Abstract 3035: Sirolimus-eluting Stents Compared With Bare Metal Stents or Coronary Artery Bypass Grafting in Patients with Multivessel Disease including Involvement of the Proximal Left Anterior Descending Artery: Analysis of the Arterial Revascularization Therapies Study part 2 (ARTS-II)
Objectives: Although Coronary Artery Bypass Grafting (CABG) has been the historical gold standard treatment for patients with multivessel disease, the ARTS-II trial found no differences in survival or overall adverse events between sirolimus-eluting stents (SES) and the surgical arm of ARTS-I. Nevertheless, previous data have suggested that patients with disease of the proximal left anterior descending artery (pLAD) may derive particular benefit from CABG. We therefore investigated the 3-year clinical outcomes in all patients in ARTS-I and ARTS-II with pLAD (AHA segment 6) involvement.
Methods: Patients in ARTS-II with disease of the pLAD (289/607, 48%) were compared with 187/600 (31%) bare metal stent (BMS) patients (ARTS-I PCI) and 206/605 (34%) surgical patients (ARTS-I CABG) with pLAD involvement from ARTS-I. The primary endpoint was the incidence of major adverse cardiac and cerebrovascular events (MACCE). Secondary endpoints included all-cause mortality, the composite of death, stroke or myocardial infarction and the need for repeat revascularization.
Findings: Complete 3-year follow-up was available for 99.6% of patients in ARTS-I and ARTS-II. The ARTS-II pLAD subgroup had better survival than both ARTS-I subgroups (ARTS-II 98.6% vs. ARTS-I PCI 95.7%, p = 0.048 and vs. ARTS-I CABG 94.7%, p = 0.01) and lower rates of the hard clinical composite endpoint of death or nonfatal myocardial infarction (ARTS-II 3.1% vs. ARTS-I PCI 9.6%, p = 0.002 and vs. ARTS-I CABG 9.7%, p = 0.002). Although the ARTS-I CABG patients had a lower need for repeat revascularization than ARTS-II (5.5% vs. 13.3%, p = 0.005), the overall composite adverse event rates (death, myocardial infarction, stroke or any repeat revascularization) were not significantly different between the ARTS-I CABG and ARTS-II patients (15.1% vs. 18.1%, p = 0.4). After 1 year, the SES patients had a reduction in the composite endpoint of death/CVA/MI (vs. ARTS-I PCI RR 0.27, 95% CI 0.11– 0.63 and vs. ARTS-I CABG RR 0.31, 95% CI 0.13– 0.74), although this was not statistically significant after 3 years.
Conclusion: In this historical, non-randomized evaluation, SES had favorable outcomes compared to CABG or BMS in patients with multivessel coronary disease including involvement of the pLAD.