Perspective

Coronary artery bypass grafting (CABG) vs. percutaneous

coronary intervention (PCI) in the treatment of multivessel
coronary disease: quo vadis? —a review of the evidences on
coronary artery disease
Cristiano Spadaccio1,2, Umberto Benedetto3
1
Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Clydebank, Glasgow, UK; 2Institute of Cardiovascular and Medical
Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK; 3Bristol Heart Institute, University of Bristol,
School of Clinical Sciences, Bristol, UK
Correspondence to: Umberto Benedetto, MD, PhD. Bristol Heart Institute, University of Bristol, School of Clinical Sciences, Level 7, Bristol Royal
Infirmary, Upper Maudlin Street, Bristol BS2 8HW, UK. Email: [email protected].

The optimal treatment of ischemic coronary artery disease (CAD) is still controversial. A number of
randomized controlled trials (RCT) and several meta-analyses have been performed and are inspiring the
current guidelines. However, a univocal consensus on the optimal therapeutic strategy for multivessel
disease has still not been reached yet. We reviewed the current evidence on this topic, focusing on both
RCT and meta-analyses. From both short and long-term studies, it emerges that in patients with multivessel
disease, coronary artery bypass grafting (CABG) is associated with better survival, lower rates of major
cardiovascular events (specifically myocardial infarction or stroke) and repeat revascularization as compared
with percutaneous coronary intervention (PCI) with drug-eluting stents.

Keywords: Coronary artery bypass grafting (CABG); percutaneous coronary intervention (PCI); multivessel
disease (MVD)

Submitted Apr 14, 2018. Accepted for publication May 28, 2018.
doi: 10.21037/acs.2018.05.17
View this article at: http://dx.doi.org/10.21037/acs.2018.05.17

Introduction PCI and CABG with regards to safety outcomes, with an

increase in repeat revascularization in PCI and a marginal
The optimal treatment of ischemic coronary artery
increase in strokes in CABG (7-11), in the more common
disease (CAD) is still at the center of a heated debate. A
situation of multivessel disease (MVD) an acceptable
number of randomized trials (RCTs) and a plethora of
retrospective studies investigated the outcomes and risk/ level of agreement has not been reached yet. Several
benefit balance of the two accepted approaches in CAD, confounding factors inherent to the nature of both RCT
namely percutaneous coronary intervention (PCI) and and meta-analyses (i.e., statistical underpower, selection
coronary artery bypass grafting (CABG) surgery. These bias, inclusion of both LM disease and MVD, etc.) could
trials have inspired the current guidelines, despite the have conspired against the possibility to reach an unbiased
presence of some unsolved questions (1). In this context, conclusion. The difficulty in generalizing the results to the
efforts have been undertaken in order to elucidate the best real-life scenario of CAD might have played an additional
treatment for unprotected left main (LM) disease, and up- role. Moreover, the currently published systematic reviews
to-date meta-analyses of RCTs have been performed with cumulating the results of the available RCTs are often
this aim in mind (2-6). If the general consensus for LM in disagreement, preventing a definitive analysis of the
disease seems to be trending towards the equivalence of evidence on the topic at present. Therefore, we reviewed

© Annals of Cardiothoracic Surgery. All rights reserved. www.annalscts.com Ann Cardiothorac Surg 2018;7(4):506-515
Annals of cardiothoracic surgery, Vol 7, No 4 July 2018 507

the current literature and the available meta-analyses data and 21% for PCI at 2 years follow-up, while the risk for
on the comparison between PCI and CABG focusing on nonfatal MI was 15% for CABG and 6.2% for PCI (18)
MVD only. (Table 1).

