ABC | Volume 112, Nº5, May 2019

Original Article Andrade et al Stent versus CABG: a meta-analysis Arq Bras Cardiol. 2019; 112(5):511-523 Figure 6 – Stent versus CABG: new revascularization (top) and new revascularization by alternative procedure (bottom). The size of each box is proportional to the number of patients of the trial. The bars represent 95% confidence interval. The diamond represents the syntheses of results. DES: trials of the drug-eluting stent era; BMS: trials of the bare-metal stent trials era; CABG: coronary artery bypass grafting;ARTS:Arterial Revascularization Therapies Study;AWESOME:Angina with extremely severe outcomes; ERACI II: Argentine randomized study: coronary angioplasty with stenting versus coronary bypass surgery in patients with multi-vessel disease; MASS II: Medicine,Angioplasty, or Surgery Study; SOS: Stent or Surgery trial; BEST: Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients with Multi‑vessel Coronary Artery; Boldriot, trial of Boldriot et al: J Am Coll Cardiol. 2011; 57: 538-545. CARDia: Coronary artery revascularization in diabetic; LE MANS: Left main coronary artery stenting; EXCEL: Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization; FREEDOM: Future Revascularization Evaluation in Patients with Diabetes Mellitus; NOBLE: Nordic-Baltic-British Left Main Revascularization Study; PRECOMBAT: Premier of Randomized Comparison of Bypass Surgery versus Angioplasty Using Sirolimus-Eluting Stent in Patients with Left Main Coronary Artery Disease; SYNTAX: Synergy between PCI with Taxus and Cardiac Surgery; Va‑Cards: Coronary Artery Revascularization in Diabetes in VA Hospitals. –0.2 –0.1 0.1 0.2 0 Favours stent Favours CABG –0.2 –0.1 0.1 0.2 0 Favours stent Favours CABG 6389 6399 100.0% 0.08 [0.07, 0.09] 3807 3807 100.0% –0.01 [–0.02, –0.00] 15 29 18 14 120 128 12 30 69 122 875 183 33 18 25 4 41 45 17 236 65 42 42 5 50 25 7 957 592 897 53 605 500 203 25.1% 15.6% 23.6% 1.4% 15.9% 13.1% 5.3% 957 592 897 53 605 500 203 24 222 9 232 1995 1995 1995 1996 1996 2001 2002 2002 2003 2003 2005 2006 2008 2008 2010 2010 2008 2005 2001 1996 1995 1995 3.5% 3.2% 7.8% 9.5% 3.5% 0.8% 3.9% 4.7% 1.6% 14.8% 14.0% 1.5% 6.9% 9.3% 15.0% 203 500 605 225 53 248 300 101 947 897 97 442 592 957 8 30 57 10 5 5 10 6 50 54 11 15 44 72 386 203 500 605 225 53 248 300 101 947 897 97 442 592 957 25 100 134 35 0.07 [0.02, 0.12] 0.08 [0.03, 0.14] 0.14 [0.10, 0.18] 0.13 [0.09, 0.17] 0.11 [0.06, 0.17] 0.19 [0.04, 0.33] 0.10 [0.05, 0.14] 0.03 [–0.01, 0.06] 0.08 [–0.00, 0.16] 0.07 [0.05, 0.10] 0.08 [0.05, 0.11] 0.01 [–0.08, 0.10] 0.03 [0.01, 0.06] 0.04 [0.01, 0.08] 0.05 [0.03, 0.08] 0.05 [0.00, 0.09] 0.04 [0.01, 0.07] –0.01 [–0.04, 0.01] –0.02 [–0.12, 0.09] –0.02 [–0.04, –0.00] –0.04 [–0.07, –0.02] –0.03 [–0.05, –0.01] Total (95% Cl) Total events Test for overall effect: Z = 14.74 (p < 0.00001) Heterogeneity: Chi 2 = 46.43, df = 14 (p < 0.0001); I 2 = 70% Total (95% Cl) Total events Test for overall effect: Z = 2.67 (p = 0.007) Heterogeneity: Chi 2 = 27.10, df = 6 (p = 0.0001); I 2 = 78% CARDIA 2002 PRECOMBAT 2002 BOUDRIOT 2003 VACARDS 2006 BEST 2008 EXCEL 2010 SINTAX 2005 FREEDOM 2003 LE MANS 2001 NOBLE 2008 ARTS 1996 AWESOME 1995 New reavascularization New reavascularization by alternative procedure ERACI II 1996 MASS II 1995 SOS 1995 EXCEL 2010 SINTAX 2005 LE MANS 2001 NOBLE 2008 ARTS 1996 MASS II 1995 SOS 1995 Study or Subgroup Stent CABG Risk Difference Risk Difference Events Total Events Total Weight Year M-H, Fixed, 95% Cl M-H, Fixed, 95% Cl having similar mortality results, for patients with LMCAD of low or intermediate complexity (SYNTAX score < 33). This may also be the case for multi-vessel disease patients with lesions of low complexity (SYNTAX score < 23). For all other patients, particularly if diabetics, surgery remains the best form of revascularization. There is the possibility that second‑generation DES and a more functional strategy, using free fractional reserve and avoiding unnecessary revascularizations will improve the comparative results of PCI in the future. The one year results of the SYNTAX II 36 study suggests that this will be true, but long-term follow-up is waited and a randomized trial with contemporary CABG is warranted. The present study presents important limitations. It is a meta-analysis of published data and not a collaborative meta-analysis with access to individual data of patients. The inclusion of BMS era trials can also be criticized. It should also be noted that 30 days mortality and late mortality showed moderate heterogeneity, reducing the robustness of our results. Otherwise, our findings apply only to patients for whom revascularization may be performed using either method, without high surgical risk, no history of prior surgical revascularization, normal or near-normal ejection fraction and with the procedures carried out in institutions of excellence. 520