Intended for healthcare professionals

Editor's Choice US editor's choice

Stents or surgery?

BMJ 2007; 334 doi: (Published 22 March 2007) Cite this as: BMJ 2007;334:0-a
  1. Douglas Kamerow, US editor (dkamerow{at}

    Stents are in the news. Which kind should you recommend: drug eluting stents, which may prevent early restenosis better but are more expensive and may lead to late thrombosis? Or bare metal stents, which may not be as good at preventing restenosis initially but are cheaper and less likely to lead to late thrombosis? News reports say that this controversy has now led to fewer doctors recommending drug eluting stents and some insurance companies reconsidering their coverage of them.

    The larger question, of course, is not just which type of stent to use. It is, “What are the relative advantages and disadvantages of the various treatments for patients with symptomatic coronary artery disease—medical therapy only, percutaneous transluminal angioplasty with stents, and coronary artery bypass grafting.” This week's BMJ helps to answer this question.

    Omer Aziz and colleagues examine the clinical effectiveness of surgery versus stenting for isolated left anterior descending artery lesions (doi: 10.1136/bmj.39106.476215.BE). Their meta-analysis of 12 studies finds that when minimally invasive surgery is done with the left internal thoracic artery it leads to significantly less angina recurrence and repeat revascularization as well as fewer adverse coronary and cerebral events than stenting. Importantly, however, mortality between the two did not differ significantly.

    The same investigators, led by Christopher Rao, performed a cost effectiveness study on their data (doi: 10.1136/bmj.39112.480023.BE). They found, unsurprisingly, that stents were more cost effective in the short term, especially during the first two years. As time passed, however, surgery became more cost-effective. They concluded that surgery may be a more cost effective medium- and long-term alternative to stenting.

    A second cost effectiveness study, by S C Griffin et al, compares coronary artery bypass grafting, percutaneous management (including stenting), and medical treatment in three tertiary care centers in London (doi: 10.1136/bmj.39129.442164.55). They followed over 1700 patients who were judged appropriate for surgery or stenting or both for six years. They found that, for those patients judged clinically appropriate for coronary artery bypass grafting, it seemed both clinically beneficial and cost effective. Medical therapy was also found cost effective. The lesser clinical benefit of percutaneous interventions did not allow them to reach standard levels of cost effectiveness.

    In an editorial commenting on all of these studies (doi: 10.1136/bmj.39154.552280.BE), David Taggart makes several points. First, the mortality advantage of surgery may have been underestimated in them because of limited follow-up time. Second, multivessel disease studies also tend to be biased against surgery because of selective randomization that favors lower-risk patients. Finally, Taggart discusses the physiologic advantages of surgery over stenting: surgery both protects larger amounts of coronary artery than stents and offers protection against new disease. He makes a persuasive case that multidisciplinary teams should be making recommendations to patients whether they should continue medical treatment or receive stents or surgery.

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