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Drug-eluting stents or coronary artery bypass grafting for unprotected left main coronary artery disease: a meta-analysis of four randomized trials and seventeen observational studies

Abstract

Background

The clinical application of drug-eluting stents (DES) or coronary artery bypass grafting (CABG) for unprotected left main coronary artery disease (ULMCAD) is still controversial. The purpose of this meta-analysis was to compare the safety and efficacy between DES and CABG for ULMCAD.

Methods

Databases of MEDLINE, EMBASE and the Cochrane Library were systematically searched.

Results

Twenty-one studies with 8,413 patients were included in this meta-analysis. The risk was lower in DES than in CABG groups at the early outcomes of death (risk ratio (RR): 0.49, 95% confidence interval (CI): 0.30–0.78), cerebrovascular events (RR: 0.19, 95% CI: 0.08–0.45) and composite endpoint (RR: 0.53, 95% CI: 0.40–0.70); death after 2 years (RR: 0.81, 95% CI: 0.66–0.99), 4 years (RR: 0.69, 95% CI: 0.53–0.90), 5 years (OR: 0.76, 95% CI: 0.61–0.95) and their total effect (RR: 0.79, 95% CI: 0.71–0.87); composite endpoint 1 year (RR: 0.69, 95% CI: 0.58–0.83), 4 years (RR: 0.69, 95% CI: 0.53–0.88), 5 years (RR: 0.74, 95% CI: 0.59–0.92) and their total effect (RR: 0.78, 95% CI: 0.71–0.85). There were no significant differences in the risk for the early outcomes of myocardial infarction (RR: 0.97, 95% CI: 0.68–1.38), death 1 year (OR: 0.81, 95% CI: 0.57–1.15) and 3 years (OR: 0.85, 95% CI: 0.69–1.04), composite endpoint of 2 years (RR: 0.88, 95% CI: 0.72–1.09) and 3 years (RR: 0.87, 95% CI: 0.73–1.04). Nonetheless, there was a lower risk for revascularization associated with CABG from 1 to 5 years and their total effect (RR: 3.77, 95% CI: 3.35–4.26). There was no difference in death, myocardial infarction, cerebrovascular events or revascularization at 1 year between RCT and observational groups.

Conclusions

Our meta-analysis indicates that DES has higher safety but higher revascularization than CABG in patients with ULMCAD in the 5 years after intervention.

Peer Review reports

Background

As is well known, approximately 4 to 9% of patients undergoing diagnostic coronary angiography [1] are found to have unprotected left main stenosis which has been shown to portend high mortality [2, 3]. Percutaneous coronary intervention (PCI) involving drug-eluting stents (DES) have increasingly been used to treat unprotected left main coronary artery disease (ULMCAD) in recent years, although coronary artery bypass grafting (CABG) has been the treatment of choice historically [4, 5]. One of the main limitations of PCI for ULMCAD is in-stent restenosis and the need for repeat revascularization, especially in bare-metal stents [6, 7]; therefore, the European Society of Cardiology guidelines and American Heart Association guidelines suggest that PCI for ULMCAD should be only reserved for those who are poor candidates for CABG [8]. However, several meta-analyses [912] of DES versus CABG for ULMCAD showed that the results are controversial, and many new clinical trials have been published in recent years [1316]. Therefore, it is necessary to conduct a new meta-analysis and to assess the safety and efficacy of DES and CABG among patients with ULMCAD in the early outcomes (≤30 days or in-hospital) and 1 to 5 years follow-up, and it is also necessary to compare the difference in safety and efficacy of DES and CABG between RCT and observational groups.

Methods

Search strategy

The data of this meta-analysis were obtained from the following sources: MEDLINE via PubMed (from 1950 to June 2012), EMBASE (June 1980 to June 2012) and the Cochrane Library database (Cochrane Central Register of Controlled Trials, from 1991 to June 2012). The following keywords were used: “coronary artery bypass”, “drug-eluting stent”, “paclitaxel-eluting stent”, “sirolimus-eluting stent”, and “left main coronary artery”. The above search strategy described was used to obtain titles and abstracts of studies that may have been relevant to this review. The titles and abstracts were screened independently by two authors (Q Li and Z Zhang), who discarded studies that were not applicable. When multiple reports from the same patients were found, only the study with the most complete data set was included in the meta-analysis. However, duplicate patients of different articles that have different types of data of outcomes were included both. Any disagreements were arbitrated by discussion with a third reviewer (RX Yin).

Included and excluded studies

Studies were included in this meta-analysis if they met the following criteria: 1) clinical trials published in peer-reviewed journals with full available text in English; 2) clinical trials comparing CABG with DES for LMCAD; 3) reporting at least one relevant clinical endpoint including revascularization, myocardial infarction, cerebrovascular events, death or the composite endpoint (death, myocardial infarction, or cerebrovascular events); and 4) follow-up duration ≥30 days. Excluded studies: 1) studies using only bare-metal stents or mixtures of bare-metal stents and DES but not comparing DES with CABG separately in the PCI group were excluded from this study; 2) studies in which it was not possible to extract data from the published results as well as those studies that did not report appropriate outcomes were also excluded.

