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Minimally Invasive Surgery vs. Stenting of the LAD Artery

This study extends the results of previous surgery-versus-stent comparisons to minimally invasive surgery.

In this single-center German study, 220 patients with isolated high-grade lesions in the proximal left anterior descending (LAD) artery were randomized either to elective intracoronary stenting or to elective, minimally invasive cardiac surgery. Surgery involved a limited left thoracotomy with distal anastomosis performed on the beating heart and aided by mechanical stabilizers. All patients had normal left-ventricular function.

All stent procedures were successful (mean number of stents, 1.2; mean stent length, 15.1 mm). By 6 months, 2 patients experienced subacute stent thrombosis and 2 suffered strokes. Surgery was successful in 95% of patients; conversion to full sternotomy was required in 5%. Reoperation was required in 3 patients due to anastomotic stenosis or occlusion, causing MIs in 2. In 2 patients, anastomosis was performed erroneously on the diagonal artery; 1 of these patients consequently required a stent.

By 6 months, there were 3 additional MIs, 1 stroke, 2 chest-wall hernia repairs, and 2 early deaths in the surgery group. However, surgery patients were significantly less likely than stent patients to experience angina (21% vs. 38%), to require antianginal medications (6% vs. 19%), and to require repeat target-vessel revascularization (8% vs. 29%).

Comment: These findings extend the results of previous surgery-versus-stent comparisons to minimally invasive surgery. By 6 months, surgery provided better relief of angina with fewer repeat revascularizations. However, surgery was associated with more early complications and longer recoveries. The choice between surgery and stenting requires consideration of many factors (e.g., lesion type and location, patient comorbidities, patient preferences) and likely will be affected greatly in the near future by the availability of drug-eluting stents.

— Howard C. Herrmann, MD

Published in Journal Watch Cardiology October 4, 2002

Citation(s):

Diegeler A et al. Comparison of stenting with minimally invasive bypass surgery for stenosis of the left anterior descending coronary artery. N Engl J Med 2002 Aug 22; 347:561-6.

• Medline abstract (Free)

MacGillivray TE and Vlahakes GJ. Angioplasty versus minimally invasive bypass surgery. N Engl J Med 2002 Aug 22; 347:551-2.

• Medline abstract (Free)

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