The effect of coronary stent type on the long-term results of coronary artery bypass surgery after stenting clinically related artery in acute coronary syndrome in patients with multivessel coronary artery disease

Justification. The results of endovascular revascularization are largely determined by the type of stents used. The use of baremetal coronary stents significantly worsens the long-term results of endovascular treatment of coronary artery disease. Given the widespread use of bare-metal coronary stents in the Russian Federation for the treatment of coronary artery disease and acute coronary syndrome, in particular, the issue of the impact of the above-mentioned endovascular interventions on the long-term results of coronary artery bypass grafting (CABG) performed after endovascular revascularization of the clinically related artery in patients with acute coronary syndrome and multivessel lesions does not lose relevance.

Aim. To compare the long-term results of the staged strategies of revascularization of the coronary bed: CABG performed after stenting the clinically related artery with third-generation biodegradable polymer-based sirolimus-eluting stents for acute coronary syndrome and CABG performed after stenting the clinically related artery with bare-metal coronary stents for acute coronary syndrome.

Material and Methods. The analysis used the data of two-year follow-up of patients who underwent two-stage revascularization: at the first stage, patients received stenting of the clinically related artery for acute coronary syndrome and, at the second stage, they received coronary artery bypass grafting no later than 90 days from the date of stenting. The study included 218 patients with multivessel lesions of the coronary bed, admitted with clinical manifestation of acute coronary syndrome. The long-term follow-up period was 24 months. The following end points were analyzed: cardiovascular mortality, myocardial infarction, re-revascularization, and combined MACCE end point (cardiovascular mortality, myocardial infarction, acute cerebrovascular accident, and re-revascularization). The observation was carried out at the hospital stage and, then, on an outpatient basis once every three months.

Results. There were no significant differences between the groups. The frequency of repeated revascularization, including repeated revascularization of the stented artery, and recurrence of angina were significantly higher in the group with baremetal coronary stents. There were no significant differences between the groups in regard to cardiovascular mortality, nonfatal myocardial infarction and acute cerebrovascular accidents. The frequency of MACCE events was significantly higher in the group of bare-metal coronary stents, mainly due to the frequency of repeated revascularizations.

Conclusion. Coronary artery bypass grafting performed in the early period after stenting of the clinically related artery using bare-metal coronary stents in patients with acute coronary syndrome and multivessel lesions was associated with a significantly larger number of repeated coronary revascularizations and higher rate of recurrent angina compared to a similar strategy, but with the use of modern third-generation biodegradable polymer-based sirolimus-eluting stents.

1. Neumann F.J., Sousa-Uva M., Ahlsson A., Alfonso F., Banning A.P., Benedetto U. et al. ESC/EACTS Guidelines on myocardial revascularization. Eur. Heart J. 2019;40(2):87–165. DOI: 10.1093/eurheartj/ehy394.

2. Abugov S.A., SaakianIu.M., Puretskii M.V., Poliakov R.S., Pirkova A.A., Boltenkov A.V. et al. Comparison of pharmacologic and endovascular strategies of treatment in CHD patients with chronic occlusions. Russian Journal of Cardiology and Cardiovascular Surgery. 2013;6(3):4–9 (In Russ.).

3. Kuznetsov V.A., Yaroslavskaya E.I., Pushkarev G.S., Zyryanov I.P., Bessonov I.S., Gorbatenko E.A. et al. Interrelation of transcutaneous coronary interventions for acute forms of coronary heart disease and mortality parameters in Тyumen region inhabitants. Russian Journal of Cardiology. 2014;(6):42–46 (In Russ.). DOI: 10.15829/1560-4071-2014- 6-42-46.

4. Keeley E.C., Boura J.A., Grines C.L. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction a quantitative review of 23 randomized trials. Lancet. 2003;361(9351):13–20. DOI: 10.1016/S0140-6736(03)12113-7.

5. Windecker S., Kolh Ph., Alfonso F., Collet J.P., Cremer J., Falk V. et al. 2014 ESC/EACTS Guidelines on myocardial revascularization. Eur. Heart J. 2014;35(37):2541–2619. DOI: 10.1093/eurheartj/ehu278.

6. Wald D.S., Morris J.K., Wald N.J., Chase A.J., Edwards R.J., Hughes L.O. et al. Randomized trial of preventive angioplasty in myocardial infarction. N. Engl. J. Med. 2013;369(12):1115–1123. DOI: 10.1056/NEJMoa1305520.

7. Cardarelli F., Bellasi A., Ou F.S., Shaw L.J., Veledar E., Roe M.T. et аl. Combined impact of age and estimated glomerular filtration rate on in – hospital mortality after percutaneous coronary intervention for acute myocardial infarction (from the American College of Cardiology National Cardiovascular Data Registry). Am. J. Cardiol. 2009;103(6):766–771. DOI: 10.1016/j.amjcard.2008.11.033.

8. Toma M., Вuller C.E., Westerhout C.M., Fu Y., O’Neill W.W., Holmes D.R. Jr. et al. Nonculprit coronary artery percutaneous coronary intervention during acute ST – segment elevation myocardial infarction: insights from the APEX–AMI trial. Eur. Heart J. 2010;31(14):1701–1707. DOI: 10.1093/eurheartj/ehq129.

9. Hannan E.L., Racz M.J., Walford G., Jones R.H., Ryan T.J., Bennett E. et al. Long-term outcomes of coronary – artery bypass grafting versus stent implantation. N. Engl. J. Med. 2005;352:2174–2183. DOI: 10.1056/NEJMoa040316.

