Bypass Surgery Offers Better Survival Than Stents

A new study finds that relatively low-risk patients undergoing coronary artery bypass graft (CABG) surgery have a survival advantage at five years over those who received bare-metal stents.

The Stent or Surgery (SoS) study was conducted in Canada and 11 European countries. It was designed to compare CABG and bare-metal-stent-assisted angioplasty in more than 900 patients with multivessel disease, before the advent of drug-eluting stents (DES). The primary end point was the need for additional revascularizations, and secondary outcomes included a composite of death, nonfatal Q-wave myocardial infarct (MI), and all-cause mortality.

The SoS results were first reported in the September 28, 2003, issue of The Lancet. They showed that 21% of patients undergoing angioplasty required repeat revascularization--the primary end point--compared with only 6% in the CABG group. Most of the re-interventions occurred in the first year. Secondary outcomes were similar in both groups, but all-cause mortality was markedly lower in the CABG group (2% vs 5% in the stent group). This benefit persisted at the five-year mark, with mortality higher in the angioplasty group (10.9% vs 6.6%). The findings were presented by cardiac surgeon Dr. John Pepper, of the Imperial College London (UK), at the World Congress of Cardiology, held in September 2006 in Barcelona (Spain).

Although it is difficult to know where these data fit in the era of drug-eluting stents, and results from ongoing trials comparing DES with surgery are still years away, the authors said it is becoming clearer which patients should go to surgery and which ones should receive stents, with larger size of the blood vessel and elderly patients being key factors against DES, since lifelong antiplatelet therapy is required.

"The idea that CABG has disappeared, that it's a thing of the 20th century, is just not true,” said Dr. Pepper. "The wholesale use of stents is not justified; we don't even know median-term results from DES yet. On the other hand, in the past, we probably performed too many CABG surgeries on young people. Instead of being competitive, interventionalists and surgeons should be consensual and continue to conduct rigorous, honest trials.”



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Imperial College London