detroit Medical
Center, Detroit, Michigan
H. Takagi MD, PhD, Department of
Cardiovascular Surgery, Shizuoka Medical
Center, Shizuoka 411-8611, Japan.
Objectives: To compare follow-up outcomes after percutaneous coronary intervention with
drug-eluting stents (DES-PCI) versus coronary artery bypass grafting (CABG) for left-main coronary
artery disease (LMCAD), we performed a meta-analysis of randomized controlled trials (RCTs) and
observational studies with propensity-score analysis.
Methods: MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were
searched through November 2016. Eligible studies were RCTs or observational studies with
propensity-score analysis of DES-PCI versus CABG enrolling patients with LMCAD and
reporting 6-month mortality, myocardial infarction (MI), stroke, or repeat revascularization (RRV).
Study-specific estimates were combined using inverse variance-weighted averages of logarithmic
hazard ratios (HRs) in the random-effects model.
Results: We identified 5 RCTs and 17 observational studies with propensity-score analysis enroll-
ing a total of 12,387 patients. Pooled analysis demonstrated a significant increase in a composite
of death, MI, and RRV (with/without stroke) after DES-PCI (HR, 1.42; P < 0.00001); no significant
difference in a composite of death and MI (with/without stroke); no significant differences in
mortality and stroke; a strong trend toward an increase in MI after DES-PCI (HR, 1.44; P 5 0.05);
and significant increases in any (HR, 1.86; P < 0.00001), target-vessel (HR, 3.28; P < 0.00001), and
target-lesion RRV (HR, 2.26; P 5 0.003) after DES-PCI.
Conclusions: When compared with CABG, DES-PCI for LMCAD was associated with increases in
RRV and the composite of death, MI, and RRV (with/without stroke), despite no differences in
mortality, MI, stroke, and the composite of death and MI (with/without stroke).
drug-eluting stents, coronary artery bypass grafting, left-main coronary artery disease, meta-analysis
For several decades, coronary artery bypass grafting (CABG) has been
considered the “gold standard” for left-main (LM) coronary artery disease
(CAD) (LMCAD) revascularization in patients eligible for surgery [1,2].
More recently, however, percutaneous coronary intervention (PCI) has
emerged as a possible alternative mode of revascularization . Drug-
eluting stents (DES) are suggested to be associated with favorable
outcomes for mortality, myocardial infarction (MI), target-vessel/lesion
(TV/TL) repeat revascularization (RRV) (TV-/TL-RRV), and major adverse
cardiac events as compared with bare-metal stents (BMS) in PCI for
LMCAD . Furthermore, a number of medium- to large-size randomized
controlled trials (RCTs) (the NOBLE [Nordic-Baltic-British left main
revascularization] study  and the EXCEL [Evaluation of XIENCE versus
Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascu-
larization] trial ) and observational studies with propensity-score analy-
sis [6,7] of PCI with DES (DES-PCI) versus CABG for LMCAD have
recently reported mid- to long-term results. Propensity-score analysis
Hisato Takagi and Tomo Ando contributed equally to this study.
Catheter Cardiovasc Interv. 2018;91:697–709. wileyonlinelibrary.com/journal/ccd
2017 Wiley Periodicals, Inc.
Received: 12 May 2017
Accepted: 16 July 2017