ABC | Volume 112, Nº5, May 2019

Original Article Stent versus Coronary Artery Bypass Surgery in Multi-Vessel and Left Main Coronary Artery Disease: A Meta-Analysis of Randomized Trials with Subgroups Evaluation Pedro José Negreiros de Andrade, 1,2 João Luiz de Alencar Araripe Falcão, 1,2 Breno de Alencar Araripe Falcão, 1,2 Hermano Alexandre Lima Rocha 1, 2 Hospital Dr. Carlos Alberto Studart Gomes de Messejana, 1 Fortaleza, CE – Brazil Universidade Federal do Ceará, 2 Fortaleza, CE – Brazil Mailing Address: Pedro José Negreiros de Andrade • Rua Francisco Holanda, 992 apt. 1101. Postal Code 60130-040, Dionísio Torres, Fortaleza, CE – Brazil E-mail: pedroneg@gmail.com, pedroneg@gmail.com Manuscript received March 05, 2018, revised manuscript August 06, 2018, accepted September 05, 2018 DOI: 10.5935/abc.20190027 Abstract Background: Comparison between percutaneous coronary intervention (PCI) using stents and Coronary Artery Bypass Grafting (CABG) remains controversial. Objective: To conduct a systematic reviewwith meta-analysis of PCI using Stents versus CABG in randomized controlled trials. Methods: Electronic databases were searched to identify randomized trials comparing PCI using Stents versus CABG for multi-vessel and unprotected left main coronary artery disease (LMCAD). 15 trials were found and their results were pooled. Differences between trials were considered significant if p < 0.05. Results: In the pooled data (n = 12,781), 30 days mortality and stroke were lower with PCI (1% versus 1.7%, p = 0.01 and 0.6% versus 1.7% p < 0.0001); There was no difference in one and two year mortality (3.3% versus 3.7%, p = 0.25; 6.3% versus 6.0%, p = 0.5). Long termmortality favored CABG (10.6% versus 9.4%, p = 0.04), particularly in trials of DES era (10.1% versus 8.5%, p = 0.01). In diabetics (n = 3,274) long term mortality favored CABG (13.7% versus 10.3%; p < 0.0001). In six trials of LMCAD (n = 4,700) there was no difference in 30 day mortality (0.6%versus 1.1%, p = 0.15), one year mortality (3% versus 3.7%, p = 0.18), and long term mortality (8.1% versus 8.1%) between PCI and CABG; the incidence of stroke was lower with PCI (0.3% versus 1.5%; p < 0.001). Diabetes and a high SYNTAX score were the subgroups that influenced more adversely the results of PCI. Conclusion: Compared with CABG, PCI using Stents showed lower 30 days mortality, higher late mortality and lower incidence of stroke. Diabetes and a high SYNTAX were the subgroups that influenced more adversely the results of PCI. (Arq Bras Cardiol. 2019; 112(5):511-523) Keywords: Myocardial Revascularization/mortality; Percutaneous Coronary Intervention; Drug-Eluting Stents; Stents; Coronary Vessels; Randomized Controlled Trial; Meta-Analysis. Introduction Percutaneous coronary intervention (PCI) using stents and coronary artery bypass grafting (CABG) are well-accepted alternatives for treatment of coronary artery disease (CAD). A large number of randomized controlled trials (RCT) comparing the two procedures were published. 1-23 Most studies were underpowered to evaluate isolated endpoints like death, stroke and acute myocardial infarction (AMI). Several meta-analyses were subsequently carried out, pooling results in order to overcome this limitation. 24-31 The largest meta-analysis included a limited number of drug-eluting stent (DES) era trials and/or included also single vessel disease and balloon era trials. On the other side, modern meta-analysis included a lower number of trials (only of DES era) and evaluated specific group of patients. 28-32 The objective of this study was to perform a systematic review of RCT comparing stents ( bare-metal and drug-eluting) versus CABG inmulti-vessel and/or left main coronary disease (LMCAD) pooling data of mortality at different periods of time and using meta-regression analysis to evaluate sub-groups. Methods Search strategies Randomized studies comparing PCI with Stents versus CABG in multivessel lesions and/or obstruction of left main CAD published between January 1990 and December 2017 were searched in the databases MEDLINE and Cochrane library and in bibliographic references published on the subject. The search terms used were: “ coronary stents” and “coronary artery bypass surgery” and “randomized controlled trial” . 511