Feasibility and cost of treatment with drug eluting stents of surgical candidates with multi-vessel coronary disease

Objective: To determine the feasibility and cost of treatment with drug eluting stents in patients with multi-vessel coronary disease referred currently for surgical revascularisation. Methods: Two experienced interventional cardiologists reviewed retrospectively the clinical records and pre-operative coronary angiograms of 209 patients who underwent their first coronary bypass operation for multi-vessel disease without other adjunctive surgical procedures at the Royal Brompton Hospital in 2002. They were classified according to the technical feasibility and completeness of percutaneous revascularisation. A cost decision-analysis model with a cost of drug eluting stents of Euro2,100 and simulated 1-year costs was constructed. Results: Mean age was 64.6 +/- 8.9 years with 54 diabetics (25.8%). Each patient received at least I arterial graft and a mean of 3.0 +/- 0.8 distal anastomoses. Mean postoperative stay was 8.9 +/- 7.2 days and total cost Euro19,821 +/- 1,964. Percutaneous revascularisation was judged to be feasible in 158 (76%) cases. The contraindications were at least 1 unfavourable total occlusion subtending viable myocardium in 48 patients (23%) and extreme tortuosity or calcification in 4 patients (2%). Percutaneous revascularisation of grafted major epicardial vessels was anticipated to be complete in 138 (66%) patients and partial but acceptable in 19 (9.1%) patients. Stenting of the left main, of a 'favourable' total occlusion, of bifurcations or in an ostial location would have been required in 32 (20.4%), 60 (38.2%), 77 (49.0%) and 74 (47.1%), respectively, of cases treated. 3.6 +/- 1.4 drug eluting stents of total length 72.6 +/- 37.3 mm were required to treat 3.3 +/- 1.2 lesions per patient at an estimated cost of Euro17,266 +/- 2,850. When one year repeat revascularisation was modelled at a rate of 15% in the stent group there was no significant cost saving from stenting. Conclusions: Although percutaneous revascularisation is feasible in 76% of patients currently undergoing coronary artery bypass grafting for multi-vessel disease, such an approach will involve frequent treatment of complex lesions for which no long term results are available and is unlikely to provide appreciable economic savings. (C) 2004 Elsevier B.V. All rights reserved.