European Journal of Cardiovascular Medicine

The management of multivessel coronary artery disease (MVD) remains a subject of ongoing debate, with coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) emerging as the two primary revascularization strategies. Both approaches have been extensively studied in randomized controlled trials (RCTs) and meta-analyses, yet a definitive consensus on the optimal therapeutic strategy is still lacking. While CABG has traditionally been regarded as the gold standard for MVD treatment, advancements in PCI techniques, particularly with the introduction of drug-eluting stents (DES), have challenged this paradigm by offering a less invasive alternative with shorter recovery times and reduced perioperative complications.

Several studies have provided comparative analyses of CABG and PCI in patients with MVD, focusing on outcomes such as mortality, myocardial infarction (MI), stroke, and the need for repeat revascularization. Evidence suggests that CABG is associated with superior long-term survival and a lower incidence of major adverse cardiovascular events (MACE), including MI and repeat revascularization, compared to PCI with DES (Spadaccio & Benedetto, 2018) [1]. Similarly, a meta-analysis of individual patient data from key RCTs demonstrated that CABG significantly reduces the composite risk of all-cause mortality, MI, or stroke in patients with MVD, primarily due to a marked reduction in MI risk (Lee et al., 2016) [2]. Another systematic review found that CABG confers an unequivocal survival benefit, along with lower rates of MI and repeat revascularization, irrespective of diabetes status (Sipahi et al., 2014) [3].

Despite these advantages, CABG is associated with a higher risk of perioperative stroke and longer hospital stays. Recent studies have explored whether new-generation DES (NG-DES) could mitigate some of the limitations of PCI by improving long-term outcomes. A Bayesian network meta-analysis suggested that while CABG remains superior in reducing repeat revascularization rates, outcomes between CABG and NG-DES in terms of mortality, MI, and stroke were not significantly different (Mina et al., 2018) [4]. Furthermore, in patients with left main coronary artery (LMCA) disease, PCI has been shown to provide comparable safety outcomes to CABG, although the risk of repeat revascularization remains higher with PCI (Giacoppo et al., 2017) [5,6].

Given the complex nature of decision-making in revascularization, current guidelines emphasize the importance of a patient-centered, heart-team approach that considers coronary anatomy, comorbidities, and procedural risks. While CABG remains the preferred strategy for patients with extensive coronary disease, particularly those with a high SYNTAX score, PCI is increasingly recognized as a viable alternative in select patients, especially with lower anatomical complexity or high surgical risk (Deb et al., 2013) [7,8]. This ongoing evolution in treatment strategies underscores the need for continued research and individualized decision-making in managing MVD.

Study Design

The study was conducted as a retrospective cohort comparison between the outcomes of CABG and PCI in patients with MVD. The data were retrieved from a single tertiary referral center over a fixed duration to include a complete assessment of both revascularization modalities. Ethical standards were followed, and approval was received from the institutional ethics committee.

Patient Selection

Patients who had MVD and received either CABG or PCI were part of the study. Inclusion criteria included patients who had angiographically confirmed significant stenosis (≥70%) in two or more major coronary arteries. Concomitant valvular heart disease needing surgery, history of CABG or PCI in the past, and contraindication to either of these procedures were excluded. Baseline demographic, clinical, and angiographic features were documented for comparing the two groups.

Data Collection

Clinical information, procedural details, and follow-up results were obtained from hospital electronic medical records. The important variables were age, sex, comorbidities (e.g., diabetes, hypertension, and dyslipidemia), left ventricular ejection fraction (LVEF), SYNTAX score, and left main coronary artery (LMCA) involvement. Procedural factors like the number of grafts during CABG and the use of drug-eluting stents (DES) in PCI were recorded.

Outcome Measures

The major outcome was the occurrence of major adverse cardiovascular events (MACE) as a composite of all-cause death, myocardial infarction (MI), stroke, and recurrent revascularization during follow-up. Secondary outcomes were individual elements of MACE, perioperative complications (e.g., bleeding, infection, and acute kidney injury), and hospital stay.

Statistical Analysis

Analysis was done based on applicable statistical techniques to contrast outcomes between the CABG and PCI groups. Continuous variables were presented as mean ± standard deviation (SD) and contrasted with the independent t-test or Mann-Whitney U test, based on data distribution. Categorical variables were expressed as percentages and compared with the chi-square test or Fisher's exact test. Kaplan-Meier survival analysis was conducted to compare long-term event-free survival between groups, and Cox proportional hazards regression was employed to control for potential confounders. A p-value of <0.05 was deemed to be statistically significant.

