Coronary stent technology: a narrative review

In their article, Chen and Jepson1 discussed the advances in coronary artery stent technology. However, the review did not outline the indications for the newer and more expensive technologies mentioned, and did not indicate how stenting compares with the established practice of coronary artery bypass grafting (CABG) for patients with coronary artery disease. How does percutaneous coronary intervention (PCI) compare with CABG based on current evidence?

The SYNTAX2 trial is a multinational trial investigating PCI versus CABG. At 5 years, the number of major adverse cardiovascular and cerebrovascular events in the CABG group was 26.9% compared with 37.3% in the PCI group. The 5-year myocardial infarction rate was 3.8% in the CABG group compared with 9.7% for PCI. Moreover, registry data showed that the cardiac death rate was 3.6% for CABG compared with 9.5% for PCI. Therefore, the group concluded that CABG should remain the standard of care for patients with multivessel coronary artery disease.2

A 2014 meta-analysis in JAMA3 comparing PCI with CABG indicated a reduction in mortality (relative risk [RR], 0.73; 95% confidence interval [CI], 0.62–0.86), myocardial infarction (RR, 0.58; 95% CI, 0.48–0.72) and revascularisation (RR, 0.29; 95% CI, 0.21–0.41), with CABG compared with PCI at a follow-up of 4.1 years. The subgroup analysis showed benefits in patients with and without diabetes.

The BEST trial4 compares second generation everolimus-eluting stents with CABG. This trial enrolled 880 patients with more than 70% stenosis of two or more coronary arteries, and followed them up to 4.6 years. At 2 years, the primary endpoint of death, myocardial infarction or revascularisation occurred in 11% of patients in the PCI group and in only 7.9% of patients in the CABG group. During long term follow-up, it occurred in 15.3% of patients in the PCI group compared with 10.6% of patients in the CABG group.4

When reviewing the available evidence in the literature, several articles support CABG over PCI.5 The benefits of CABG persist, despite the development of second generation drug-eluting stents. CABG provides superior long term results in patients with multivessel coronary disease in regard to mortality, myocardial infarction and need for revascularisation. Therefore, CABG remains the gold standard of treatment for these patients.