Types of outcome measures

The safety endpoints of this meta-analysis were death, cerebrovascular events, myocardial infarction and the composite endpoint of death, myocardial infarction or cerebrovascular events. The efficacy endpoint was revascularization. Death was defined as death from any cause. Myocardial infarction included Q-wave and non-Q-wave myocardial infarction. Cerebrovascular events included ischemic attacks, stroke and reversible ischemic neurological deficits. Revascularization was the need for repeated CABG or PCI.

Data extraction and management

Two investigators independently extracted data according to the author details and the following information was extracted from each study: methodological quality, first author, the year of publication, number of patients in each group (CABG or DES), baseline characteristics, interventions, outcomes, and duration of follow-up. Otherwise, probabilities of death or other endpoints were estimated from published Kaplan-Meier survival curves. Discrepancies were resolved by discussion. When repeated publications of the same trial were identified, data were extracted from the repeated publications and reported as a single trial.

Quality of the evidence recommendations methodology

The evidence recommendations in our meta-analysis were graded according to the Grading of Recommendations Assessment Development and Evaluation (GRADE) system by Grade software [17]. The quality of the evidence was classified in four levels: high (), moderate (), low () or very low ().

Statistical analysis

We carried out statistical analysis by the Review Manager software 5.1.0 (updated in March 2011 by the Cochrane Collaboration). Dichotomous outcomes of individual studies were expressed as risk ratio (RR) with 95% confidence intervals (CI). The pooled effects were calculated using fixed-effects models when there was no significant heterogeneity but the random effects model was analyzed to ensure robustness of the model chosen and susceptibility to outliers, or using random effects models when there was significant heterogeneity. The fixed effects model was analyzed to ensure robustness of the model chosen and susceptibility to outliers. The point estimate of the RR was considered statistically significant at the 2-tailed P ≤0.05 level. Heterogeneity was analyzed using a χ2 test on N-1 degrees of freedom [18]. I 2 values of 25%, 50% and 75% correspond to low, medium and high levels of heterogeneity, respectively. Subgroup analysis was used to explore possible sources of heterogeneity (e.g., duration of follow-up, type of outcomes and study quality). Sensitivity analyses were performed omitting a single study at a time or analyzing another model chosen. If enough studies were identified, funnel plots were used to investigate reporting biases [19]. The baseline characteristics were analyzed with χ2 test for categorical variables.

Results

Characteristics of included studies

Twenty-one studies met our criteria for inclusion in the meta-analysis (Figure 1). Four studies were randomized controlled trials [13, 15, 20, 21] and seventeen studies were observational studies [48, 14, 16, 2236]. Several studies may have had duplicate patients but they had different types data of outcomes, e.g., one study [20] included death outcomes but another [13] did not. A total of 8,413 patients were included in the analysis. There were 4,731 patients who received CABG and 3,682 patients who received PCI with DES. The main characteristics of the studies are shown in Table 1.

Figure 1
figure 1

Flow chart showing study selection process.

Table 1 Main characteristics of included studies

Baseline characteristics of the trials

The baseline clinical characteristics between the PCI and CABG groups are detailed in Table 2. There were no significant differences in the prevalence of hypertension, current smoking, diabetes mellitus, previous stroke, and chronic renal failure between the two groups (P >0.05 for all). The proportions of females and previous PCI were lower but the prevalence of hyperlipidemia, previous myocardial infarction and right coronary artery disease were higher in CABG than in PCI groups (P <0.05 for all).

Table 2 Baseline clinical characteristics

Clinical outcomes

The early outcomes (≤30 days or in-hospital)

The early outcomes of DES and CABG groups and the pooled effects are shown in Figure 2. Pooled effects indicated that CABG group had higher risk of death (RR: 0.49, 95% CI: 0.30–0.78, P = 0.003), cerebrovascular events (RR: 0.19, 95% CI: 0.08–0.45, P = 0.0002) and composite endpoint (RR: 0.53, 95% CI: 0.40–0.70, P <0.00001) than the PCI group. There was no difference in myocardial infarction (RR: 0.97, 95% CI: 0.68–1.38, P = 0.86) between CABG and PCI groups.

Figure 2
figure 2

Comparison of the early outcomes (≤30 days or in-hospital) between PCI and CABG groups.