The clinical trials The meta-analyses

Since the advent of drug-eluting stents (DES) and the Despite the significance of the conclusion reached by
evidence attesting to their superiority over bare metal the aforementioned RCTs, several meta-analyses have
stents (12), several trials have been published investigating been performed with the aim of circumventing the issues
PCI outcomes in comparison to CABG. The BEST pertaining to being under-powered.
investigators undertook an RCT to demonstrate non- Our group performed a systematic review and meta-
inferiority of Everolimus eluting stent in respect to CABG. analysis of five RCTs, encompassing a total of 4,563
Despite being abandoned due to slow recruitment, the patients with MVD (19). PCI with DES was associated with
trials produced results from more than 800 patients, a 154% increased relative risk of repeat revascularization,
demonstrating an occurrence of the primary endpoint, late mortality (increased by 51%) and MI (increased by
a composite of death due to myocardial infarction (MI) 102%) when compared to CABG. On the hand, CABG was
or target-vessel revascularization at 2 years, of 11.0% in hampered by a 29% increase risk of stroke, but the absolute
the patients in the PCI group and of 7.9% in those in the risk increase in stroke was minimal when compared with
CABG group with a still significant difference at longer the absolute risk reduction in mortality and MI. A number-
follow-up [median, 4.6 years (15.3% of the patients in the to-treat analysis demonstrated that placing CABG over
PCI group and in 10.6% of those in the CABG group)] (13). DES-PCI in 100 subjects, 3–4 deaths, 4–5 MI and 8–9
The SYNTAX trial tested non-inferiority of PCI versus repeat revascularizations would be prevented at the expense
CABG in 1,800 patients. Non-inferiority criteria were not of one extra stroke after an average follow-up of 3.4 years.
met as rates of major adverse cardiac or cerebrovascular Interestingly, subgroup analysis suggested that CABG
events at 12 months were significantly higher in the PCI would improve survival and minimize the risk of subsequent
group (17.8%, vs. 12.4% for CABG). This was thought MI independent of the presence of diabetes. Conversely,
to be due to an increased rate of repeat revascularization the increased risk of stroke associated with CABG might be
(13.5% vs. 5.9%) in the PCI group (14,15). The CARDia of clinical significance only in diabetic patients.
trial was the first examining the treatment of CAD Moreover, the results of this meta-analysis refuted the
in a subgroup of diabetic patients, demonstrating the existing dogmatic view that the survival benefit guaranteed
superiority of CABG in this subset with combined rates by CABG is only relevant to three-vessel disease.
of mortality, MI, stroke and repeated revascularization Conversely, the benefit of CABG was also significant in
of 11.3% in the CABG group and 19.3% in the PCI the presence of two vessel disease and/or proximal left
group at 1 year (16). The FREEDOM trial confirmed descending artery disease. On the other hand, data showed
these findings in 1,900 patients with complex MVD and that the increased risk of subsequent MI following DES-
diabetes, demonstrating comparatively worse 5-year rates PCI was likely to be significant only in cases of three-vessel
of a composite outcome, including death from any cause, disease (19).
nonfatal MI, or nonfatal stroke, in the PCI group (26.6% Another large meta-analysis encompassing seven RCTs
vs. 18.7% in the CABG group). Despite the incidence for a total 5,835 patients confirmed the results of the
of stroke being higher in CABG cohort, death and MI previously mentioned study, demonstrating a reduction
were significantly higher in the PCI group, leading to the in the mortality risk, MI and repeated revascularization in
conclusion that diabetic population would best benefit CABG versus first generation DES, at the expense of an
from CABG rather than PCI (17). increased stroke risk (20).
Subsequently, the VA-CARDS investigators reported Sipahi and colleagues performed another review
the results of a randomized trial comparing interventions including six randomized studies (N=6,055), with their
exclusively with drug-eluting stents and surgery in patients meta-analysis illustrating a significant reduction in total
with diabetes and high-complex CAD. Despite being mortality, MI, and repeat revascularization with CABG
underpowered, all-cause mortality was 5.0% for CABG compared with PCI (21). However, unlike the previous

© Annals of Cardiothoracic Surgery. All rights reserved. www.annalscts.com Ann Cardiothorac Surg 2018;7(4):506-515
 Table 1 Overview of randomized controlled trials
508
Syntax Patients assigned Medically
Study Number Mean Median
score Male treated
(year of Country Inclusion criteria of vessels age Stents used follow-up
mean CABG DES-PCI gender diabetes
publication) diseased (years) (years)
(≥33) (on insulin)

CARDia, United Diabetics with multivessel NR 3VD: 63% 242 248 64 74% 100% (38%) SES (69%) 1
2010 (16) Kingdom and disease including PLAD 2VD: 32% BMS (31%)
Ireland PLAD: 5%

FREEDOM, Multinational Diabetes and stenosis of 26 (19%) 3VD: 83% 947 953 63 71% 100% (32%) SES (51%) 3.8
2012 (17) more than 70% in two 2VD: 17% PES (43%)
or more major epicardial
vessels

VA CARDS, US Diabetics with multivessel 22 (13%) 3VD: 63% 97 101 62 99% 100% (47%) SES (20%) 2
2013 (18) disease including PLAD 2VD: 24% PES (35%)
PLAD: 13% EES (18%)

© Annals of Cardiothoracic Surgery. All rights reserved.

