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Cardiovascular Research Foundation: Transcatheter Cardiovascular Therapeutics (TCT)
VIDEO: Bioresorbable Absorb unexpectedly humbled by metallic DES
WASHINGTON – The bioabsorbable vascular scaffold bubble suddenly burst with the first 3-year follow-up data from a randomized trial that unexpectedly showed that the Absorb device significantly underperformed compared with Xience, a widely-used, second-generation metallic drug-eluting stent.
“As a pioneer of BVS [bioresorbable vascular scaffold] I’m disappointed,” Patrick W. Serruys, MD, said at the Transcatheter Cardiovascular Therapeutics annual meeting. “The performance of the comparator stent was spectacular.”
Xience surpassed Absorb in several other secondary endpoints. For example, the in-device binary restenosis rate was 7.0% with Absorb and 0.7% with Xience; the in-segment binary restenosis rate was 8% with Absorb and 3% with Xience. Target-vessel MIs occurred in 7% of the Absorb patients and 1% of the Xience patients, while clinically indicated target-lesion revascularization occurred in 6% of the Absorb patients and 1% of the Xience patients.
Another notable finding was that definite or probable in-device thrombosis occurred in nine Absorb patents and in none of the Xience patients, a statistically significant difference. Six of the Absorb thrombotic events occurred more than 1 year after the device was placed, and in several instances these thromboses occurred more than 900 days after placement, when the BVS had largely resorbed.
“These thromboses are occurring at the late stages of BVS degradation,” Dr. Serruys noted. “The Absorb polymer is basically gone after 3 years, but it’s replaced by a proteoglycan, and some proteoglycans are quite thrombogenic,” a possible explanation for the “mysterious” very late thromboses, he said.
These “disappointing” results my be linked to inadequate lesion preparation, appropriate sizing of the BVS for the lesion, and inconsistent postdilatation of the BVS, three steps that became the guiding mantra for BVS use starting a couple of years ago, said Giulio G. Stefanini, MD, an interventional cardiologist at Humanitas Research Hospital in Milan and a discussant for the report at the meeting, which was sponsored by the Cardiovascular Research Foundation.
Dr. Stefanini said that even though the Absorb stent became available for routine use in Europe starting in 2012, the device gained little traction since then in his own practice and throughout Italy. Currently it’s used for fewer than 5% of coronary interventions in Italy, he estimated. That’s largely because “we have failed to identify a population that benefits.” Other issues include the extra time needed to place a BVS, and the need for longer treatment with dual antiplatelet therapy for patients who receive a BVS, compared with when they receive a modern metallic drug-eluting stent. The Absorb BVS received Food and Drug Administration approval for routine U.S. use in July 2016.
“It would be beautiful to have a fully bioresorbable stent. It’s a lovely concept, but we’re not there yet,” Dr. Stefanini observed.
ABSORB II was sponsored by Abbott Vascular, which markets the Absorb device. Dr. Serruys has received research support from Abbott Vascular and has been a consultant to several other device and drug companies. Dr. Stefanini has been a consultant to Boston Scientific, B.Braun, and Edwards.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
mzoler@frontlinemedcom.com
On Twitter @mitchelzoler
We were all disappointed by the ABSORB II 3-year results. It was really surprising that even the vasomotion endpoint was, if anything, a little better with Xience, which performed amazingly well in this trial. Both arms of the study did well out to 3 years, but the Xience patients did better.
The Absorb bioresorbable vascular scaffold (BVS) is an early-stage device, and based on these results I wouldn’t give up on the BVS concept. But we need to be very careful with Absorb and which patients we implant with it. We need to make sure we carefully use thorough lesion preparation, correct sizing, and postdilatation in every patient, and we need to carefully select the right patients.
The main issue with the Absorb BVS in this trial was scaffold thrombosis, so we need to use a BVS only in patients with the lowest thrombosis risk, which means younger patients without renal failure, calcified vessels, and a larger-diameter target coronary artery. Younger patients have the most to gain from receiving a BVS. Younger patients who need a coronary intervention often collect several stents over the balance of their life, and it’s in these patients where you’d prefer that the stents eventually disappear.
Paul S. Teirstein, MD , is chief of cardiology and director of interventional cardiology at the Scripps Clinic in La Jolla, Calif. He has received research support from and has been a consultant to Abbott Vascular, Boston Scientific, and Medtronic. He made these comments in an interview .