Death after 1 to 5 years post-operation

Death after 1 to 5 years post-operation between the CABG and PCI groups is shown in Figure 3. Pooled effects showed that CABG group had higher risk of death than the PCI group after 2 years (RR: 0.81, 95% CI: 0.66–0.99, P = 0.04), 4 years (RR: 0.69, 95% CI: 0.53–0.90, P = 0.007), 5 years (OR: 0.76, 95% CI: 0.61–0.95, P = 0.02) and total pooled outcome (RR: 0.79, 95% CI: 0.71–0.87, P <0.00001). There was no difference in deaths at 1 year (RR: 0.80, 95% CI: 0.63–1.02, P = 0.07) and 3 years (OR: 0.85, 95% CI: 0.69–1.04, P = 0.11) between the CABG and PCI groups.

Figure 3
figure 3

Comparison of the outcome of death from 1 to 5 years post-operation between PCI and CABG groups.

Composite endpoint at 1 to 5 years post-operation

The outcomes of composite endpoint of death, myocardial infarction and cerebrovascular events at 1 to 5 year post-operation between CABG and PCI groups are detailed in Figure 4. Pooled effects showed that CABG group had higher composite endpoint risk than PCI group after 1 year (RR: 0.69, 95% CI: 0.58–0.83, P = 0.0001), 4 years (RR: 0.69, 95% CI: 0.53–0.88, P = 0.003), 5 years (RR: 0.74, 95% CI: 0.59–0.92, P = 0.007) and total pooled outcome (RR: 0.78, 95% CI: 0.71–0.85, P <0.00001). There was no difference in composite endpoint at 2 years (RR: 0.88, 95% CI: 0.72–1.09, P = 0.24) and 3 years (RR: 0.87, 95% CI: 0.73–1.04, P = 0.14) between the CABG and PCI groups.

Figure 4
figure 4

Comparison of the outcome of composite endpoint of death, myocardial infarction and cerebrovascular events from 1 to 5 years post-operation between PCI and CABG groups.

Revascularization at 1 to 5 years post-operation

The outcomes of revascularization at 1 to 5 years post-operation between PCI and CABG groups are shown in Figure 5. Pooled effects showed that PCI group had higher revascularization risk than CABG group at 1 year (RR:3.38, 95% CI: 2.75–4.15, P <0.00001), 2 years (RR: 3.81, 95% CI: 2.93–4.95, P <0.00001), 3 years (RR: 4.42, 95% CI: 3.40–5.75, P <0.00001), 4 years (RR: 3.22, 95% CI: 2.28–4.54, P <0.00001) and 5 years (RR: 4.43, 95% CI: 3.08–6.37, P <0.00001), and total pooled outcome (RR: 3.77, 95% CI: 3.35–4.26, P <0.00001).

Figure 5
figure 5

Comparison of the revascularization at 1 to 5 years post-operation between PCI and CABG groups.

Outcomes at 1 year between RCT and observational groups

The outcomes of RCT and observational groups at 1 year are shown in Figures 6, 7, 8, 9. Pooled effects showed that there were no different outcomes between RCT and observational groups in death, myocardial infarction, cerebrovascular events or revascularization. There were also no differences in both death and myocardial infarction for CABG and PCI in both RCT and observational groups (P >0.05 for each). The PCI group had higher revascularization risk than the CABG group (P <0.00001), whereas the CABG group had higher cerebrovascular events risk than the PCI group (P = 0.001) in the two groups.

Figure 6
figure 6

Comparison of DES and CABG of myocardial infarction at 1 year post-operation between RCT and observational groups.

Figure 7
figure 7

Comparison of DES and CABG for the outcome of cerebrovascular events at 1 year post-operation between RCT and observational groups.

Figure 8
figure 8

Comparison of DES and CABG for the outcome of death at 1 year post-operation between RCT and observational groups.

Figure 9
figure 9

Comparison of DES and CABG for the outcome of revascularization at 1 year post-operation between RCT and observational groups.

Sensitivity analysis

Sensitivity analyses were performed to assess the contribution of each study to the pooled estimate and by excluding individual studies one at a time and recalculating the pooled RR estimates for the remaining studies. Eliminating the studies with more than 300 patients or fewer than 100 patients in each group did not substantially change the pooled point estimate. Moreover, analysis of four RCTs separately did not also substantively alter the overall result of our analysis. Last but not least, performing transition of model also did not substantially change the pooled point estimate.

Discussion

The results of the present meta-analysis showed that the early subtotal outcomes of death, cerebrovascular events and composite endpoint; death at 2, 4 and 5 years post-operation and composite endpoint at 1, 4 and 5 years post-operation, combined with their total outcomes, were lower risk in PCI than in CABG groups. There was no difference in the risk for the early outcomes of myocardial infarction, death at 3 years and composite endpoint at 2 and 3 years. Nevertheless, there was a lower risk for revascularization associated with CABG. There was no significant difference in death, myocardial infarction, cerebrovascular events or revascularization between RCT and observational groups.

