Single‐digit target vessel revascularization in multivessel coronary interventions with sirolimus‐eluting stents: Goodbye to coronary bypass grafting

The Rotterdam group reports in this issue the 1-year (360 59 days) follow-up of 99 consecutive patients treated with sirolimus-eluting stents (Cypher, Cordis Europa, Roden, Belgium). All patients received a stent on a lesion located on the left anterior descending coronary in addition to stents implanted on the right coronary artery and/or on the circumflex. Important features of these patients are 25% had treated diabetes, 31% had prior myocardial infarction, and 19% had a prior coronary intervention. On the average, 3.5 stents were implanted on each patient for a 62.6 mm of total stent length; one patient out of five received more than five stents. The authors give us important data about safety and effectiveness. At 30 days, the overall incidence of adverse events was 3% (one death, one myocardial infarction, and one percutaneous revascularization); there were no events of stent thrombosis. At clinical follow-up obtained in all except for two patients, the only adverse events were the need for new percutaneous coronary interventions, which became necessary in eight patients. Remarkable is the fact that half of these new revascularizations became necessary due to restenosis while the other four were performed for disease progression. At 1 year there was an event-free survival of 85.6%. Few considerations are necessary. As pointed out by the authors, only 16% of the patients were treated on the three major coronary arteries. This feature makes this population slightly different from a traditional surgical group undergoing revascularization. The average number of grafts in the surgical cohorts of the Arterial Revascularization Therapy Study (ARTS) [1] was 2.5 and in the Surgery or Stenting (SOS) study [2] was 2.8. Patients treated on multiple vessels are exposed on a much higher risk of restenosis due to the possible additive risk for each lesion in the specific patient. The lack of mandated angiographic follow-up is not necessarily a limitation because it brings these findings close to the real world where clinical symptoms trigger new invasive evaluations. We well know that any routine angiographic follow-up is responsible for the need of new revascularization procedures [3,4]. On the other hand, the lack of a routine noninvasive evaluation performed at follow-up may give an excessive optimistic picture. Various trials have demonstrated that the mortality associated with percutaneous coronary intervention (PCI) for patients with multivessel disease is comparable to that of coronary artery bypass grafting (CABG) [1,2,5]. The safety of PCI in such patients is well established and the need for emergency CABG has almost been abolished. In this study, only one patient required emergency CABG. In the ARTS trial [1], 1,205 patients with multivessel disease were randomized to either PCI or CABG. There was no significant difference in mortality between the two groups (2.8% for CABG and 2.5% for PCI; P NS). Similarly in the ERACI II trial [6], which compared PCI and CABG in 450 patients with multivessel disease, freedom from death or myocardial infarction was similar in the two groups. In this study, total major adverse clinical events at 9 months (acute myocardial infarction, death, and target vessel revascularization) occurred in 10% of all patients, with death occurring in one patient. These rates are lower than those reported in the ARTS trial at 1 year mainly due to a lower rate of target vessel revascularization (8% at 6 months vs. 21%). It is interesting to note that the need for a new revascularization approaches the single digits reported in the surgical arms of the ARTS and SOS studies (3.8% and 6%, respectively). It is interesting to compare recent studies utilizing the sirolimus-eluting stents. In the Sirolimus-Eluting Stents Versus Standard Stents in Patients With Stenosis in a Native Coronary Artery (SIRIUS) study [7], in which there was mandated angiographic follow-up, the need for target lesion revascularization was 4.1%; the same number in the European Sirolimus-Eluting Stent in Coronary Lesions (E-SIRIUS) study [8] was 4%. The fact that in