A study shows that the risks of major complications are comparable after coronary stenting and bypass surgery over several years.
The Stanford-led multinational research found that mortality and stroke rates were similar between the two interventions, with only a marginally increased risk of myocardial infarction after stenting.
Historically, comparative studies favoured bypass surgery for better long-term outcomes.
The authors attribute these updated findings to advancements in interventional cardiology and surgical techniques, with the integration of contemporary data into clinical decision-making vital.
The trial results provide valuable insights for cardiothoracic surgeons and interventionalists in evaluating the most effective revascularisation strategies.
William Fearon, principal investigator, said: ‘Overall, the difference in outcomes has narrowed dramatically between stenting and bypass surgery. This is the first study to consider contemporary approaches when comparing the two procedures, and it gives us a big, much-needed update.’
The trial involved 48 centres, enrolling hundreds of patients with multivessel disease, tracked over five years.
Procedurally, bypass involves creating a new conduit by grafting a vessel, such as the saphenous vein or internal mammary artery, to bypass obstructed arteries – a major operation requiring median sternotomy.
Conversely, stenting entails percutaneous insertion of expandable metal scaffolds into coronary arteries via femoral or radial access, often performed as outpatient procedures.
While previous data suggested that bypass had superior durability, findings now demonstrate similar long-term safety and efficacy.
In the study, 1,500 patients with three-vessel disease were randomised to surgery or stenting. Following up on the initial results, the combined significant complication rate was equivalent, with stenting showing a modestly increased rate of repeat procedures (15.6% vs. 7.8%).
Technological advances in stent design, featuring improved flexibility, anti-inflammatory properties, and drug-eluting capabilities, likely underpin these improved outcomes.
The adoption of physiological guidance using fractional flow reserve (FFR) measurement has refined patient selection, reducing unnecessary stenting and complication rates.
The study demonstrated that FFR-guided interventions led to fewer unnecessary procedures compared to angiography alone, embodying the principles of precision medicine.
Despite this progress, surgeon assessment remains critical, especially in patients with complex or multiple lesions or comorbidities such as diabetes, where bypass might continue to be advantageous.
The results provide critical data to tailor interventions to each patient’s specific clinical context.
The study is published in The Lancet.