We were all disappointed by the ABSORB II 3-year results. It was really surprising that even the vasomotion endpoint was, if anything, a little better with Xience, which performed amazingly well in this trial. Both arms of the study did well out to 3 years, but the Xience patients did better.
The Absorb bioresorbable vascular scaffold (BVS) is an early-stage device, and based on these results I wouldn’t give up on the BVS concept. But we need to be very careful with Absorb and which patients we implant with it. We need to make sure we carefully use thorough lesion preparation, correct sizing, and postdilatation in every patient, and we need to carefully select the right patients.
The main issue with the Absorb BVS in this trial was scaffold thrombosis, so we need to use a BVS only in patients with the lowest thrombosis risk, which means younger patients without renal failure, calcified vessels, and a larger-diameter target coronary artery. Younger patients have the most to gain from receiving a BVS. Younger patients who need a coronary intervention often collect several stents over the balance of their life, and it’s in these patients where you’d prefer that the stents eventually disappear.
Paul S. Teirstein, MD , is chief of cardiology and director of interventional cardiology at the Scripps Clinic in La Jolla, Calif. He has received research support from and has been a consultant to Abbott Vascular, Boston Scientific, and Medtronic. He made these comments in an interview .
We were all disappointed by the ABSORB II 3-year results. It was really surprising that even the vasomotion endpoint was, if anything, a little better with Xience, which performed amazingly well in this trial. Both arms of the study did well out to 3 years, but the Xience patients did better.
The Absorb bioresorbable vascular scaffold (BVS) is an early-stage device, and based on these results I wouldn’t give up on the BVS concept. But we need to be very careful with Absorb and which patients we implant with it. We need to make sure we carefully use thorough lesion preparation, correct sizing, and postdilatation in every patient, and we need to carefully select the right patients.
The main issue with the Absorb BVS in this trial was scaffold thrombosis, so we need to use a BVS only in patients with the lowest thrombosis risk, which means younger patients without renal failure, calcified vessels, and a larger-diameter target coronary artery. Younger patients have the most to gain from receiving a BVS. Younger patients who need a coronary intervention often collect several stents over the balance of their life, and it’s in these patients where you’d prefer that the stents eventually disappear.
Paul S. Teirstein, MD , is chief of cardiology and director of interventional cardiology at the Scripps Clinic in La Jolla, Calif. He has received research support from and has been a consultant to Abbott Vascular, Boston Scientific, and Medtronic. He made these comments in an interview .
WASHINGTON – The bioabsorbable vascular scaffold bubble suddenly burst with the first 3-year follow-up data from a randomized trial that unexpectedly showed that the Absorb device significantly underperformed compared with Xience, a widely-used, second-generation metallic drug-eluting stent.
“As a pioneer of BVS [bioresorbable vascular scaffold] I’m disappointed,” Patrick W. Serruys, MD, said at the Transcatheter Cardiovascular Therapeutics annual meeting. “The performance of the comparator stent was spectacular.”
Xience surpassed Absorb in several other secondary endpoints. For example, the in-device binary restenosis rate was 7.0% with Absorb and 0.7% with Xience; the in-segment binary restenosis rate was 8% with Absorb and 3% with Xience. Target-vessel MIs occurred in 7% of the Absorb patients and 1% of the Xience patients, while clinically indicated target-lesion revascularization occurred in 6% of the Absorb patients and 1% of the Xience patients.
Another notable finding was that definite or probable in-device thrombosis occurred in nine Absorb patents and in none of the Xience patients, a statistically significant difference. Six of the Absorb thrombotic events occurred more than 1 year after the device was placed, and in several instances these thromboses occurred more than 900 days after placement, when the BVS had largely resorbed.
“These thromboses are occurring at the late stages of BVS degradation,” Dr. Serruys noted. “The Absorb polymer is basically gone after 3 years, but it’s replaced by a proteoglycan, and some proteoglycans are quite thrombogenic,” a possible explanation for the “mysterious” very late thromboses, he said.
