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Eur J Cardiothorac Surg 2004;26:528-534
© 2004 Elsevier Science NL

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

^a Department of Cardiology, Royal Brompton and Harefield NHS Trust, Sydney Street, London SW3 6NP, UK
^b Clinical Trials and Evaluation Unit, Royal Brompton and Harefield NHS Trust, Sydney Street, London SW3 6NP, UK
^c Department of Cardiac Surgery, Royal Brompton and Harefield NHS Trust, Sydney Street, London SW3 6NP, UK

Received 23 March 2004; accepted 5 May 2004.

^* Corresponding author. Tel./fax: +44-20-7351-8530
e-mail: j.pepper{at}rbh.nthames.nhs.uk

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 2,100 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 1 arterial graft and a mean of 3.0±0.8 distal anastomoses. Mean post-operative stay was 8.9±7.2 days and total cost 19,821±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 17,266±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.

Key Words: Coronary bypass grafting • Percutaneous coronary intervention • Drug eluting stents • Cost

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