ZES (2%)
MIXED (16%)
BMS (1%)

SYNTAX*, Multinational Significant stenosis in 28, NR 3VD: 100% 549 546 64 80% 27% (11%) PES 5
2014 (15) vessels supplying all three 2VD: 0%
major epicardial territories

BEST South Korea, Stenosis of more than 24 (16%) 3VD: 77% 442 438 64 72% 41% (4%) EES 2
TRIAL, China, 70% of the vessel 2VD: 23%
2015 (13) Malaysia, diameter in major

www.annalscts.com
and Thailand epicardial vessels in the
territories of at least two
coronary arteries

*, subgroup analysis. 3VD, three-vessel disease; 2VD, two-vessel disease; PLAD, proximal left anterior descending artery disease; DES-PCI, drug-eluting stent
percutaneous coronary intervention; CABG: coronary artery bypass grafting; BMS, bare-metal stent; SES, sirolimus-eluting stent; PES, paclitaxel-eluting stent; ZES,
zotarolimus-eluting stent; EES, everolimus eluting stent; NR, not reported.

Ann Cardiothorac Surg 2018;7(4):506-515

Spadaccio and Benedetto. CABG vs. PCI
Annals of cardiothoracic surgery, Vol 7, No 4 July 2018 509

studies, these authors found a trend toward excess strokes revascularization is associated to increased mortality and
with CABG, but this was not significant. The conclusions repeated revascularization independently on the mode
drawn suggest CABG as the best treatment option of treatment (27). Zimarino and colleagues echoed those
in patients with MVD compared with PCI, given the results in another meta-analysis of 28 studies reporting on
undisputable reduction in long-term mortality, MIs and clinical outcomes of MVD patients treated with complete
repeat revascularizations, irrespective of the presence of and incomplete revascularization, with extensive (>80%)
diabetes (21). use of stents for PCI or arterial conduits in CABG. They
An interesting work has been recently reported by achieved similar results and demonstrated a larger clinical
Fanari and colleagues, who performed a meta-analysis of benefit of complete revascularization in diabetic patients.
six RCTs and investigated the results of the long-term Interestingly, the survival benefit and reduction in relative
follow-up of the studies. Despite potential bias due to the risk of cardiovascular events was better in the patients
presence of an additional RCT involving unprotected LM enrolled in the more recent studies (28).
disease (22), this study demonstrated that at 1 year, PCI was More recently, Lee et al. in a meta-analysis of 3,280
associated with a significantly higher incidence of target patients pooled results from the BEST (Randomized
vessel revascularization, lower incidence of stroke and no Comparison of Coronary Artery Bypass Surgery and
difference in death or MI compared to CABG. However, at Everolimus Eluting Stent Implantation in the Treatment
5 years, PCI was associated with a higher incidence of death of Patients with Multivessel Coronary Artery Disease),
and MI. Increased mortality in the PCI group was mainly PRECOMBAT (Premier of Randomized Comparison of
found in diabetics (23). Bypass Surgery vs. Angioplasty Using Sirolimus-Eluting
An ad hoc meta-analysis on MVD in the diabetic Stent in Patients with Left Main Coronary Artery Disease),
population encompassing 14 studies (five RCTs and nine and SYNTAX (Synergy Between PCI With Taxus and
observational) documented a much higher risk of repeat Cardiac Surgery) trials. The study was focused on a
intervention and adverse cardiovascular/cerebrovascular composite outcome including of all-cause death, MI, or
events in the DES/PCI cohort compared to CABG, stroke.
although early morbidities seemed to favor percutaneous The results showed that CABG, as compared with PCI
procedures (24). with DES, decreased long-term rates of the composite
A previous and similar study on diabetic population outcome and repeat revascularization, when compared
confirmed that CABG in diabetic patients with MVD at low with DES-PCI in LM or MVD, although the advantage of
to intermediate surgical risk (defined as EUROSCORE <5) CABG was more pronounced in the latter subcategory (10).
is superior to MVD PCI with DES. Despite an increase in Chang et al. reported the results of a patient-level meta-
stroke risk, CABG reduced overall death, nonfatal MI, and analysis comparing the effect of CABG versus PCI with
repeat revascularization (25). DES on long-term mortality in 1,275 nondiabetic patients
In a meta-regression analysis using event rates as a with multivessel CAD. Results showed superiority of
dependent variable to test for an interaction between CABG in terms of short and long-term mortality, MI and
baseline clinical features (i.e., age, gender, diabetes repeat revascularization, in absence of significant group
mellitus, previous MI and ejection fraction) and choice differences as far as stroke was concerned. The conclusions
of revascularization, D’Ascenzo et al. concluded that drawn echoed previous results and demonstrated
PCI significantly reduces the risk of stroke compared to superiority of CABG also in nondiabetic patients with
CABG. particularly in female patients, but the risk of multivessel CAD (29).
revascularization is increased with PCI, especially in women In a pooled analysis of individual patient-level data of the
and in those with diabetes (26). SYNTAX and BEST randomized trials, Cavalcante et al.
An interesting point has been raised in meta-analyses analyzed the outcomes of 1,166 patients in which 577 were
and systematic reviews on CAD with respect to the randomized to PCI and 589 to CABG. In patients with
comparison of outcomes in complete or incomplete MVD with proximal left anterior descending artery (LAD)
revascularization. A large preliminary investigation, involvement, CABG is associated with a significantly lower
including 35 studies and 89,883 patients, demonstrated that rate of cardiac death, MI and all-cause revascularization
complete revascularization is more commonly achieved when compared with DES-PCI. There was no difference
with CABG rather than PCI, and that incompleteness of among the groups as far as all-cause mortality and stroke