These “disappointing” results my be linked to inadequate lesion preparation, appropriate sizing of the BVS for the lesion, and inconsistent postdilatation of the BVS, three steps that became the guiding mantra for BVS use starting a couple of years ago, said Giulio G. Stefanini, MD, an interventional cardiologist at Humanitas Research Hospital in Milan and a discussant for the report at the meeting, which was sponsored by the Cardiovascular Research Foundation.
Dr. Stefanini said that even though the Absorb stent became available for routine use in Europe starting in 2012, the device gained little traction since then in his own practice and throughout Italy. Currently it’s used for fewer than 5% of coronary interventions in Italy, he estimated. That’s largely because “we have failed to identify a population that benefits.” Other issues include the extra time needed to place a BVS, and the need for longer treatment with dual antiplatelet therapy for patients who receive a BVS, compared with when they receive a modern metallic drug-eluting stent. The Absorb BVS received Food and Drug Administration approval for routine U.S. use in July 2016.
“It would be beautiful to have a fully bioresorbable stent. It’s a lovely concept, but we’re not there yet,” Dr. Stefanini observed.
ABSORB II was sponsored by Abbott Vascular, which markets the Absorb device. Dr. Serruys has received research support from Abbott Vascular and has been a consultant to several other device and drug companies. Dr. Stefanini has been a consultant to Boston Scientific, B.Braun, and Edwards.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
mzoler@frontlinemedcom.com
On Twitter @mitchelzoler
WASHINGTON – The bioabsorbable vascular scaffold bubble suddenly burst with the first 3-year follow-up data from a randomized trial that unexpectedly showed that the Absorb device significantly underperformed compared with Xience, a widely-used, second-generation metallic drug-eluting stent.
“As a pioneer of BVS [bioresorbable vascular scaffold] I’m disappointed,” Patrick W. Serruys, MD, said at the Transcatheter Cardiovascular Therapeutics annual meeting. “The performance of the comparator stent was spectacular.”
Xience surpassed Absorb in several other secondary endpoints. For example, the in-device binary restenosis rate was 7.0% with Absorb and 0.7% with Xience; the in-segment binary restenosis rate was 8% with Absorb and 3% with Xience. Target-vessel MIs occurred in 7% of the Absorb patients and 1% of the Xience patients, while clinically indicated target-lesion revascularization occurred in 6% of the Absorb patients and 1% of the Xience patients.
Another notable finding was that definite or probable in-device thrombosis occurred in nine Absorb patents and in none of the Xience patients, a statistically significant difference. Six of the Absorb thrombotic events occurred more than 1 year after the device was placed, and in several instances these thromboses occurred more than 900 days after placement, when the BVS had largely resorbed.
“These thromboses are occurring at the late stages of BVS degradation,” Dr. Serruys noted. “The Absorb polymer is basically gone after 3 years, but it’s replaced by a proteoglycan, and some proteoglycans are quite thrombogenic,” a possible explanation for the “mysterious” very late thromboses, he said.
These “disappointing” results my be linked to inadequate lesion preparation, appropriate sizing of the BVS for the lesion, and inconsistent postdilatation of the BVS, three steps that became the guiding mantra for BVS use starting a couple of years ago, said Giulio G. Stefanini, MD, an interventional cardiologist at Humanitas Research Hospital in Milan and a discussant for the report at the meeting, which was sponsored by the Cardiovascular Research Foundation.
Dr. Stefanini said that even though the Absorb stent became available for routine use in Europe starting in 2012, the device gained little traction since then in his own practice and throughout Italy. Currently it’s used for fewer than 5% of coronary interventions in Italy, he estimated. That’s largely because “we have failed to identify a population that benefits.” Other issues include the extra time needed to place a BVS, and the need for longer treatment with dual antiplatelet therapy for patients who receive a BVS, compared with when they receive a modern metallic drug-eluting stent. The Absorb BVS received Food and Drug Administration approval for routine U.S. use in July 2016.
“It would be beautiful to have a fully bioresorbable stent. It’s a lovely concept, but we’re not there yet,” Dr. Stefanini observed.
ABSORB II was sponsored by Abbott Vascular, which markets the Absorb device. Dr. Serruys has received research support from Abbott Vascular and has been a consultant to several other device and drug companies. Dr. Stefanini has been a consultant to Boston Scientific, B.Braun, and Edwards.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
mzoler@frontlinemedcom.com
On Twitter @mitchelzoler
Key clinical point:
Major finding: In-stent or in-scaffold late luminal loss averaged 0.25 mm with Xience and 0.37 mm with Absorb, a statistically significant difference.
