Large studies of angioplasty (without stenting) versus bypass surgery indicate that the less invasive modality is associated with lower costs but results in a greater need for subsequent revascularization. It is now common practice to follow angioplasty with placement of a stent at the site of the treated blockage to decrease the rate of restenosis. In a randomized study of 1,205 patients at more than 60 treatment centers, Serruys and colleagues revisit the issue of endovascular versus open-heart surgery for treatment of multivessel coronary artery disease.

Patients were eligible for randomization on the agreement of a surgeon and an interventional cardiologist that either treatment modality could provide an equivalent degree of revascularization. Exclusion criteria included left main coronary artery disease and a history of stroke or myocardial infarction within the previous week. Patients were assessed at one, six and 12 months post-procedure. Statistical models predicted that 600 patients would be needed to adequately compare the two procedures; the study investigators successfully enrolled twice that number. A total of 25 patients did not receive the procedure to which they were randomly assigned, and 14 stent patients required post-procedure bypass surgery as a result of unsuccessful angioplasty.

Overall survival at one year post-procedure was the same in both groups, and there was no significant difference in the occurrence of myocardial infarction or stroke. Overall medical costs were substantially lower in the stent group ($6,441 per patient) than in the bypass group ($10,653 per patient), but this difference narrowed to less than $3,000 when the costs of repeat revascularization were included. A total of 17 percent of the stent group required another revascularization procedure, compared with 4 percent of the bypass group. No chest pain was reported in 79 percent of patients treated with stenting and 90 percent of patients who underwent bypass surgery. Quality-of-life measures were not significantly different when assessed as a whole.

The study authors conclude that stenting is less expensive than bypass grafting and not associated with any increased risk of death, stroke or myocardial infarction, but does carry a higher risk of subsequent revascularization.