PCI with Everolimus Eluting Stents vs CABG for Left Main Coronary Artery Disease: The EXCEL Trial
- Coronary-artery bypass is a standard treatment of choice for left main coronary artery disease patients, but some trials suggest PCI with stenting could be a good alternative therapeutic option.
- The EXCEL randomized trial found that complete revascularization via PCI with everolimus-eluting stents is noninferior to CABG for left-main CAD with respect to the study’s primary and secondary endpoints.
Patients with left main coronary artery disease (CAD) are at a significantly high risk for cardiovascular events due to vessel occlusion that compromises flow in up to three-fourths of the left ventricle. Bypass surgery had been the standard treatment of choice for left main CAD in the past, yet innovations and advancements in cardiology has led to the use of more refined and less invasive therapies.
Randomized trials have suggested that patients with low or intermediate anatomic complexity can achieve revascularization via percutaneous coronary intervention (PCI) with stunting.1 Patients presenting with more intricate CAD, however, may require coronary-artery bypass grafting (CABG).
A study published in The New England Journal of Medicine compared the effect of PCI with everolimus-eluting stents and CABG in 1905 patients with obstructive left main CAD.2 Primary endpoint was all-cause mortality, myocardial infarction, or stroke at 3 years (Figure 1).
Secondary endpoints were the same as primary, except these endpoints were measured at 30 days and included ischemia-driven revascularization at 3 years. Those patients included in this analysis had at least 50-70% or more stenosis of the left main coronary artery.
Patients were randomized into either PCI (n=948) or CABG (n=957). An average of 2.4 stents were used in the PCI group per patient, and about 2.6 grafts were used in the patients receiving CABG.
After three years’ follow-up, the primary composite endpoint was roughly the same in each group: 15.4% in PCI and 14.7% in CABG. There was a difference between the two groups in respect to the 30-day endpoints, with 4.9% of the PCI group and 7.9% of the CABG experiencing death, stroke, or myocardial infarction.
Additionally, ischemia-driven revascularization was more common after PCI at follow-up than CABG; however, bleeding was more of an issue with those undergoing CABG. Despite these observed differences, it’s important to note that PCI with stenting can still be a viable, noninferior alternative to CABG in left main CAD patients.
- Morice MC, Serruys PW, Kappetein AP, et al. Five-year outcomes in patients with left main disease treated with either percutaneous coronary intervention or coronary artery bypass grafting in the synergy between percutaneous coronary intervention with taxus and cardiac surgery trial. Circulation. 2014;129(23):2388-2394.
- Stone GW, Sabik JF, Serruys PW, et al. Everolimus-Eluting Stents or Bypass Surgery for Left Main Coronary Artery Disease. The New England Journal of Medicine. 2016.