Data source: ABSORB II, a multicenter, randomized trial that enrolled 501 patients.
Disclosures: ABSORB II was sponsored by Abbott Vascular, which markets the Absorb device. Dr. Serruys has received research support from Abbott Vascular and has been a consultant to several other device and drug companies. Dr. Stefanini has been a consultant to Boston Scientific, B.Braun and Edwards.
PCI noninferior to CABG for certain left main CAD
Percutaneous coronary intervention (PCI) using everolimus-eluting stents was found noninferior to coronary artery bypass grafting (CABG) with respect to the composite end point of death, stroke, or myocardial infarction at 3 years among patients with left main coronary artery disease and low or intermediate anatomical complexity, according to a report presented at the Transcatheter Cardiovascular Therapeutics annual meeting and published simultaneously in the New England Journal of Medicine.
The rate of this composite outcome was lower with PCI than with CABG during the first 30 days following the procedure, but higher between day 30 and year 3. In addition, the 3-year rate of revascularization was slightly higher with PCI (23.1% vs 19.1%), but the rate of periprocedural MI and major adverse events was lower (8.1% vs 23.0%).
Taken together, these results “suggest that PCI with everolimus-eluting stents is an acceptable or perhaps preferred alternative to CABG in selected patients with left main CAD who are candidates for either procedure,” said Gregg W. Stone, MD, of Columbia University Medical Center, New York, and his associates in the EXCEL (Evaluation of XIENCE versus CABG for Effectiveness of Left Main Revascularization) trial.
This study was funded by Abbott Vascular, maker of the everolimus-eluting stent (the XIENCE). The company also participated in the design of the trial and in the selection and management of the treatment sites.
Until now, it was generally agreed that most patients with left main CAD would have better outcomes with CABG than with PCI, based on the results of earlier trials comparing the two approaches. But contemporary drug-eluting stents have better safety and efficacy profiles than first-generation stents, and surgical techniques have also improved over time, so a study comparing the current standards of care was warranted, Dr. Stone and his associates said (New Engl J Med. 2016 Oct 31. doi:10.1056/NEJMoa1610227).
They assessed 1,905 patients at 126 medical centers in 17 countries in the open-label noninferiority trial. Participants had left main coronary artery stenosis of 70% or more (estimated visually) or of 50%-70% (estimated by invasive or noninvasive testing) if the stenosis was judged to be hemodynamically significant. The study participants also were required to have low or intermediate anatomical complexity of the involved portion of the coronary artery, as defined by a SYNTAX score of 32 or lower. A total of 948 patients were randomly assigned to PCI and 957 to CABG.
The primary composite end point – the rate of death, stroke, or MI assessed at a median of 3 years of follow-up – was 15.4% with PCI and 14.7% with CABG, a nonsignificant difference (Hazard Ratio, 1.00) that demonstrates the noninferiority of PCI. This rate was consistently noninferior across all subgroups of patients, regardless of age, sex, and the presence or absence of diabetes or chronic kidney disease.
At 30 days, the rate of the composite end point was 4.9% with PCI and 7.9% with CABG, which also demonstrates the noninferiority of PCI. At 3 years, secondary end points including the rate of ischemia-driven revascularization also showed the noninferiority of PCI, as did each of the individual components of the primary composite end point.
The rate of death, stroke, or MI was lower at 30 days with PCI than with CABG, mainly because there were fewer MIs with PCI. But a post-hoc analysis showed that this rate was higher with PCI than with CABG after 30 days.
During follow-up, ischemia-driven revascularization was more common after PCI (12.6%) than after CABG (7.5%). However, symptomatic graft occlusion after CABG (5.4%) was more frequent than definite stent thrombosis after PCI (0.7%).
Periprocedural major adverse events developed in 8.1% of the PCI group and 23.0% of the CABG group, and the difference was attributed mainly to fewer arrhythmias, infections, and blood transfusions in the PCI group. Cardiovascular mortality was similar between the two study groups, though all-cause mortality was higher with PCI due to an excess of fatal infections and malignancies in that group.
The investigators noted several limitations with the EXCEL trial. First, treatment blinding wasn’t possible, so some degree of bias may have resulted.