Recently, three meta-analyses [10, 12, 37], including RCTs and observational studies, showed no significant differences in the safety between CABG and DES, and superiority of CABG to DES for repeated revascularization in patients with ULMCAD. A meta-analysis including 3,773 patients and follow-up of 3 years believed that PCI was emerging as an acceptable option. However, the PCI group in the meta-analysis was mixed with bare-metal stents and DES but did not compare DES with CABG separately, which might have led to the less robust results [37]. The meta-analysis by Lee et al. [10] included 8 clinical studies and 1 year follow-up. However, the number of patients in the CABG and DES groups was wrong in one study [38] and the total number of studies and patients was small, which may also have led to weak results. The meta-analysis by Zheng et al. [12] published in 2011 was heavily based on observational studies (13 observational studies and 2 RCTs) and a 5-year follow-up in the two groups, however, it abstracted and combined unadjusted risk estimates not only from randomized trials but also from observational studies, which did not strengthen the conclusion.

Two recent meta-analyses including a single RCT have been published. In one meta-analysis including three RCTs, Kajimoto et al. [9] showed that there was no significant difference in the risk of death and myocardial infarction in two groups but was superior to target vessel revascularization and major adverse cardiac and cerebrovascular events in CABG than in PCI group at 1 year. Therefore, they believed that CABG remains the standard of care for the treatment of left main coronary artery disease. However, the meta-analysis included a large power article [39] with 1,800 patients mixed with left main coronary artery disease and three-vessel coronary disease but not comparing the results of left main coronary artery disease in the two groups separately, which also affected the results.

The meta-analysis by Desch et al. [40] including four RCTs showed that there were no significant differences in the clinical endpoints of death and myocardial infarction between the PCI and CABG groups. While stroke was more frequent in surgical patients, the risk of repeated revascularization was higher in the PCI up to 2 years. Therefore they believe PCI to be useful only as an alternative to CABG in anatomically suited patients and with an increased risk of adverse surgical outcomes. However, the meta-analysis included an article [41] assessing mixed bare-metal stents and DES but not comparing DES with CABG separately, and the size of the study population was small.

In the present study, however, we exclude the articles that mixed left main coronary artery disease and three-vessel coronary disease but did not compare left main coronary artery disease in the two groups separately, or articles assessing mixed bare-metal stents and DES but not comparing DES with CABG separately, and we included more studies (four RCTs and 17 observational studies) and larger number of patients (total 8,413). Further, we performed the systematic review using a different method, which may be the reason for the different outcomes with the previous meta-analyses. We also performed the analysis of RCT and observational groups separately, there was no significant difference in death, myocardial infarction, cerebrovascular events or revascularization between RCT and observational groups. These also made our conclusion more robust.

Quality of the evidence

Some of the evidence GRADE level was low because most of the included studies were poor quality. Seventeen studies were observational studies and were not performed with the method of randomization and allocation concealment, which might lead to selection bias and an exaggerated RR. Combined with not performing methods of blinding could result in performance, attrition and detection bias. These method limitations caused down grade of the quality of evidence. On the other hand, some differences in baseline characteristics among treatment groups might have an unknown influence on the estimated effects that would increase inconsistent results, and some trials in these groups had inconsistent results and high heterogeneity; all this also caused downgrade of the quality of evidence. Furthermore, only the articles in English were included in this analysis and we were unable to search for grey articles, which might be a source of potential publication bias in this study. The low quality of GRADE did not allow a robust conclusion for some groups in this population.

However, some total or subtotal RRs had a large effect. All RCTs describe the method of randomization and allocation concealment. These subgroups of RCT had consistent results and low heterogeneity, but the size of the study population of RCT was a bit small and the pooled analysis showed a wide CI. Therefore, some of the evidence GRADE level was moderate (Figure 10).

Figure 10
figure 10

Summary of finding for the main comparison.

Other limitations should also be discussed in our study. Firstly, only four RCT were in the included studies in our meta-analysis, and two RCTs had duplicate patients and most types of data of outcomes in the two studies were repeated. Therefore, in the future, more randomized studies to compare DES with CABG in patients with left main coronary artery disease are necessary. What is more, many studies’ period of follow-up was short and only three observational studies [23, 30, 31] reported long-term follow-up (5 years). Therefore, more long-term results are necessary in the future.

Conclusions

Our meta-analysis indicates that DES has a lower safety risk than CABG but is inferior to CABG for repeated revascularization in patients with ULMCAD in the 5 years after intervention. There was no difference in death, myocardial infarction, cerebrovascular events or revascularization between RCT and observational groups.

Abbreviations

CABG:

Coronary artery bypass grafting

CI:

Confidence interval

DES:

Drug-eluting stents

PCI:

Percutaneous coronary intervention

RR:

Risk ratio

ULMCAD:

Unprotected left main coronary artery disease.

