Does previous percutaneous coronary stenting compromise the long-term efficacy of subsequent coronary artery bypass surgery? A microsimulation study.
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.
Rao
Christopher
C
Department of Biosurgery and Surgical Technology, Imperial College London, United Kingdom.
Stanbridge
Rex De Lisle
Rde L
Chikwe
Joanna
J
Pepper
John
J
Skapinakis
Petros
P
Aziz
Omer
O
Darzi
Ara
A
Athanasiou
Thanos
T
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