1. DES are not Good Enough for Diabetics—CABG will be the Default
Spencer King MD MACC
St Joseph’s Heart and Vascular Institute
Professor of Medicine, Emeritus
Emory University
CRT 2012

2. Spencer B. King, MD Honoraria: Celonova Biosciences nContact Surgical
Consulting Fees:
Network for Continuing Medical Education

3. Why is CABG Better?
Historically PCI has not competed with CABG in patients with diabetes.
Stenting did not materially change that
DES have reduced reintervention and a non LAD DES may have superior longivity compaired to veingrafts
But we have not addressed the superior redundancy achieved with CABG

4. EAST EMORY NHLBI All EAST Patients 82.7 79.3 % Survival p = 0.40 1 3 4
CABG (n=194)
PTCA (n=198)
p = 0.40 1 3 4 5 8 2 7 6
Treated Diabetic Patients
Patients without Diabetes
% Survival
% Survival
CABG (n=30)
PTCA (n=29)
CABG (n=164)
PTCA (n=169)
p = 0.23
p = 0.71 1 3 4 5 8 2 7 6 1 3 4 5 8 2 7 6
Years after Randomization
King SB III et al. J Am Coll Cardiol 2000;35:

5. Comparative Effectiveness of Coronary Bypass Surgery and Percutaneous Coronary Interventions for Multivessel Disease: A Collaborative Analysis of Individual Patient Data from Ten Randomized Trials
Mark A Hlatky MD, Derek B Boothroyd PhD, Dena M Bravata MD MS, Eric Boesma PhD, Jean Booth MS, Maria M Brooks PhD, Didier Carrie MD, Timothy C Clayton MS, Nicholas Danchin MD, Marcus Flather MD, Whady A Hueb MD, Jan Kahler MD, Sheryl F Kelsey PhD, Spencer B King MD, Andrzej S Kosinski PhD, Nueza Lopes MD, Kathryn M McDonald MM, Alfredo Rodriguez MD, Patrick Serruys MD, Ulrich Sigwart MD, Rodney H Stables MD, Douglas K Owens MD MS, Stuart J Pocock PhD
Lancet: 2009

9. Kaplan-Meier Curves of Freedom From Clinical Events
Serruys, P. W. et al. J Am Coll Cardiol 2010;55:
Copyright ©2010 American College of Cardiology Foundation. Restrictions may apply.

10. Kapur, A. et al. J Am Coll Cardiol 2010;55:432-440
Primary End Point Event-Free Survival CABG Versus PCI and MACCE Event-Free Survival CABG Versus PCI
Kapur, A. et al. J Am Coll Cardiol 2010;55:
CARDia Trial
Copyright ©2010 American College of Cardiology Foundation. Restrictions may apply.

15. Ann Thorac Surg 2011;92:

16. Diabetic
Non Diabetic
MACCE
Death,CVA,MI

17. SYNTAX 3 Year Outcomes (Diabetes n=452)
CABG Stent pValue
MACCE <0.001
Death/CVA/MI
Death

18. Lee, S.-W. et al. J Am Coll Cardiol Intv 2011;4:310-316
Kaplan-Meier Curves for Outcome According to Stent Type During 4-Year Follow-Up
Lee, S.-W. et al. J Am Coll Cardiol Intv 2011;4:
Copyright ©2011 American College of Cardiology Foundation. Restrictions may apply.

19. Mahmud, E. et al. J Am Coll Cardiol Intv 2009;2:240-252
Cumulative Frequency Distribution of 9-Month In-Stent and In-Segment Late Loss by Quantitative Coronary Angiography
Mahmud, E. et al. J Am Coll Cardiol Intv 2009;2:
Copyright ©2009 American College of Cardiology Foundation. Restrictions may apply.

22. FREEDOM Recruitment
as of 3/8/10
1900
2005
2006
2007
2008
2009
2010

23. Regional Update 1881 patients US - 356 140 sites Canada – 18 sites
Poland – 94
Germany – 93
Spain – 99
France - 70
Argentina – 62
Brazil – 361
Europe - 478
Australasia - 194
140 sites
US – 49 sites
Canada – 18 sites
Mexico – 1 site
South America - 11 sites
Argentina – 5 sites
Brazil – 4 sites
Colombia – 2 sites
Europe – 37 sites
Italy – 3 sites
France – 5 sites
Spain – 6 sites
Germany – 7 sites
Poland – 6 sites
UK - 4 sites
Israel – 3 sites
Czech Republic -2 site
Australia – 15 sites
New Zealand – 3 sites
India – 6 sites 24

24. PCI Procedure Summary PCI/DES Staging: % unstaged procedure
% staged procedures involving >1
hospitalization
66.2%
33.8%
71.2%
Mean total # of lesions attempted across all stages
4.2 ± 1.5
Mean total # drug-eluting stents placed per patient (across all stages)
4.3 ± 1.8
Reopro used during index procedure (stage 1 for staged procedures)
49.7%
Heparin administered
83.9%
Bivalirudin administered
14.9% 25

25. CABG Procedure Summary
Off – pump
21.4%
LIMA to LAD
88.0% 26

26. SUCCESSES
FREEDOM is now the largest database of diabetic subjects with multivessel coronary disease

27. Conclusions
PCI with DES is probably appropriate for many patients with one or two vessel disease
For more diffuse disease, common in diabetic patients, CABG continues to be the first consideration