References

  1. Lenzen MJ, Boersma E, Bertrand ME, Maier W, Moris C, Piscione F, Sechtem U, Stahle E, Widimsky P, de Jaegere P, op Reimer WJ S, Mercado N, Wijns W: Management and outcome of patients with established coronary artery disease: the Euro Heart Survey on coronary revascularization. Eur Heart J. 2005, 26: 1169-1179. 10.1093/eurheartj/ehi238.

    Article  CAS  PubMed  Google Scholar 

  2. Varnauskas E: Twelve-year follow-up of survival in the randomized European Coronary Surgery Study. N Engl J Med. 1988, 319: 332-337. 10.1056/NEJM198808113190603.

    Article  CAS  PubMed  Google Scholar 

  3. Taylor HA, Deumite NJ, Chaitman BR, Davis KB, Killip T, Rogers WJ: Asymptomatic left main coronary artery disease in the Coronary Artery Surgery Study (CASS) registry. Circulation. 1989, 79: 1171-1179. 10.1161/01.CIR.79.6.1171.

    Article  CAS  PubMed  Google Scholar 

  4. Caracciolo EA, Davis KB, Sopko G, Kaiser GC, Corley SD, Schaff H, Taylor HA, Chaitman BR: Comparison of surgical and medical group survival in patients with left main equivalent coronary artery disease. Long-term CASS experience. Circulation. 1995, 91: 2335-2344. 10.1161/01.CIR.91.9.2335.

    Article  CAS  PubMed  Google Scholar 

  5. Patel MR, Dehmer GJ, Hirshfeld JW, Smith PK, Spertus JA: ACCF/SCAI/STS/AATS/AHA/ASNC 2009 Appropriateness Criteria for Coronary Revascularization: a report by the American College of Cardiology Foundation Appropriateness Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, and the American Society of Nuclear Cardiology Endorsed by the American Society of Echocardiography, the Heart Failure Society of America, and the Society of Cardiovascular Computed Tomography. J Am Coll Cardiol. 2009, 53: 530-553. 10.1016/j.jacc.2008.10.005.

    Article  PubMed  Google Scholar 

  6. Marzocchi A, Saia F, Piovaccari G, Manari A, Aurier E, Benassi A, Cremonesi A, Percoco G, Varani E, Magnavacchi P, Guastaroba P, Grilli R, Maresta A: Long-term safety and efficacy of drug-eluting stents: two-year results of the REAL (REgistro AngiopLastiche dell'Emilia Romagna) multicenter registry. Circulation. 2007, 115: 3181-3188. 10.1161/CIRCULATIONAHA.106.667592.

    Article  CAS  PubMed  Google Scholar 

  7. Lagerqvist B, James SK, Stenestrand U, Lindback J, Nilsson T, Wallentin L: Long-term outcomes with drug-eluting stents versus bare-metal stents in Sweden. N Engl J Med. 2007, 356: 1009-1019. 10.1056/NEJMoa067722.

    Article  CAS  PubMed  Google Scholar 

  8. Smith SC, Feldman TE, Hirshfeld JW, Jacobs AK, Kern MJ, King SB, Morrison DA, O'Neil WW, Schaff HV, Whitlow PL, Williams DO, Antman EM, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Nishimura R, Ornato JP, Page RL, Riegel B, American College of Cardiology/American Heart Association Task Force on Practice Guidelines; ACC/AHA/SCAI Writing Committee to Update 2001 Guidelines for Percutaneous Coronary Intervention: ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update 2001 Guidelines for Percutaneous Coronary Intervention). Circulation. 2006, 113: 166-286.

    Article  Google Scholar 

  9. Kajimoto K, Miyauchi K, Yamamoto T, Daida H, Amano A: Meta-analysis of randomized controlled trials on the treatment of unprotected left main coronary artery disease: one-year outcomes with coronary artery bypass grafting versus percutaneous coronary artery intervention with drug-eluting stent. J Card Surg. 2012, 27: 152-157. 10.1111/j.1540-8191.2011.01410.x.

    Article  PubMed  Google Scholar 

  10. Lee MS, Yang T, Dhoot J, Liao H: Meta-analysis of clinical studies comparing coronary artery bypass grafting with percutaneous coronary intervention and drug-eluting stents in patients with unprotected left main coronary artery narrowings. Am J Cardiol. 2010, 105: 1070-1075. 10.1016/j.amjcard.2009.12.007.

    Article  CAS  PubMed  Google Scholar 

  11. Takagi H, Umemoto T: A meta-analysis of randomized trials and adjusted observational studies of drug-eluting stents versus coronary artery bypass grafting for unprotected left main coronary artery disease. Int J Cardiol. 2011, 150: 341-343. 10.1016/j.ijcard.2011.05.027.

