Most certainly, as we read this title, we imagine the conclusion (as does the editor): patients with prior cerebrovascular disease (CEVD) benefit from a less invasive revascularization strategy, such as PCI. However, the EXCEL outcomes tell us that patients with left main coronary artery disease (LMCAD) and a history of CEVD will not benefit from either one over the other.

Logically, it shows this subgroup sees more events than patients with no history of CEVD, but this increased events rate appears indifferent to revascularization type.

The EXCEL trial (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) included patients with left main CAD and low and intermediate SYNTAX score randomized to PCI with everolimus eluting stent vs. myocardial revascularization surgery (CABG). Effects of prior CEVD were measured at 30 days and 3 years and were defined as prior stroke, transient ischemic attack, or carotid artery disease.

Read also: TAVR Learning Curve and Volume-Outcomes Relationship Plateau.

Of 1898 patients included in the study, 233 (12.3%) had a history of CEVD. This subgroup presented more comorbidities (including hypertension, diabetes, peripheral artery disease, anemia, chronic kidney disease, or prior PCI) than patients with no history of CEVD.

Prior CEVD was associated to nearly three times more strokes, both at 30 days (2.2% vs.0.8%; p=0.05) and at 3 years (6.4% vs. 2.2%; p=0.0003). It was also observed nearly double the combined events rate at 3 years, which included death, stroke or myocardial infarction (25.0% vs. 13.6%; p<0.0001).

Read also: Long-Term Foramen Ovale Closure after Cryptogenic Stroke.

The relative effect of PCI on CEVD rate at 30 days and 3 years, and on the combined events at 3 years, compared against CABG, was consistent both in patients with a history of CEVD and in patients with no history of CEVD.

Conclusion

Patients with a history of CEVD and left main CAD present higher CEVD and events rate after revascularization, regardless the strategy.

The EXCEL outcomes do not support a revascularization strategy as ‘preferred’ for this group of patients.

Original title: Left Main Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Patients with Prior Cerebrovascular Disease. Results from the EXCEL Trial.

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