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David Hildick-Smith Sussex Cardiac Centre

David Hildick-Smith Sussex Cardiac Centre. Background to ARTS. Meta-analysis of randomised trials comparing coronary angioplasty with bypass surgery. Pocock SJ, Henderson RA, Rickards AF, Hampton JR, King SB 3rd, Hamm CW, Puel J, Hueb W, Goy JJ, Rodriguez A. Lancet 1995.

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David Hildick-Smith Sussex Cardiac Centre

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  1. David Hildick-Smith Sussex Cardiac Centre

  2. Background to ARTS Meta-analysis of randomised trials comparing coronary angioplasty with bypass surgery.Pocock SJ, Henderson RA, Rickards AF, Hampton JR, King SB 3rd, Hamm CW, Puel J, Hueb W, Goy JJ, Rodriguez A. Lancet 1995 • Previous POBA studies • Meta-analysis • 3300 patients • 1660 CABG, 1710 PTCA • Deaths 79 PCI vs 73 CABG • Revascularisation rates 33% PCI v 3% CABG

  3. Background to ARTS • Rationale for ARTS • stent technology • CABG technology • economic evaluation

  4. Methods • At least two lesions amenable to PCI or CABG, agreed by surgeon and cardiologist • Allowed: • total occlusions (<1 month) • bifurcations • thrombus • calcification • tortuosity • LVEF >30% • No previous revascularisations

  5. Endpoints • Primary • freedom from death, stroke, MI, revascularisation • Secondary • angina status • medication use • cost effectiveness at 12 months

  6. Results • 1200 patients at 67 centres • Matched demographics • Crossovers: • 6 to surgery • 19 to stenting

  7. Results • 99% in PCI group had assigned Rx • 96% in CABG had assigned Rx • PCI 2.6±1.1 lesions stented • CABG 2.6±1.1 anastomoses made • Arterial grafts in 93% • 95% of these had LIMA to LAD

  8. One-year analysis

  9. survival event-free survival

  10. ARTS I Conclusions • No significant difference between groups for death • 17% difference in revascularisations favouring CABG • Lower costs ($3,000) favouring PCI

  11. ARTS I – 3 years

  12. survival event-free survival

  13. ~Diabetic subgroup~

  14. ~Proximal LAD subgroup~

  15. ~Predictors of outcome~

  16. ARTS I – 5 years Serruys P. European Society of Cardiology Congress 2004; August 28-September 1, 2004; Munich, Germany.

  17. ARTS I – 5 years

  18. ARTS I – 5 years

  19. meanwhile….

  20. The Rosy Prophecy

  21. ARTS II – the rationale

  22. ARTS II: Design Cypher stent N=607 ARTS II CABG N= 605 ARTS I R Crown stent N= 600

  23. ARTS II • Aim: • non-inferiority of sirolimus-eluting stents compared with the surgical arm of ARTS I • Endpoints: • as for ARTS I

  24. ARTS II: Baseline Demographics

  25. ARTS II: Procedural Details

  26. ARTS II: Stented Length • Average stented length: • ARTS II = 72.5mm • ARTS I = 47.6mm

  27. ARTS II: 6m Clinical Results

  28. ARTS II: 6m Clinical Results

  29. Conclusions • “Early indications are that DES may be as good as CABG for multivessel disease revascularisation” (M.Leon 2004) • Wait for 1-year data

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