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A best-of-both-worlds approach of coronary artery bypass grafting (CABG) coupled with percutaneous coronary intervention (PCI) did not make for more effective or safe treatment of multivessel coronary artery disease (CAD) over surgery alone, long-term data showed.

Five years after participants of the Hybrid Revascularization for Multivessel Coronary Artery Disease (HYBRID) trial were randomized to CABG with or without stenting, rates of all-cause mortality were statistically indistinguishable: 6.4% for hybrid revascularization and 9.2% for CABG only (P=0.69), reported Mateusz Tajstra, MD, of Poland's Medical University of Silesia, and colleagues in JACC: Cardiovascular Interventions.

Other outcomes also turned out similar between groups, namely:

• MI: 4.3% versus 7.2% (P=0.30)
• Repeat revascularization: 37.2% versus 45.4% (P=0.38)
• Stroke: 2.1% versus 4.1% (P=0.35)
• Major adverse cardiac and cerebrovascular events: 45.2% versus 53.4% (P=0.39)

Moreover, CABG and hybrid revascularization yielded the same long-term risks no matter patients' initial EuroSCORE and SYNTAX scores, Tajstra's group added.

Under the combined strategy, operators set out to perform CABG -- with durable grafts of the left internal mammary artery (LIMA) -- for the left anterior descending (LAD) artery and PCI in non-LAD targets. It was recommended that these patients get dual antiplatelet therapy with aspirin and clopidogrel (Plavix) for at least 12 months after stent placement.

The hybrid approach was hoped to be safer to due its less-invasive nature and avoidance of aortic clamping and manipulation.

"Our study shows that hybrid coronary revascularization is a promising coronary revascularization strategy in selected patients with multivessel CAD," the authors maintained. They noted that this strategy doesn't have a strong endorsement in American or European guidelines and, as such, has not made its way to routine clinical practice yet.

That is unlikely to change anytime soon, Tajstra and colleagues suggested in noting that HYBRID was the only randomized trial of its kind.

"While these 5-year data are very welcome, the overall published hybrid coronary revascularization experience remains small and mostly hypothesis-generating," commented Adrian Messerli, MD, and Naoki Misumida, MD, both of University of Kentucky HealthCare in Lexington. "To be fair, all available data suggest hybrid coronary revascularization is feasible and safe in skilled hands, with 1- and 5-year outcomes non-inferior to conventional CABG in low- to intermediate-risk patients with multivessel CAD."

Yet there is an comparing hybrid revascularization to multivessel PCI, Messerli and Misumida pointed out in an accompanying editorial.

"Pending these results, hybrid coronary revascularization may yet become a more commonly utilized third interventional strategy for certain patients with multivessel CAD," the editorialists suggested. But "[u]ntil hybrid coronary revascularization can prove superiority to conventional CABG in clinical outcomes such as significant morbidity or stroke reduction, adoption of this strategy will likely continue to be modest."

After all, the editorialists noted, several hurdles stand in the way of wider adoption, ranging from "clinical unknowns" to practical limitations such as the costs and logistics of running a hybrid operation room.

The study investigators had randomized 200 patients to hybrid coronary revascularization or CABG alone at their center in 2009-2012. Groups shared similar baseline characteristics, and all patients were prescribed aspirin indefinitely.

Nine patients were lost to follow-up, which resulted in lack of power to detect a difference in all-cause mortality, Tajstra's group acknowledged.