    Article  PubMed  Google Scholar 

  12. Zheng S, Zheng Z, Hou J, Hu S: Comparison between drug-eluting stents and coronary artery bypass grafting for unprotected left main coronary artery disease: a meta-analysis of two randomized trials and thirteen observational studies. Cardiology. 2011, 118: 22-32. 10.1159/000324169.

    Article  CAS  PubMed  Google Scholar 

  13. Boudriot E, Thiele H, Walther T, Liebetrau C, Boeckstegers P, Pohl T, Reichart B, Mudra H, Beier F, Gansera B, Neumann FJ, Gick M, Zietak T, Desch S, Schuler G, Mohr FW: Randomized comparison of percutaneous coronary intervention with sirolimus-eluting stents versus coronary artery bypass grafting in unprotected left main stem stenosis. J Am Coll Cardiol. 2011, 57: 538-545. 10.1016/j.jacc.2010.09.038.

    Article  PubMed  Google Scholar 

  14. Caggegi A, Capodanno D, Capranzano P, Chisari A, Ministeri M, Mangiameli A, Ronsivalle G, Ricca G, Barrano G, Monaco S, Di Salvo ME, Tamburino C: Comparison of one-year outcomes of percutaneous coronary intervention versus coronary artery bypass grafting in patients with unprotected left main coronary artery disease and acute coronary syndromes (from the CUSTOMIZE Registry). Am J Cardiol. 2011, 108: 355-359. 10.1016/j.amjcard.2011.03.050.

    Article  PubMed  Google Scholar 

  15. Park SJ, Kim YH, Park DW, Yun SC, Ahn JM, Song HG, Lee JY, Kim WJ, Kang SJ, Lee SW, Lee CW, Park SW, Chung CH, Lee JW, Lim DS, Rha SW, Lee SG, Gwon HC, Kim HS, Chae IH, Jang Y, Jeong MH, Tahk SJ, Seung KB: Randomized trial of stents versus bypass surgery for left main coronary artery disease. N Engl J Med. 2011, 364: 1718-1727. 10.1056/NEJMoa1100452.

    Article  CAS  PubMed  Google Scholar 

  16. Rittger H, Rieber J, Kogler K, Sinha A, Schmidt M, Breithardt OA, Biggar P, Einsle F, Diegeler A, Brachmann J: Clinical outcome and quality of life after interventional treatment of left main disease with drug-eluting-stents in comparison to CABG in elderly and younger patients. Clin Res Cardiol. 2011, 100: 439-446. 10.1007/s00392-010-0262-3.

    Article  CAS  PubMed  Google Scholar 

  17. Higgins JPT, Green S: Cochrane handbook for systematic reviews of interventions version 5.1.0 [updated March 2011]. The Cochrane Collaboration. 2011, Available at: http://www.cochrane-handbook.org

    Google Scholar 

  18. Higgins JP, Thompson SG, Deeks JJ, Altman DG: Measuring inconsistency in meta-analyses. BMJ. 2003, 327: 557-560. 10.1136/bmj.327.7414.557.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Higgins JPT, Green S: Cochrane handbook for systematic reviews of interventions version 5.0.0 [updated February 2008]. The Cochrane Collaboration. 2008, Available at: http://www.cochrane-handbook.org

    Google Scholar 

  20. Boudriot E, Liebetrau C, Walther T, Thiele H, Pohl T, Boeckstegers P, Reichart B, Beier F, Mudra H, Kemkes BM, Gick M, Neumann FJ, Schuler G, Mohr FW: Randomized, multicenter trial between PCI with sirolimus eluting stent and CABG for patients with unprotected left main stenosis. 1-year-results. Circulation. 2008, 118: 739-

    Google Scholar 

  21. Morice MC, Serruys PW, Kappetein AP, Feldman TE, Stahle E, Colombo A, Mack MJ, Holmes DR, Torracca L, van Es GA, Leadley K, Dawkins KD, Mohr F: Outcomes in patients with de novo left main disease treated with either percutaneous coronary intervention using paclitaxel-eluting stents or coronary artery bypass graft treatment in the Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery (SYNTAX) trial. Circulation. 2010, 121: 2645-2653. 10.1161/CIRCULATIONAHA.109.899211.

    Article  CAS  PubMed  Google Scholar 

  22. Cheng CI, Lee FY, Chang JP, Hsueh SK, Hsieh YK, Fang CY, Chen SM, Yang CH, Yip HK, Chen MC, Fu M, Wu CJ: Long-term outcomes of intervention for unprotected left main coronary artery stenosis: coronary stenting vs coronary artery bypass grafting. Circ J. 2009, 73: 705-712. 10.1253/circj.CJ-08-0804.

    Article  PubMed  Google Scholar 

  23. Chieffo A, Magni V, Latib A, Maisano F, Ielasi A, Montorfano M, Carlino M, Godino C, Ferraro M, Calori G, Alfieri O, Colombo A: 5-year outcomes following percutaneous coronary intervention with drug-eluting stent implantation versus coronary artery bypass graft for unprotected left main coronary artery lesions the Milan experience. JACC Cardiovasc Interv. 2010, 3: 595-601.

