title: Does previous percutaneous coronary stenting compromise the long-term efficacy of subsequent coronary artery bypass surgery? A microsimulation study.
abstract: 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.
authors.affiliation: Department of Biosurgery and Surgical Technology, Imperial College London, United Kingdom.
authors.forename: Christopher
authors.initials: C
authors.lastname: Rao
authors.forename: Rex De Lisle
authors.initials: Rde L
authors.lastname: Stanbridge
authors.forename: Joanna
authors.initials: J
authors.lastname: Chikwe
authors.forename: John
authors.initials: J
authors.lastname: Pepper
authors.forename: Petros
authors.initials: P
authors.lastname: Skapinakis
authors.forename: Omer
authors.initials: O
authors.lastname: Aziz
authors.forename: Ara
authors.initials: A
authors.lastname: Darzi
authors.forename: Thanos
authors.initials: T
authors.lastname: Athanasiou
mesh_terms: D015906:Angioplasty, Balloon, Coronary / Q000379:methods / Q000401:mortality; D002423:Cause of Death; D001026:Coronary Artery Bypass / Q000379:methods / Q000401:mortality*; D023921:Coronary Stenosis / Q000000981:diagnostic imaging / Q000628:therapy*; D005500:Follow-Up Studies; D006801:Humans; D008390:Markov Chains; D008955:Models, Cardiovascular; D015233:Models, Statistical; D009204:Myocardial Revascularization / Q000379:methods*; D011788:Quality of Life; D019057:Quality-Adjusted Life Years; D011859:Radiography; D012086:Reoperation; D018570:Risk Assessment; D015607:Stents; D016019:Survival Analysis; D013997:Time Factors