The role of percutaneous transluminal coronary angioplasty in coronary revascularization

Purpose of Assessment

To review the current status of the use of PTCA and alternative technologies for treating coronary artery disease, evidence for patient benefit, costs and related economic implications, methodological rigor of available evidence, and related implications.

Methods

Systematic review, Summary of availiable cost/economic analyses

Primary Data Collection

Literature review. MEDLARS searches and reference lists from publications.

Basis for selection of data; type of study included

No set selection criteria were used; this structured overview summarized the available studies and described their relative and overall rigor.

Review process for the publication

Internal review by SBU Board and SBU Expert Group. Additional external review by experts in the field.

Content of Report

Heart disease is the leading cause of mortality and a major cause of morbidity in Sweden. The main treatments for coronary artery disease (CAD) are medical treatment (primarily with drugs), coronary artery bypass grafting (CABG), and percutaneous transluminal coronary angioplasty (PTCA).

Since first being applied in humans in 1977, the use of PTCA has increased dramatically in western nations, while the use of CABG has continued to increase. The increase in PTCA use is due to a combination of factors, including: broadened clinical indications, increased number and experience of practitioners, improved technology, the large population with CAD, and greater patient and physician demand. The relationship between PTCA and CABG is both substitutional and additive.

Marked international differences in the use of PTCA and CABG reflects uncertainty regarding clinical indications and mediating economic and professional factors. Large and costly increases in their use have occurred despite a very limited understanding about their relative health, economic and social merits.

Available comparisons of PTCA and CABG, none of which are based on randomized controlled trials (RCTs), indicate that PTCA requires a shorter hospital stay, causes less procedure-related disability, has a lower initial cost, and enables earlier return to work with higher productivity than CABG. However, clinically significant restenosis is generally thought to occur in about 25–40% of lesions treated by PTCA, which may require repeat PTCAs or CABG.

Among hundreds of studies involving PTCA published between 1980 and 1990, there were no RCTs comparing PTCA to CABG, though several were initiated in the late 1980s. Other RCT results indicated that there is no difference between CABG and medical therapy in patients return to work and subsequent hospitalisation.

Few studies address the cost or cost-effectiveness of PTCA and other revascularization procedures and most of these are methodologically weak. Cost estimates for Sweden range from SEK 75,000-110,000 for CABG and SEK 35,000–50,000 for PTCA. Although PTCA is initially less costly than CABG, costs associated with PTCA appear to be greater in later years, and it is premature to conclude that PTCA is a cost-effective substitute for CABG.

The limitations of PTCA and the magnitude of CAD present opportunities for alternative technologies. A burgeoning variety of new recanalization technologies are, or have been, under investigation, such as laser angioplasty, thermal angioplasty, atherectomy, and intravascular stents.