    Article  PubMed  Google Scholar 

  24. Chieffo A, Morici N, Maisano F, Bonizzoni E, Cosgrave J, Montorfano M, Airoldi F, Carlino M, Michev I, Melzi G, Sangiorgi G, Alfieri O, Colombo A: Percutaneous treatment with drug-eluting stent implantation versus bypass surgery for unprotected left main stenosis: a single-center experience. Circulation. 2006, 113: 2542-2547. 10.1161/CIRCULATIONAHA.105.595694.

    Article  CAS  PubMed  Google Scholar 

  25. Ghenim R, Roncalli J, Tidjane AM, Bongard V, Ziani A, Boudou N, Dumonteil N, Marcheix B, Leobon B, Carrie D: One-year follow-up of nonrandomized comparison between coronary artery bypass grafting surgery and drug-eluting stent for the treatment of unprotected left main coronary artery disease in elderly patients (aged > or = 75 years). J Interv Cardiol. 2009, 22: 520-526. 10.1111/j.1540-8183.2009.00503.x.

    Article  PubMed  Google Scholar 

  26. Kang SH, Park KH, Choi DJ, Park KW, Chung WY, Lim C, Kim KB, Kim HS: Coronary artery bypass grafting versus drug-eluting stent implantation for left main coronary artery disease (from a two-center registry). Am J Cardiol. 2010, 105: 343-351. 10.1016/j.amjcard.2009.09.036.

    Article  PubMed  Google Scholar 

  27. Lee MS, Kapoor N, Jamal F, Czer L, Aragon J, Forrester J, Kar S, Dohad S, Kass R, Eigler N, Trento A, Shah PK, Makkar RR: Comparison of coronary artery bypass surgery with percutaneous coronary intervention with drug-eluting stents for unprotected left main coronary artery disease. J Am Coll Cardiol. 2006, 47: 864-870. 10.1016/j.jacc.2005.09.072.

    Article  CAS  PubMed  Google Scholar 

  28. Makikallio TH, Niemela M, Kervinen K, Jokinen V, Laukkanen J, Ylitalo I, Tulppo MP, Juvonen J, Huikuri HV: Coronary angioplasty in drug eluting stent era for the treatment of unprotected left main stenosis compared to coronary artery bypass grafting. Ann Med. 2008, 40: 437-443. 10.1080/07853890701879790.

    Article  CAS  PubMed  Google Scholar 

  29. Palmerini T, Barlocco F, Santarelli A, Bacchi-Reggiani L, Savini C, Baldini E, Alessi L, Ruffini M, Di Credico G, Piovaccari G, Di Bartolomeo R, Marzocchi A, Branzi A, De Servi S: A comparison between coronary artery bypass grafting surgery and drug eluting stent for the treatment of unprotected left main coronary artery disease in elderly patients (aged > or =75 years). Eur Heart J. 2007, 28: 2714-2719. 10.1093/eurheartj/ehm403.

    Article  PubMed  Google Scholar 

  30. Park DW, Kim YH, Yun SC, Lee JY, Kim WJ, Kang SJ, Lee SW, Lee CW, Kim JJ, Choo SJ, Chung CH, Lee JW, Park SW, Park SJ: Long-term outcomes after stenting versus coronary artery bypass grafting for unprotected left main coronary artery disease: 10-year results of bare-metal stents and 5-year results of drug-eluting stents from the ASAN-MAIN (ASAN Medical Center-Left MAIN Revascularization) Registry. J Am Coll Cardiol. 2010, 56: 1366-1375. 10.1016/j.jacc.2010.03.097.

    Article  PubMed  Google Scholar 

  31. Park DW, Seung KB, Kim YH, Lee JY, Kim WJ, Kang SJ, Lee SW, Lee CW, Park SW, Yun SC, Gwon HC, Jeong MH, Jang YS, Kim HS, Kim PJ, Seong IW, Park HS, Ahn T, Chae IH, Tahk SJ, Chung WS, Park SJ: Long-term safety and efficacy of stenting versus coronary artery bypass grafting for unprotected left main coronary artery disease: 5-year results from the MAIN-COMPARE (Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary Angioplasty Versus Surgical Revascularization) registry. J Am Coll Cardiol. 2010, 56: 117-124. 10.1016/j.jacc.2010.04.004.

    Article  PubMed  Google Scholar 

  32. Sanmartin M, Baz JA, Claro R, Asorey V, Duran D, Pradas G, Iniguez A: Comparison of drug-eluting stents versus surgery for unprotected left main coronary artery disease. Am J Cardiol. 2007, 100: 970-973. 10.1016/j.amjcard.2007.04.037.