Second, prerandomization SYNTAX scores estimating the anatomical complexity of the affected vessels weren’t always accurate, and 24% of the patients in this study proved to have complex lesions when their procedures were undertaken. However, the rate of the primary composite end point was the same in this subgroup of patients as in the overall patient population.
Third, long-term medications after PCI differ from those after CABG, and the investigators said further study is needed to determine how these differences may have contributed to patient outcomes. And finally, longer follow-up is needed to assess whether more differences between the two study groups emerge over time. Five-year follow-up of this study population is now under way.
Dr. Stone and his associates reported ties to numerous industry sources.
The well-designed and rigorously conducted EXCEL trial’s take-home message is that most patients with left main CAD can now be managed equally well using either PCI or CABG, provided that their treatment team is as experienced as those participating in the study.
PCI may be favored in some patients because of its greater periprocedural safety, shorter hospital stay, and more rapid recovery. However, the composite rate of death, stroke, or MI after 30 days was higher with PCI (11.5% vs 7.9%). It is reassuring that these study participants will be followed for another 2 years so that longer-term events can be assessed.
Eugene Braunwald, MD, is in the Thrombolysis in Myocardial Infarction Study Group, in the cardiovascular division at Brigham and Women’s Hospital, and in the department of medicine at Harvard Medical School. He reported having no relevant financial disclosures. Dr. Braunwald made these remarks in an editorial accompanying Dr. Stone’s report (New Engl J Med. 2016 Oct 31. doi:10.1056/NEJMe1612570).
The well-designed and rigorously conducted EXCEL trial’s take-home message is that most patients with left main CAD can now be managed equally well using either PCI or CABG, provided that their treatment team is as experienced as those participating in the study.
PCI may be favored in some patients because of its greater periprocedural safety, shorter hospital stay, and more rapid recovery. However, the composite rate of death, stroke, or MI after 30 days was higher with PCI (11.5% vs 7.9%). It is reassuring that these study participants will be followed for another 2 years so that longer-term events can be assessed.
Eugene Braunwald, MD, is in the Thrombolysis in Myocardial Infarction Study Group, in the cardiovascular division at Brigham and Women’s Hospital, and in the department of medicine at Harvard Medical School. He reported having no relevant financial disclosures. Dr. Braunwald made these remarks in an editorial accompanying Dr. Stone’s report (New Engl J Med. 2016 Oct 31. doi:10.1056/NEJMe1612570).
The well-designed and rigorously conducted EXCEL trial’s take-home message is that most patients with left main CAD can now be managed equally well using either PCI or CABG, provided that their treatment team is as experienced as those participating in the study.
PCI may be favored in some patients because of its greater periprocedural safety, shorter hospital stay, and more rapid recovery. However, the composite rate of death, stroke, or MI after 30 days was higher with PCI (11.5% vs 7.9%). It is reassuring that these study participants will be followed for another 2 years so that longer-term events can be assessed.
Eugene Braunwald, MD, is in the Thrombolysis in Myocardial Infarction Study Group, in the cardiovascular division at Brigham and Women’s Hospital, and in the department of medicine at Harvard Medical School. He reported having no relevant financial disclosures. Dr. Braunwald made these remarks in an editorial accompanying Dr. Stone’s report (New Engl J Med. 2016 Oct 31. doi:10.1056/NEJMe1612570).
Percutaneous coronary intervention (PCI) using everolimus-eluting stents was found noninferior to coronary artery bypass grafting (CABG) with respect to the composite end point of death, stroke, or myocardial infarction at 3 years among patients with left main coronary artery disease and low or intermediate anatomical complexity, according to a report presented at the Transcatheter Cardiovascular Therapeutics annual meeting and published simultaneously in the New England Journal of Medicine.
The rate of this composite outcome was lower with PCI than with CABG during the first 30 days following the procedure, but higher between day 30 and year 3. In addition, the 3-year rate of revascularization was slightly higher with PCI (23.1% vs 19.1%), but the rate of periprocedural MI and major adverse events was lower (8.1% vs 23.0%).
Taken together, these results “suggest that PCI with everolimus-eluting stents is an acceptable or perhaps preferred alternative to CABG in selected patients with left main CAD who are candidates for either procedure,” said Gregg W. Stone, MD, of Columbia University Medical Center, New York, and his associates in the EXCEL (Evaluation of XIENCE versus CABG for Effectiveness of Left Main Revascularization) trial.
