Serruys P W, Unger F, Sousa J E, Jatene A, Bonnier H J, Schönberger J P, Buller N, Bonser R, van den Brand M J, van Herwerden L A, Morel M A, van Hout B A
Academisch Ziekenhuis Rotterdam Dijkzigt, The Netherlands.
N Engl J Med. 2001 Apr 12;344(15):1117-24. doi: 10.1056/NEJM200104123441502.
The recent recognition that coronary-artery stenting has improved the short- and long-term outcomes of patients treated with angioplasty has made it necessary to reevaluate the relative benefits of bypass surgery and percutaneous interventions in patients with multivessel disease.
A total of 1205 patients were randomly assigned to undergo stent implantation or bypass surgery when a cardiac surgeon and an interventional cardiologist agreed that the same extent of revascularization could be achieved by either technique. The primary clinical end point was freedom from major adverse cardiac and cerebrovascular events at one year. The costs of hospital resources used were also determined.
At one year, there was no significant difference between the two groups in terms of the rates of death, stroke, or myocardial infarction. Among patients who survived without a stroke or a myocardial infarction, 16.8 percent of those in the stenting group underwent a second revascularization, as compared with 3.5 percent of those in the surgery group. The rate of event-free survival at one year was 73.8 percent among the patients who received stents and 87.8 percent among those who underwent bypass surgery (P<0.001 by the log-rank test). The costs for the initial procedure were $4,212 less for patients assigned to stenting than for those assigned to bypass surgery, but this difference was reduced during follow-up because of the increased need for repeated revascularization; after one year, the net difference in favor of stenting was estimated to be $2,973 per patient.
As measured one year after the procedure, coronary stenting for multivessel disease is less expensive than bypass surgery and offers the same degree of protection against death, stroke, and myocardial infarction. However, stenting is associated with a greater need for repeated revascularization.
最近人们认识到冠状动脉支架置入术改善了接受血管成形术患者的短期和长期预后，这使得有必要重新评估多支血管病变患者接受搭桥手术和经皮介入治疗的相对获益。
当心脏外科医生和介入心脏病专家一致认为两种技术均可实现相同程度的血运重建时，共有1205例患者被随机分配接受支架植入或搭桥手术。主要临床终点是术后一年无重大不良心脑血管事件。还确定了所使用的医院资源成本。
在术后一年，两组在死亡、中风或心肌梗死发生率方面无显著差异。在未发生中风或心肌梗死而存活的患者中，支架置入组有16.8%的患者接受了二次血运重建，而手术组为3.5%。接受支架治疗的患者一年无事件生存率为73.8%，接受搭桥手术的患者为87.8%（对数秩检验，P<0.001）。接受支架置入的患者初始手术成本比接受搭桥手术的患者少4212美元，但由于重复血运重建需求增加，随访期间这种差异缩小；一年后，支架置入相对于搭桥手术的净成本差异估计为每位患者2973美元。
术后一年的评估结果显示，多支血管病变的冠状动脉支架置入术比搭桥手术成本更低，并且在预防死亡、中风和心肌梗死方面提供相同程度的保护。然而，支架置入术与更高的重复血运重建需求相关。
