Comparison of bypass surgery and drug-eluting stenting in diabetic patients with left main and/or multivessel disease: A systematic review and meta-analysis of randomized and nonrandomized studies

Background: With advances in theinterventional field, the choice between coronary artery bypass grafting (CABG) and percutaneous coronary intervention with drug-eluting stents (PCI-DES) for the diabetic subset with left main (LM) and/or multivessel disease (MVD) remains consistently controversial. Methods and results: We conducted a systematic review of randomized controlled trials (RCTs) and observational controlled trials (OCTs) comparing the two strategies for the diabetic subset with LM and/or MVD. PubMed, EMBASE, CENTRAL databases, Google Scholar and SinoMed were systematically searched for eligible studies without language and publica­tion restrictions. We identified 19 trials (4 randomized and 15 nonrandomized), enrolling 5,805 patients in OCTs and 3,060 patients in RCTs, respectively. PCI-DES was associated with higher mortality compared with CABG (11.7% DES vs. 9.1% CABG, RR 1.23, 95% CI 1.00–1.53, p = 0.06). Patients after PCI-DES had higher prevalence of myocardial infarction (MI) when compared with CABG (8.5% DES vs. 4.6% CABG, RR 1.68, 95% CI 1.20–2.37, p = 0.003). PCI-DES patients were at substantially lower risk of stroke (2.0% DES vs. 3.9% CABG, RR 0.51, 95% CI 0.39–0.67, p < 0.00001), but at several-fold higher risk of repeat revascularization (19.0% DES vs. 6.3% CABG, RR 2.95, 95% CI 2.46–3.55, p < 0.00001). The OCT patients risked a lower mortality as compared to the RCT patients (9.6% OCTs vs. 11.9% RCTs, RR 0.81, 95% CI 0.71–0.92, p = 0.001). Conclusions: CABG for patients with diabetes mellitus and LM and/or MVD had advan­tages over PCI-DES in all-cause death, nonfatal MI, and repeat revascularization, but the substantial disadvantage in nonfatal stroke. The high-selected patients (RCTs) risked a higher mortality than the real-world patients (OCTs).