This study was funded by Abbott Vascular, maker of the everolimus-eluting stent (the XIENCE). The company also participated in the design of the trial and in the selection and management of the treatment sites.
Until now, it was generally agreed that most patients with left main CAD would have better outcomes with CABG than with PCI, based on the results of earlier trials comparing the two approaches. But contemporary drug-eluting stents have better safety and efficacy profiles than first-generation stents, and surgical techniques have also improved over time, so a study comparing the current standards of care was warranted, Dr. Stone and his associates said (New Engl J Med. 2016 Oct 31. doi:10.1056/NEJMoa1610227).
They assessed 1,905 patients at 126 medical centers in 17 countries in the open-label noninferiority trial. Participants had left main coronary artery stenosis of 70% or more (estimated visually) or of 50%-70% (estimated by invasive or noninvasive testing) if the stenosis was judged to be hemodynamically significant. The study participants also were required to have low or intermediate anatomical complexity of the involved portion of the coronary artery, as defined by a SYNTAX score of 32 or lower. A total of 948 patients were randomly assigned to PCI and 957 to CABG.
The primary composite end point – the rate of death, stroke, or MI assessed at a median of 3 years of follow-up – was 15.4% with PCI and 14.7% with CABG, a nonsignificant difference (Hazard Ratio, 1.00) that demonstrates the noninferiority of PCI. This rate was consistently noninferior across all subgroups of patients, regardless of age, sex, and the presence or absence of diabetes or chronic kidney disease.
At 30 days, the rate of the composite end point was 4.9% with PCI and 7.9% with CABG, which also demonstrates the noninferiority of PCI. At 3 years, secondary end points including the rate of ischemia-driven revascularization also showed the noninferiority of PCI, as did each of the individual components of the primary composite end point.
The rate of death, stroke, or MI was lower at 30 days with PCI than with CABG, mainly because there were fewer MIs with PCI. But a post-hoc analysis showed that this rate was higher with PCI than with CABG after 30 days.
During follow-up, ischemia-driven revascularization was more common after PCI (12.6%) than after CABG (7.5%). However, symptomatic graft occlusion after CABG (5.4%) was more frequent than definite stent thrombosis after PCI (0.7%).
Periprocedural major adverse events developed in 8.1% of the PCI group and 23.0% of the CABG group, and the difference was attributed mainly to fewer arrhythmias, infections, and blood transfusions in the PCI group. Cardiovascular mortality was similar between the two study groups, though all-cause mortality was higher with PCI due to an excess of fatal infections and malignancies in that group.
The investigators noted several limitations with the EXCEL trial. First, treatment blinding wasn’t possible, so some degree of bias may have resulted.
Second, prerandomization SYNTAX scores estimating the anatomical complexity of the affected vessels weren’t always accurate, and 24% of the patients in this study proved to have complex lesions when their procedures were undertaken. However, the rate of the primary composite end point was the same in this subgroup of patients as in the overall patient population.
Third, long-term medications after PCI differ from those after CABG, and the investigators said further study is needed to determine how these differences may have contributed to patient outcomes. And finally, longer follow-up is needed to assess whether more differences between the two study groups emerge over time. Five-year follow-up of this study population is now under way.
Dr. Stone and his associates reported ties to numerous industry sources.
Percutaneous coronary intervention (PCI) using everolimus-eluting stents was found noninferior to coronary artery bypass grafting (CABG) with respect to the composite end point of death, stroke, or myocardial infarction at 3 years among patients with left main coronary artery disease and low or intermediate anatomical complexity, according to a report presented at the Transcatheter Cardiovascular Therapeutics annual meeting and published simultaneously in the New England Journal of Medicine.
The rate of this composite outcome was lower with PCI than with CABG during the first 30 days following the procedure, but higher between day 30 and year 3. In addition, the 3-year rate of revascularization was slightly higher with PCI (23.1% vs 19.1%), but the rate of periprocedural MI and major adverse events was lower (8.1% vs 23.0%).