10. Thuijs D., Mohr F.W., Serruys P.W., Mack M.J., Holmes D.R., Morice M.C. et al. 10-year survival after bypass surgery versus drug-eluting stents: preliminary results of the randomized SYNTAX extended survival study “SYNTAXES”. https://www.acc.org/~/media/Clinical/PDF-Files/Approved-PDFs/2018/09/21/TCT-2018-Slides/Sept24-Mon/3pmET_SYNTAXES-tct-2018.pdf.

11. Buchanan G.L., Chieffo A., Bernelli C., Montorfano M., Carlino M., Latib A. et al. Two-year outcomes following unprotected left main stenting with first vs. new – generation drug – eluting stents: the FINE registry. Eurointervention. 2013;9(7):809–816. DOI: 10.4244/EIJV917A134.

12. Kassimis G., Banning A.P. Is it time to take bare metal stents off the catheter laboratory shelf? Eur. Heart J. 2016;37(45):3372–3375. DOI: 10.1093/eurheartj/ehw215.

13. James S.K., Stenestrand U., Lindback J., Carlsson J., Schersten F., Nilsson T. et al. Long-term safety and efficacy of drug-eluting versus bare-metal stents in Sweden. N. Engl. J. Med. 2009;360:1933–1945. DOI: 10.1056/NEJMoa0809902.

14. Burne R.A., Serruys P.W., Baumbach A., Escaned J., Fajadet J., James S. et al. Report of a European Society of Cardiology – European Association of Percutaneous Cardiovascular Interventions task force on the evaluation of coronary stents in Europe: executive summary. Eur. Heart J. 2015;36:2608–2620. DOI: 10.1093/eurheartj/ehv203.

15. Alekyan B.G., Grigor’yan A.M., Staferov A.V., Karapetyan N.G. Endovascular diagnostics and treatment in the Russian Federation (2017). Russian Journal of Endovascular Surgery. 2018;5(2):93–240 (In Russ.). DOI: 10.24183/2409-4080-2018-5-2-93-240.

16. Alekyan B.G., Grigor’yan A.M., Staferov A.V. Endovascular diagnostics and treatment in the Russian Federation (2016). Мoscow: LA Graphics; 2016:220 (In Russ.).

17. Bonaa K.H., Mannsverk J., Wiseth R., Aaberge L., Myreng Y., Nygård O. et al. Drug-Eluting or bare-metal Stents for cronary artery disease. N. Engl. J. Med. 2016;375:1242–1252. DOI: 10.1056/NEJMoa 1607991.

18. Lagerqvist B., James S.K., Stenestrand U., Lindback J., Nilsson T., Wallentin L. Long-term outcomes with drug-eluting stents versus baremetal stents in Sweden. N. Engl. J. Med. 2007;356:1009–1019. DOI: 10.1056/NEJMoa067722.

19. Kaiser C., Galatius S., Jeger R., Gilgen N., Skov Jensen J., Naber C. et al. Long-term efficacy and safety of biodegradable-polymer biolimuseluting stents: main results of the Basel Stent Kosten – Effectivitats Trial PROspective Validation Examination II (Basket – Prove II), a randomized controlled non inferiority 2 – year outcome trial. Circulation. 2015;131:74–81. DOI: 10.1161/CIRCULATIONAHA.114.013520.

20. Hsieh M.J., Chen C.C., Chang S.H., Wang C.Y., Lee C.H., Lin F.C. et al. Long-term outcomes of drug-eluting stents versus bare-metal stents in large coronary arteries. Int. J. Cardiol. 2013;168(4):3785–3790. DOI: 10.1016/j.ijcard.2013.06.005.

21. Thielmann M., Leyh R., Massoudy P., Neuhäuser M., Aleksic I., Kamler M. et al. Prognostic significance of multiple previous percutaneous interventions in patients undergoing elective coronary artery bypass surgery. Circulation. 2006;114(1):I441–I447. DOI: 10.1161/CIRCULATIONAHA.105.001024.

22. Rao C., Stanbridge R.L., Chikwe J., Pepper J., Skapinakis P., Aziz O. et al. Does previous percutaneous coronary stenting compromise the long-term efficacy of subsequent coronary artery bypass surgery? A microsimulation study. Ann. Thorac. Surg. 2008;85(2):501–507. DOI: 10.1016/j.athoracsur.2007.09.036.

23. Chocron S.C., Baillot R., Rouleau J.L., Warnica W.J., Block P., Johnstone D. et al. Impact of previous percutaneous transluminal coronary angioplasty and/or stenting revascularization on outcomes after surgical revascularization: insights from the imagine study. Eur. Heart J. 2008;29(2):673–679. DOI: 10.1093/eurheartj/ehn026.

24. Weintraub W.S., Grau-Sepulveda M.V., Weiss J.M., O’Brien S.M., Peterson E.D., Kolm P. et al. Comparative effectiveness of revascularization strategies. N. Engl. J. Med. 2012;366:1467–1476. DOI: 10.1056/NEJMoa1110717.

25. Stone G.W., Sabik J.F., Serruys P.W., Simonton C.A., Genereux P., Puskas J. et al. Everolimus-eluting stents or bypass surgery for left main coronary artery disease. N. Engl. J. Med. 2016;375(23):2223–2235. DOI: 10.1056/NEJMoa1610227.

26. Emmert M.Y. CABG in the era of modern PCI. Eur. Heart J. 2017;38(26):2029–2032. DOI: 10.1093/eurheartj/ehx328.