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(Circulation. 2004;109:1114-1120.)
© 2004 American Heart Association, Inc.

Clinical Investigation and Reports

Three-Year Outcome After Coronary Stenting Versus Bypass Surgery for the Treatment of Multivessel Disease

Victor M.G. Legrand, MD, PhD; Patrick W. Serruys, MD, PhD; Felix Unger, MD, PhD; Ben A. van Hout, PhD; Mathias C.M. Vrolix, MD; Geert M.P. Fransen, MD; Torsten Toftegaard Nielsen, MD, DMSc; Peter Kildeberg Paulsen, MD, DMSc; Ricardo Seabra Gomes, MD; João M.G. de Queiroz e Melo, MD; José P. Marques dos Santos Neves, MD; Wietze Lindeboom, MSc; Bianca Backx, PhD, on behalf of the Arterial Revascularization Therapy Study (ARTS) Investigators

From CHU Sart-Tilman, Liège, Belgium (V.M.G.L.); University Medical Center Erasmus (P.W.S.) and Cardialysis (W.L., B.B.), Rotterdam, the Netherlands; Klinik für Herzchirurgie, Landeskliniken, Salzburg, Austria (F.U.); University Medical Center Utrecht, Utrecht, the Netherlands (B.A.v.H.); Ziekenhuis Oost Limburg, Genk, Belgium (M.C.M.V., G.M.P.F.); Skejby Sygehus, Aarhus, Denmark (T.T.N., P.K.P.); and Hospital de la Santa Cruz, Linda A. Velha, Portugal (R.S.G., J.M.G.Q.M., J.P.M.S.N.).

Correspondence to Professor P.W. Serruys, MD, PhD, Interventional Cardiology Department, Heartcenter/University Medical Center Rotterdam Erasmus, Thoraxcenter, Bd-408, Dr Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands. E-mail p.w.j.c.serruys{at}erasmusmc.nl

Received February 4, 2003; de novo received October 7, 2003; revision received December 1, 2003; accepted December 2, 2003.

Background— The primary results of Arterial Revascularization Therapy Study reported a greater need for repeated revascularization after percutaneous coronary intervention with stenting (PCI). However, PCI was less expensive than coronary artery bypass grafting (CABG) and offered the same degree of protection against death, stroke, and myocardial infarction.

Methods and Results— Patients with multivessel disease (n=1205) were randomly assigned to either CABG or PCI and followed up for up to 3 years. Survival rates without stroke or myocardial infarction were similar in each group at 1 year and 3 years (90.5% versus 91.4% for PCI versus CABG at 1 year and 87.2% versus 88.4% for PCI versus CABG at 3 years). However, the respective repeat revascularization rates were 21.2% and 26.7% at 1 and 3 years in patients allocated to PCI, compared with 3.8% and 6.6% in patients allocated to CABG (P<0.0001). Diabetes (P<0.0009) and maximal pressure for stent deployment (P<0.002) are the strongest independent predictors of events at 3 years after PCI, whereas left anterior descending coronary artery grafting (P<0.006) is the best predictor of event-free survival at 3 years after CABG. The incremental cost of surgery compared with PCI for an event-free patient was 19 257 at 1 year but decreased to 10 492 at 3 years. It remained at 142 391 at 3 years when revascularization procedures were excluded in the efficacy end point, however.

Conclusions— Three-year survival rates without stroke and myocardial infarction are identical in both groups, and the cost/benefit ratio of stenting is determined primarily by the increasing need for revascularization in the PCI group.

Key Words: coronary disease • revascularization • surgery • stents • cost-benefit analysis

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