Commentary

For most patients who need coronary revascularisation, the best procedure is clear-cut: bypass surgery for left-main or extensive 3-vessel disease and angioplasty for single-vessel disease. In the “grey zone” between these 2 extremes (about 15% of patients), either procedure is an option. In the early 1990s, several randomised controlled trials in such patients found equal rates of mortality and MI, but better angina relief with surgery.¹ However, after enrollment in these trials was complete, coronary stents became available. Although stents reduce restenosis, they are more expensive than balloon angioplasty, and it was unclear whether their development made previous trials obsolete. ARTS is the first trial to compare stenting with bypass surgery, and its results are similar to those of previous trials: no difference in death, MI, or stroke, but more repeated procedures and angina in patients who received stents. Thus, the principles derived from earlier clinical trials are still applicable in the stent era.

The major concern about stents is their high cost. In previous trials of balloon angioplasty and bypass surgery, the 30% initial cost advantage of angioplasty was trimmed to < 5% over several years. In ARTS, the 40% initial cost advantage of stents was cut to 22% over 1 year but the difference was still statistically significant; however, costs in Europe are quite different from those in the USA and the follow up in ARTS was too short to capture all the late costs. Thus, the cost effectiveness of stenting compared with that of bypass surgery remains uncertain, especially in the USA. Nevertheless, stents are a safe alternative for patients with multivessel coronary disease who wish to avoid bypass surgery.