冠脉支架和冠脉搭桥用于左主干病变的比较

Stents versus Coronary-Artery Bypass Grafting for Left Main Coronary Artery Disease

背景：已有一些研究比较冠脉支架和冠脉搭桥。但是关于两种治疗方式用于无保护左主干病变的长期预后还缺乏相关数据。

方法：我们比较了2000年1月-2006年7月在韩国无保护冠脉左主干疾病采用冠脉支架治疗（1102例）和冠脉搭桥治疗（1138例）。我们采用“倾向评分匹配法”比较了整体人群和不同支架类型亚组中的不良事件（死亡；死亡、Q波性心肌梗死或卒中的复合终点；靶血管重建）。

结果：在整体匹配的人群，支架组和冠脉搭桥组死亡（支架组的危险比，1.18；95％可信区间0.77-1.80）、复合终点（支架组危险比1.10，95％可信区间0.75-1.62）没有显著差异。支架组靶血管重建率显著高于冠脉搭桥组（危险比4.76，95％可信区间2.80-8.11）。裸金属支架组与冠脉搭桥组比较以及药物洗脱支架组与冠脉搭桥组比较结果均类似，尽管裸金属支架组有死亡率及复合终点发生率高的趋势。

结论：在无保护左主干病变队列人群中，我们没有发现接受冠脉支架和冠脉搭桥的患者之间死亡和复合终点（死亡、Q波性心肌梗死或卒中）发生率的显著差异。但是，支架，即便是药物洗脱支架，比冠脉搭桥有更高的靶血管重建率。

Stents versus Coronary-Artery Bypass Grafting for Left Main Coronary Artery Disease

Ki Bae Seung, M.D., Duk-Woo Park, M.D., Young-Hak Kim, M.D., Seung-Whan Lee, M.D., Cheol Whan Lee, M.D., Myeong-Ki Hong, M.D., Seong-Wook Park, M.D., Sung-Cheol Yun, Ph.D., Hyeon-Cheol Gwon, M.D., Myung-Ho Jeong, M.D., Yangsoo Jang, M.D., Hyo-Soo Kim, M.D., Pum Joon Kim, M.D., In-Whan Seong, M.D., Hun Sik Park, M.D., Taehoon Ahn, M.D., In-Ho Chae, M.D., Seung-Jea Tahk, M.D., Wook-Sung Chung, M.D., and Seung-Jung Park, M.D.

Background Several studies have compared the treatment effects of coronary stenting and coronary-artery bypass grafting (CABG). However, there are limited data regarding the long-term outcomes of these two interventions for patients with unprotected left main coronary artery disease.

Methods We evaluated 1102 patients with unprotected left main coronary artery disease who underwent stent implantation and 1138 patients who underwent CABG in Korea between January 2000 and June 2006. We compared adverse outcomes (death; a composite outcome of death, Q-wave myocardial infarction, or stroke; and target-vessel revascularization) with the use of propensity-score matching in the overall cohort and in separate subgroups according to type of stent.

Results In the overall matched cohort, there was no significant difference between the stenting and CABG groups in the risk of death (hazard ratio for the stenting group, 1.18; 95% confidence interval [CI], 0.77 to 1.80) or the risk of the composite outcome (hazard ratio for the stenting group, 1.10; 95% CI, 0.75 to 1.62). The rates of target-vessel revascularization were significantly higher in the group that received stents than in the group that underwent CABG (hazard ratio, 4.76; 95% CI, 2.80 to 8.11). Comparisons of the group that received bare-metal stents with the group that underwent CABG and of the group that received drug-eluting stents with the group that underwent CABG produced similar results, although there was a trend toward higher rates of death and the composite end point in the group that received drug-eluting stents.

Conclusions In a cohort of patients with unprotected left main coronary artery disease, we found no significant difference in rates of death or of the composite end point of death, Q-wave myocardial infarction, or stroke between patients receiving stents and those undergoing CABG. However, stenting, even with drug-eluting stents, was associated with higher rates of target-vessel revascularization than was CABG.

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