    Article  PubMed  Google Scholar 

  33. Seung KB, Park DW, Kim YH, Lee SW, Lee CW, Hong MK, Park SW, Yun SC, Gwon HC, Jeong MH, Jang Y, Kim HS, Kim PJ, Seong IW, Park HS, Ahn T, Chae IH, Tahk SJ, Chung WS, Park SJ: Stents versus coronary-artery bypass grafting for left main coronary artery disease. N Engl J Med. 2008, 358: 1781-1792. 10.1056/NEJMoa0801441.

    Article  CAS  PubMed  Google Scholar 

  34. Shimizu T, Ohno T, Ando J, Fujita H, Nagai R, Motomura N, Ono M, Kyo S, Takamoto S: Mid-term results and costs of coronary artery bypass vs. drug-eluting stents for unprotected left main coronary artery disease. Circ J. 2010, 74: 449-455. 10.1253/circj.CJ-09-0586.

    Article  PubMed  Google Scholar 

  35. White AJ, Kedia G, Mirocha JM, Lee MS, Forrester JS, Morales WC, Dohad S, Kar S, Czer LS, Fontana GP, Trento A, Shah PK, Makkar RR: Comparison of coronary artery bypass surgery and percutaneous drug-eluting stent implantation for treatment of left main coronary artery stenosis. JACC Cardiovasc Interv. 2008, 1: 236-245.

    Article  PubMed  Google Scholar 

  36. Wu X, Chen Y, Liu H, Teirstein PS, Kirtane AJ, Ge C, Song X, Chen X, Gu C, Huang F, Lv S: Comparison of long-term (4-year) outcomes of patients with unprotected left main coronary artery narrowing treated with drug-eluting stents versus coronary-artery bypass grafting. Am J Cardiol. 2010, 105: 1728-1734. 10.1016/j.amjcard.2010.01.353.

    Article  PubMed  Google Scholar 

  37. Naik H, White AJ, Chakravarty T, Forrester J, Fontana G, Kar S, Shah PK, Weiss RE, Makkar R: A meta-analysis of 3,773 patients treated with percutaneous coronary intervention or surgery for unprotected left main coronary artery stenosis. JACC Cardiovasc Interv. 2009, 2: 739-747. 10.1016/j.jcin.2009.05.020.

    Article  PubMed  Google Scholar 

  38. Serruys PW, Morice MC, Kappetein AP, Colombo A, Holmes DR, Mack MJ, Stahle E, Feldman TE, van den Brand M, Bass EJ, Van Dyck N, Leadley K, Dawkins KD, Mohr FW: Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med. 2009, 360: 961-972. 10.1056/NEJMoa0804626.

    Article  CAS  PubMed  Google Scholar 

  39. Cohen DJ, Van Hout B, Serruys PW, Mohr FW, Macaya C, den Heijer P, Vrakking MM, Wang K, Mahoney EM, Audi S, Leadley K, Dawkins KD, Kappetein AP: Quality of life after PCI with drug-eluting stents or coronary-artery bypass surgery. N Engl J Med. 2011, 364: 1016-1026. 10.1056/NEJMoa1001508.

    Article  CAS  PubMed  Google Scholar 

  40. Desch S, Boudriot E, Rastan A, Buszman PE, Bochenek A, Mohr FW, Schuler G, Thiele H: Bypass surgery versus percutaneous coronary intervention for the treatment of unprotected left main disease: a meta-analysis of randomized controlled trials. Herz. 2013, 38: 48-56. 10.1007/s00059-012-3596-y.

    Article  CAS  PubMed  Google Scholar 

  41. Buszman PE, Kiesz SR, Bochenek A, Peszek-Przybyla E, Szkrobka I, Debinski M, Bialkowska B, Dudek D, Gruszka A, Zurakowski A, Milewski K, Wilczynski M, Rzeszutko L, Buszman P, Szymszal J, Martin JL, Tendera M: Acute and late outcomes of unprotected left main stenting in comparison with surgical revascularization. J Am Coll Cardiol. 2008, 51: 538-545. 10.1016/j.jacc.2007.09.054.

    Article  PubMed  Google Scholar 

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Acknowledgments

This study was supported by the Science Foundation of Guangxi Returned Oversea Scholars (No: 0991004).

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Correspondence to Rui-Xing Yin.

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The authors declare that they have no competing interests.

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QL conceived the study, participated in the design, collected the data, performed statistical analyses, and drafted the manuscript. ZZ helped to collect the data and perform statistical analyses. RXY conceived the study, participated in the design, and helped to draft the manuscript. All authors read and approved the final manuscript.

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Li, Q., Zhang, Z. & Yin, RX. Drug-eluting stents or coronary artery bypass grafting for unprotected left main coronary artery disease: a meta-analysis of four randomized trials and seventeen observational studies. Trials 14, 133 (2013). https://doi.org/10.1186/1745-6215-14-133

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