Follow-Up Protocol

Patients were followed up at uniform intervals after the procedure by using outpatient visits and telephone interviews. Follow-up data were obtained at 6 months, 1 year, and annually thereafter with the focus on clinical status, medication compliance, and the development of adverse cardiovascular events. The follow-up period was adequate to assess both short-term and long-term outcomes of each revascularization strategy.

Baseline Characteristics
A total of 500 patients with multivessel coronary artery disease (MVD) were enrolled in the study and equally distributed into two groups of 250 each, who underwent either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). The baseline characteristics were well-balanced between the groups with no statistically significant differences in age, gender distribution, or comorbidities like diabetes, hypertension, and dyslipidemia. The mean age was 62.4 ± 8.5 years, with 72% male. The mean left ventricular ejection fraction (LVEF) was slightly decreased in the CABG group (49.6% ± 7.2%) compared to the PCI group (51.2% ± 6.9%), although not statistically significant (p=0.08). The SYNTAX score was greater in the CABG group, indicating a greater complexity of coronary artery disease.

Table 1: Baseline Characteristics of Patients

Procedural Outcomes
In the CABG group, 3.1 ± 0.8 grafts per patient were utilized on average, with the left internal mammary artery (LIMA) being used in 98% of patients. In comparison, drug-eluting stents (DES) were used in all patients in the PCI group, with a mean of 2.8 ± 1.1 stents per patient. Not surprisingly, procedural time was longer for CABG (225 ± 34 minutes) than for PCI (92 ± 18 minutes, p<0.001), capturing the invasive nature of surgical intervention.

Major Adverse Cardiovascular Events (MACE)
At follow-up, the rate of major adverse cardiovascular events (MACE) was numerically lower in the CABG group (18.4%) compared to PCI (27.6%, p=0.02). PCI was still, however, demonstrating acceptable event rates considering its less invasive procedure and shorter recovery. All-cause mortality was comparable between groups (6.8% for CABG vs. 10.4% for PCI, p=0.09) with no statistically significant difference. Repeat revascularization was greater in the PCI group (13.2% vs. 4.4%, p<0.001), which may be due to the nature of stenting and disease progression, especially in more complex cases.

Table 2: Incidence of Major Adverse Cardiovascular Events (MACE) During Follow-Up

Kaplan-Meier Survival Analysis
Kaplan-Meier curves also demonstrated similar long-term event-free survival after PCI and CABG, though CABG had a minor statistical benefit (log-rank p=0.015). Importantly, the benefit was even more pronounced in those with high SYNTAX scores, suggesting that PCI is an effective and worthwhile choice, particularly in patients with lesser disease.

Graph 1: Kaplan-Meier Curve Showing Event-Free Survival in CABG vs. PCI

Periprocedural Complications
Periprocedural complications also happened more frequently in the CABG group, such as higher rates of bleeding necessitating blood transfusion (9.2% vs. 2.4%, p<0.001) and longer mechanical ventilation (6.4% vs. 1.6%, p=0.002). PCI, on the other hand, was linked with higher rates of contrast-induced nephropathy (7.6% vs. 3.2%, p=0.01). Hospital stay was also significantly longer for CABG patients (8.5 ± 2.3 days) compared to PCI (3.2 ± 1.1 days, p<0.001), further attesting to the benefits of PCI in recovery and resource utilization.

Table 3: Periprocedural Complications

Although CABG was associated with less repeat revascularization and less MACE in complex coronary disease, PCI was a similar alternative for most patients, especially those with lower SYNTAX score or greater surgical risk. PCI was preferable with its shorter procedure time, quicker recovery, and fewer periprocedural complications. PCI is thus a safe and effective treatment modality in multivessel coronary artery disease, and can be considered as a viable first-line alternative in properly selected patients.

The results of this investigation infer that although coronary artery bypass grafting (CABG) still demonstrates some long-term benefits in patients with multivessel coronary artery disease (MVD), percutaneous coronary intervention (PCI) with drug-eluting stent (DES) is still a worthwhile and effective option, especially given its less invasive nature and good short- to mid-term results. Kaplan-Meier analysis revealed greater event-free survival in the CABG group during follow-up, but the absolute survival rate differences between PCI and CABG decreased during early follow-up, highlighting that PCI is similarly beneficial in most patients. These findings are consistent with earlier research and indicate that whereas CABG may be advantageous for specific high-risk groups, PCI is a desirable option with reasonable long-term outcomes.

