A multi-centre randomised controlled trial of minimally invasive direct coronary bypass grafting versus percutaneous transluminal coronary angioplasty with stenting for proximal stenosis of the left anterior descending coronary artery

Reeves B C, Angelini G D, Bryan A J, Taylor F C, Cripps T, Spyt T J, Samani NJ, Roberts JA, Jacklin P, Seehra HK, Culliford LA, Keenan DJM, Rowlands DJ, Clarke B, Stanbridge R, Foale R
Record ID 32004000197
English
Authors' objectives:

To compare the (a) clinical and (b) cost-effectiveness of minimally invasive direct coronary artery bypass grafting (MIDCAB) and percutaneous transluminal coronary angioplasty (PTCA) with or without stenting in patients with single-vessel disease of the left anterior descending coronary artery (LAD).

Authors' results and conclusions: Participants were recruited from November 1999 to December 2001; 1091 of 12,828 consecutive patients undergoing a diagnostic angiogram or elective PTCA had proximal stenosis of the LAD. Of the 1091, 127 were eligible and consented to take part; 100 were randomised and the remaining 27 consented to follow-up. All randomised participants were included in an intention-to-treat analysis of survival free from cardiac-related events, which found a non-significant benefit from MIDCAB (hazard ratio = 0.77, 95% confidence interval 0.38 to 1.57, p = 0.47). Cumulative rates of cardiac-related events at 12 months were estimated to be 7.1 and 9.2% for MIDCAB and PTCA, respectively. There were no important differences between MIDCAB and PTCA with respect to angina symptoms or disease-specific or generic quality of life.
Authors' recommendations: We found no evidence that MIDCAB was more effective than PTCA. However, the trial did not have sufficient power and we cannot rule out this possibility. The procedure costs of MIDCAB were considerably higher than those of PTCA. Given the small and non-significant differences in effectiveness between MIDCAB and PTCA and the considerably higher costs of MIDCAB, it is unlikely that MIDCAB represents a cost-effective use of resources in the reference population. Recent advances in cardiac surgery mean that surgeons now tend to carry out off-pump bypass grafting via a sternotomy instead of MIDCAB. At the same time, cardiologists are treating more patients with multi-vessel disease by PTCA. Future primary research should focus on this comparison. Other small trials of PTCA versus MIDCAB have now finished and a more conclusive answer to the original objective could be provided by a systematic review.
Authors' methods: Randomised controlled trial
Details
Project Status: Completed
URL for project: http://www.hta.ac.uk/1103
Year Published: 2004
English language abstract: An English language summary is available
Publication Type: Not Assigned
Country: England, United Kingdom
MeSH Terms
  • Coronary Artery Bypass
  • Costs and Cost Analysis
  • Stents
  • Coronary Disease
Contact
Organisation Name: NIHR Health Technology Assessment programme
Contact Address: NIHR Journals Library, National Institute for Health and Care Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK
Contact Name: journals.library@nihr.ac.uk
Contact Email: journals.library@nihr.ac.uk
Copyright: 2009 Queen's Printer and Controller of HMSO
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