Comparison of stenting with minimally invasive bypass surgery for high grade stenosis of the proximal left anterior descending coronary artery: six months follow up of randomized study

ABSTRACT

High grade stenosis of the proximal left anterior descending coronary artery [LAD] in patients with single-vessel disease is associated with a significantly worse prognosis than lesions at any other location. To compare the merits of stenting with minimally invasive coronary artery bypass [MICAB] surgery for high grade stenosis of isolated proximal LAD. One hundred patients with isolated high grade lesion [stenosis] >75% of laminal diameter in the proximal LAD were included. The patients were classified into two groups Group A included 50 patients in whom successful stenting was performed. Group B included 50 patients in whom successful MICAB was performed. In group A the mean percentage of stenosis was significantly reduced to 10.48 +/- 4.112. After stenting, non of the patients died, 2Q wave infarction, 2 non Q wave infarction and 1 required coronary bypass surgery, 1 stroke, 3 LAD dissection, 5 angina pectoris, 3 needed revascu-larization, 4 vascular complications and 4 needed blood transfusion. In group B, after surgery 1 patient had Q wave infarction, 1 non Q wave infarction, 2 patients needed necessary sternotomy because of an intramyocardial segment of the LAD, 3 angina pectoris, 2 needed revascularization, 2 vascular complications, 2 needed blood transfusion, 2 developed AF and 2 chest wall hernias. The mean duration of lCU stay after surgery was 2.62 +/- 1.086 days as compared to 1.8 +/- 1.591 days after stenting [p < 0.05], the mean duration of hospitalization after surgery was 8.64 +/- 3.186 days as compared to 2.34 +/- 2.471 days after stenting [p < 0.01], Follow-up was complete for all patients except two patients in each group [2 patients died in group B while in group A one patients traveled and other was excluded, eleven asymptomatic patients refused repeated cardiac catheterization after stenting, as did 13 patients after surgery. No statistically significant difference was found between both groups as regard to positive exercise stress test [p > 0.05]. After stenting, the angina class improved 79.2% were free of angina. After surgery, the mean angina class improved, 91.6% of patients were free of angina. After six months of follow up, in-stent restenosis was detected in 11 patients [29.7%] and subgroup analysis showed a restenosis rate 15.4 for type B lesion and 46.2% for type C lesion. The recurrence of stenosis was more in type C and B than type A in stenting group. In surgical group, 3 patients [8.6%] had stenosis > 50% of the luminal diameter at the anatomic region, and subgroup analysis showed a restenosis rate of 3.6% for type B lesions and 21.4% for type C lesions. The recurrence of stenosis was more in type C and B than type A in surgical group. Secondary end points were 56% in group A vs 26% in group B. Stenting and minimally invasive bypass surgery are safe and effective treatment options for high grade lesions in the proximal LAD; MICAB requires longer hospitalization, more cost but has better an-giographic outcome while stenting has higher target vessel revascularization and secondary adverse cardiac event than MICAB