Study Evaluates EXCEL Trial Data on the Influence of Lesion Site on PCI Outcomes

July 10, 2018—Anthony H. Gershlick, MBBS, et al published an investigation of left main (LM) percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) according to lesion site in the EXCEL trial. The study is available online in Journal of the American College of Cardiology (JACC): Cardiovascular Interventions. The study sought to determine the extent to which the site (distal bifurcation vs ostial/shaft) of the LM coronary artery lesion influences the outcomes of revascularization with PCI versus CABG.

The background of this investigation is that in the randomized EXCEL trial, which evaluated the effectiveness of PCI with the Xience drug-eluting stents (Abbott Vascular) compared with CABG for LM revascularization, the 1,905 patients with LM disease and site-assessed SYNTAX scores of < 32 showed similar rates of the composite primary endpoint of death, myocardial infarction (MI), or stroke at 3 years.

As summarized in JACC: Cardiovascular Interventions, the outcomes from the EXCEL trial were analyzed according to the presence of angiographic core laboratory–determined diameter stenosis ≥ 50% involving the distal LM bifurcation (n = 1,559; 84.2%) versus disease isolated to the LM ostium or shaft (n = 293; 15.8%).

The investigators reported that at 3 years, there were no significant differences between PCI and CABG for the primary composite endpoint of death, MI, or stroke for treatment of both distal LM bifurcation disease (15.6% vs 14.9%; odds ratio [OR], 1.08; 95% confidence interval [CI], 0.81–1.42; P = .61) and isolated LM ostial/shaft disease (12.4% vs 13.5%; OR, 0.9; 95% CI, 0.45–1.81; P = .77) (P interaction = .65).

However, at 3 years, ischemia-driven revascularization occurred more frequently after PCI than CABG in patients with LM distal bifurcation disease (13% vs 7.2%; OR, 2.00; 95% CI, 1.41–2.85; P = .0001), but were not significantly different in patients with disease only at the LM ostium or shaft (9.7% vs. 8.4%; OR, 1.18; 95% CI, 0.52–2.69; P = 0.68) (P interaction = .25).

In the EXCEL trial, PCI and CABG resulted in comparable rates of death, MI, or stroke at 3 years for treatment of LM disease, including those with distal LM bifurcation disease. Repeat revascularization rates during follow-up after PCI compared with CABG were greater for lesions in the distal LM bifurcation but were similar for disease isolated to the LM ostium or shaft, concluded the investigators in JACC: Cardiovascular Interventions.