Taken together, these results “suggest that PCI with everolimus-eluting stents is an acceptable or perhaps preferred alternative to CABG in selected patients with left main CAD who are candidates for either procedure,” said Gregg W. Stone, MD, of Columbia University Medical Center, New York, and his associates in the EXCEL (Evaluation of XIENCE versus CABG for Effectiveness of Left Main Revascularization) trial.
This study was funded by Abbott Vascular, maker of the everolimus-eluting stent (the XIENCE). The company also participated in the design of the trial and in the selection and management of the treatment sites.
Until now, it was generally agreed that most patients with left main CAD would have better outcomes with CABG than with PCI, based on the results of earlier trials comparing the two approaches. But contemporary drug-eluting stents have better safety and efficacy profiles than first-generation stents, and surgical techniques have also improved over time, so a study comparing the current standards of care was warranted, Dr. Stone and his associates said (New Engl J Med. 2016 Oct 31. doi:10.1056/NEJMoa1610227).
They assessed 1,905 patients at 126 medical centers in 17 countries in the open-label noninferiority trial. Participants had left main coronary artery stenosis of 70% or more (estimated visually) or of 50%-70% (estimated by invasive or noninvasive testing) if the stenosis was judged to be hemodynamically significant. The study participants also were required to have low or intermediate anatomical complexity of the involved portion of the coronary artery, as defined by a SYNTAX score of 32 or lower. A total of 948 patients were randomly assigned to PCI and 957 to CABG.
The primary composite end point – the rate of death, stroke, or MI assessed at a median of 3 years of follow-up – was 15.4% with PCI and 14.7% with CABG, a nonsignificant difference (Hazard Ratio, 1.00) that demonstrates the noninferiority of PCI. This rate was consistently noninferior across all subgroups of patients, regardless of age, sex, and the presence or absence of diabetes or chronic kidney disease.
At 30 days, the rate of the composite end point was 4.9% with PCI and 7.9% with CABG, which also demonstrates the noninferiority of PCI. At 3 years, secondary end points including the rate of ischemia-driven revascularization also showed the noninferiority of PCI, as did each of the individual components of the primary composite end point.
The rate of death, stroke, or MI was lower at 30 days with PCI than with CABG, mainly because there were fewer MIs with PCI. But a post-hoc analysis showed that this rate was higher with PCI than with CABG after 30 days.
During follow-up, ischemia-driven revascularization was more common after PCI (12.6%) than after CABG (7.5%). However, symptomatic graft occlusion after CABG (5.4%) was more frequent than definite stent thrombosis after PCI (0.7%).
Periprocedural major adverse events developed in 8.1% of the PCI group and 23.0% of the CABG group, and the difference was attributed mainly to fewer arrhythmias, infections, and blood transfusions in the PCI group. Cardiovascular mortality was similar between the two study groups, though all-cause mortality was higher with PCI due to an excess of fatal infections and malignancies in that group.
The investigators noted several limitations with the EXCEL trial. First, treatment blinding wasn’t possible, so some degree of bias may have resulted.
Second, prerandomization SYNTAX scores estimating the anatomical complexity of the affected vessels weren’t always accurate, and 24% of the patients in this study proved to have complex lesions when their procedures were undertaken. However, the rate of the primary composite end point was the same in this subgroup of patients as in the overall patient population.
Third, long-term medications after PCI differ from those after CABG, and the investigators said further study is needed to determine how these differences may have contributed to patient outcomes. And finally, longer follow-up is needed to assess whether more differences between the two study groups emerge over time. Five-year follow-up of this study population is now under way.
Dr. Stone and his associates reported ties to numerous industry sources.
Key clinical point: PCI was found noninferior to CABG regarding the composite end point of death, stroke, or myocardial infarction in certain patients with left main CAD.
Major finding: The primary composite end point – the rate of death, stroke, or MI assessed at a median of 3 years of follow-up – was 15.4% with PCI and 14.7% with CABG, a nonsignificant difference (HR, 1.00) that demonstrates the noninferiority of PCI.
Data source: An international open-label randomized trial involving 1,905 patients followed for 3 years.
Disclosures: The EXCEL trial was funded by Abbott Vascular, maker of the everolimus-eluting stent used in this study. The company participated in the design of the trial and in selection and management of the treatment sites, but was not involved in managing or analyzing the data or writing the manuscript. Dr. Stone and his associates reported ties to numerous industry sources.