Comparison of coronary artery bypass surgery and percutaneous coronary intervention in patients with diabetes: a meta-analysis of randomised controlled trials

People with diabetes have a 30 per cent less chance of dying if they undergo coronary artery bypass surgery rather than opening the artery through angioplasty and inserting a stent, a new study has found.

Comparison of coronary artery bypass surgery and percutaneous coronary intervention in patients with diabetes: a meta-analysis of randomised controlled trials

Dr Subodh Verma MD a e g , Michael E Farkouh MD e f h, Bobby Yanagawa MD g, David H Fitchett MD b e h, Muhammad R Ahsan MD a, Prof Marc Ruel MD l, Sachin Sud MD h m, Milan Gupta MD a e h n, Shantanu Singh k, Nandini Gupta MD a l, Asim N Cheema MD b e h, Prof Lawrence A Leiter MD c e h i, Paul W M Fedak MD o, Hwee Teoh PhD a c e, David A Latter MD a e g, Prof Valentin Fuster MD p q, Dr Jan O Friedrich MD d e h j

The choice between coronary artery bypass surgery (CABG) and percutaneous coronary intervention (PCI) for revascularisation in patients with diabetes and multivessel coronary artery disease, who account for 25% of revascularisation procedures, is much debated. We aimed to assess whether all-cause mortality differed between patients with diabetes who had CABG or PCI by doing a systematic review and meta-analysis of randomised controlled trials (RCTs) comparing CABG with PCI in the modern stent era.

We searched Medline, Embase, and the Cochrane Central Register of Controlled Trials from Jan 1, 1980, to March 12, 2013, for studies reported in English. Eligible studies were those in which investigators enrolled adult patients with diabetes and multivessel coronary artery disease, randomised them to CABG (with arterial conduits in at least 80% of participants) or PCI (with stents in at least 80% of participants), and reported outcomes separately in patients with diabetes, with a minimum of 12 months of follow-up. We used random-effects models to calculate risk ratios (RR) and 95% CIs for pooled data. We assessed heterogeneity using I2. The primary outcome was all-cause mortality in patients with diabetes who had CABG compared with those who had PCI at 5-year (or longest) follow-up.

Findings

The initial search strategy identified 3414 citations, of which eight trials were eligible. These eight trials included 7468 participants, of whom 3612 had diabetes. Four of the RCTs used bare metal stents (BMS; ERACI II, ARTS, SoS, MASS II) and four used drug-eluting stents (DES; FREEDOM, SYNTAX, VA CARDS, CARDia). At mean or median 5-year (or longest) follow-up, individuals with diabetes allocated to CABG had lower all-cause mortality than did those allocated to PCI (RR 0·67, 95% CI 0·52—0·86; p=0·002; I2=25%; 3131 patients, eight trials). Treatment effects in individuals without diabetes showed no mortality benefit (1·03, 0·77—1·37; p=0·78; I2=46%; 3790 patients, five trials; pinteraction=0.03). We identified no differences in outcome whether PCI was done with BMS or DES. When present, we identified no clear causes of heterogeneity.

Interpretation

In the modern era of stenting and optimum medical therapy, revascularisation of patients with diabetes and multivessel disease by CABG decreases long-term mortality by about a third compared with PCI using either BMS or DES. CABG should be strongly considered for these patients.

Transparent nanocrystalline yttria-stabilized-zirconia calvarium prosthesis- This may have implications in other areas also!

Abstract 

Laser-based diagnostics and therapeutics show promise for many neurological disorders. However, the poor transparency of cranial bone (calvaria) limits the spatial resolution and interaction depth that can be achieved, thus constraining opportunity in this regard. Herein, we report preliminary results from efforts seeking to address this limitation through use of novel transparent cranial implants made from nanocrystalline yttria-stabilized zirconia (nc-YSZ). Using optical coherence tomography (OCT) imaging of underlying brain in an acute murine model, we show that signal strength is improved when imaging through nc-YSZ implants relative to native cranium. As such, this provides initial evidence supporting the feasibility of nc-YSZ as a transparent cranial implant material. Furthermore, it represents a crucial first step towards realization of an innovative new concept we are developing, which seeks to eventually provide a clinically-viable means for optically accessing the brain, on-demand, over large areas, and on a chronically-recurring basis, without need for repeated craniectomies.

Transparent cranial implants could serve as a critical enabler for laser-based diagnosis and treatment of many neurological disorders. However, the intrinsic brittleness of transparent implants reported thus far predisposes them to catastrophic fracture-based failure, thus limiting opportunity for clinical translation. Novel nanocrystalline transparent implants are reported herein that seek to address this limitation through use of zirconia, a tough ceramic with well-proven biocompatibility in other chronic implantation applications.

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