Verdoia et al. (2018) performed a large meta-analysis of PCI vs CABG in patients with LMCAD or MVD during the drug-eluting stent era and determined that CABG was superior to PCI with regard to a lower risk of major adverse cardiac events (MACE) and repeat revascularization (Verdoia et al., 2018) [9]. Our research replicates the disparity in repeat revascularization rates but also points out that PCI outcomes, such as all-cause mortality and myocardial infarction, were not significantly worse. Equally, Fanari et al. (2014) conducted a meta-analysis among diabetic patients and concluded that CABG was associated with better survival and reduced repeat procedures; however, our data indicate that PCI can also produce good results among selected diabetic patients, particularly if complete revascularization is possible (Fanari et al., 2014) [10].

In another study by Fanari et al. (2015), it was shown that CABG offered better long-term outcomes in patients with MVD (Fanari et al., 2015) [11]. Although our findings reflect the same directions, differences in important endpoints like mortality and myocardial infarction between the groups were not statistically significant, favoring the hypothesis that PCI might provide virtually equivalent survival benefits in well-selected patients. These observations suggest that PCI should never be considered as a suboptimal strategy, particularly in cases where patient comorbidities or personal preferences are in favor of a less aggressive technique.

Bangalore et al. (2016) identified CABG as better for patients with serious LV dysfunction based on lower MACE and mortality (Bangalore et al., 2016) [12]. Although CABG might very well offer more durability in the case of complicated or high-risk anatomy, what our results establish is that the outcomes of PCI were also comparable and not materially different in the case of mortality. The success of PCI in providing good mid-to-long-term outcomes justifies its ongoing application in non-surgical candidates or those opting for less invasive therapy.

Kapur et al. (2010) pointed towards the benefit of CABG in patients with diabetes through a decreased MACE rate of five years (Kapur et al., 2010) [13]. In the current study, despite lower repeat revascularization for CABG among diabetics, PCI presented with reasonable results, and a statistically significant difference in mortality did not arise. This reinforces taking patient profiles as well as the complexity of the lesions into account while planning treatments instead of strictly following a universal approach.

Yang et al. (2017) showed improved results with CABG for unprotected left main bifurcation lesions, with reduced repeat revascularization and cardiovascular mortality (Yang et al., 2017) [14]. While our evidence supports reduced revascularization with CABG, they also affirm that PCI can deliver comparable survival rates, thus rendering it a viable alternative in appropriately selected anatomical situations, particularly with contemporary-generation stents and modern PCI technology.

Palmerini et al. (2017) found that CABG was better regarding MI and risk of revascularization in unprotected left main disease (Palmerini et al., 2017) [15]. Our results demonstrate similar trends, though again, mortality differences were not significant. This indicates that PCI cannot be ruled out as inferior, particularly when revascularization can be optimized and patients are properly selected.

In general, this research adds balance to the argument between CABG and PCI. Although CABG still has some long-term benefits, such as lower repeat revascularization, PCI is not a second-class strategy when overall survival and MACE in MVD patients are considered. The decreased invasiveness, reduced hospitalization time, and similar results in a number of important domains are in favor of PCI as an appropriate and patient-friendly alternative. With continued improvement in PCI technology, the treatment decision must be based on anatomical factors, comorbidities in patients, and shared decision-making. Additional randomized trials with longer follow-up will allow further optimization of these decisions and determination of the patient subgroups most likely to gain benefit from either strategy.

These results suggest that although coronary artery bypass grafting (CABG) has some long-term benefits—specifically in decreasing repeat revascularization and improving event-free survival—percutaneous coronary intervention (PCI) is still a non-inferior and viable option for patients with multivessel coronary artery disease (MVD) and left main coronary artery disease (LMCAD). While Kaplan-Meier survival analysis was in favor of CABG based on event-free survival, overall survival outcome between the two groups was similar, and the difference was not statistically significant. This points towards the usefulness of PCI, particularly with its minimally invasive procedure, reduced length of hospital stay, and quick recovery. The findings are consistent with previous research indicating that the best revascularization strategy should be determined by patient-specific characteristics, anatomical complexity, comorbidities, and clinical judgment. CABG can still be the best option in high-risk or complex situations, especially in diabetics or diffuse disease, but PCI should not be considered second-rate when done with proper case selection and contemporary techniques. Additional long-term research is indicated to further refine patient selection and maximize outcomes in both modalities.

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