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Original Articles: Cardiovascular

Does Previous Percutaneous Coronary Stenting Compromise the Long-Term Efficacy of Subsequent Coronary Artery Bypass Surgery? A Microsimulation Study

^a Department of Biosurgery and Surgical Technology, Imperial College London, United Kingdom
^b Department of Cardiothoracic Surgery, St. Mary’s Hospital, London, United Kingdom
^c Department of Cardiothoracic Surgery, Mount Sinai Hospital, New York, New York
^d Department of Cardiothoracic Surgery, National Heart and Lung Institute, Imperial College London, Royal Brompton Hospital, London, United Kingdom
^e Department of Psychiatry, University of Ioannina School of Medicine, Ioannina, Greece

Accepted for publication September 20, 2007.

^_* Address correspondence to Mr Athanasiou, Department of Biosurgery and Surgical Technology, Imperial College London, 10th Floor, QEQM Building, St. Mary’s Hospital, London W2 1NY, United Kingdom (Email: tathan5253{at}aol.com).

Background: This study aims to compare long-term survival and health-related quality of life in patients undergoing coronary artery bypass surgery with and without previous coronary stenting.

Methods: Markov microsimulation was used to model long-term survival and quality of life after surgical revascularization using data from referenced sources. Probabilistic sensitivity analysis was used to investigate the effect of uncertainty associated with the model parameters on the microsimulation results.

Results: Percutaneous coronary stenting was found to significantly decrease the effectiveness of coronary surgery. The model suggests that after a single stenting procedure ten-year survival was reduced by 3.3% (SD 0.7%), from 79.9% (SD 1.3%) to 76.6% (SD 1.4%). Similarly, after multiple stenting procedures ten-year survival was reduced by 3.5% (SD 0.7%) to 76.4% (SD 1.4%). Over a ten-year period a single stenting procedure reduced the quality adjusted life year (QALY) payoff by 0.25 QALY (SD 0.11 QALY) and multiple stenting procedures reduced the QALY payoff by 0.27 QALY (SD 0.08 QALY).

Conclusions: This study suggests that patients who undergo surgical bypass after stenting have worse long-term outcomes than patients who undergo surgical revascularization without previous percutaneous intervention. The pathophysiological mechanisms for this are not fully understood and must be further investigated. The findings of this study suggest that the timing of surgical bypass in relation to percutaneous intervention is important. This may have significant implications for clinical practice, suggesting that greater emphasis should be placed on selecting the optimum initial revascularization strategy.

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