© Annals of Cardiothoracic Surgery. All rights reserved. www.annalscts.com Ann Cardiothorac Surg 2018;7(4):506-515
510 Spadaccio and Benedetto. CABG vs. PCI

were concerned, but the combined outcome of major

In patients with LM disease, CABG reduced

Incomplete revascularization has increased

In MVD patients, CABG reduced the risk of

CABG in diabetic patients with MVD at low
adverse cardiovascular and cerebrovascular events (i.e., all-

revascularization risk and increased stroke

to intermediate surgical risk (EuroSCORE

Complete revascularization is more com-

cause death, MI, stroke, revascularization) favored CABG.

mortality and RR independently on the

monly achieved with CABG than PCI
<5) is superior to MVD PCI with DES
The authors concluded that in patients with MVD CABG
was superior in terms of survival and cardiovascular events

mortality, but increased stroke

to drug-eluting stents at 5 years of follow-up (30).
Nevertheless, a recent systematic review featured in The
Lancet by Head and colleagues, including 11 randomized

mode of treatment
trials and involving a total of 11,518 patients, illustrated
equivalence in the long-term safety outcomes between the
modalities of revascularization for unprotected LM disease.
Conversely, the benefit of CABG was restricted to complex

Notes

risk
MVD and diabetic patients (31) (Table 2).

revascularization

Favors CABG

Favors CABG
Discussion

Repeat
The optimal treatment strategy for CAD remains

(RR)
controversial, as illustrated by the contradictory conclusions

–
reached even in the context of meta-analyses of the same

cerebrovascular
RCTs. Although some standpoints, such as the higher risk

Favors PCI

Favors PCI
of repeat revascularization and cardiovascular event in DES-
Stroke or

PCI remain consistent throughout the literature, the hard event

endpoints regarding early mortality, long-term survival and

–
strokes are constantly put in doubt by subsequent study
sub-analyses. The reason underlying this uncertainty might
Myocardial
infarction

find its root in the low power and statistical bias inherent in
Favors

Favors
CABG

CABG
some of the studies included in the systematic reviews.
(MI)

The mortality rate of treated CAD has dramatically

reduced over the years, independently of the mode of
Favors CABG

Favors CABG
revascularization adopted. Consequently, conspicuous
Mortality

sample sizes are required to achieve significance, given the

diminishing power of these studies. On one side, this calls
–

for new event-driven designed trials, and on the other,

6 months–
follow-up

it makes the interpretation and reliability of the results

Years at

4 years

5 years

reached by both RCTs and their systematic reviews/meta-

analyses rather difficult. The composite primary endpoint of
–

major cerebrovascular and cardiac adverse events (MACCE)

patients
number

89,883
3,052

5,835

recurrently described in every RCT represents a product

Total

of

of this issue, and has been introduced to avoid the power

Table 2 Overview of meta-analyses

limitations of these trials.

7 RCTs; MVD

From the review of both the trials and meta-analyses,

35 studies
included

it appears that the main pillar sustaining the benefit of

Studies

4 RCTs

+ LMD

CABG compared to PCI is the reduced rate of repeat

Table 2 (continued)

revascularizations, as the weight of the lower rate of

MACCEs is jeopardized by the relative increased incidence
Garcia et al.,
Author, date

Al Ali et al.,
et al., 2013

of stroke in this group. However, repeat revascularization

2013 (27)

2014 (20)
Hakeem

is considered a “soft” endpoint and no trial seems to have

(25)

been adequately powered to assess the more important

© Annals of Cardiothoracic Surgery. All rights reserved. www.annalscts.com Ann Cardiothorac Surg 2018;7(4):506-515
 Table 2 (continued)

Total
Myocardial Stroke or Repeat
Studies number Years at
Author, date Mortality infarction cerebrovascular revascularization Notes
included of follow-up
(MI) event (RR)
patients

Sipahi et al., 6 RCT 6,055 4.1 years Favors CABG Favors Non-significant Favors CABG CABG is superior to PCI independently on
2014 (21) CABG diabetes

Lim et al., 5 RCT; 9 OBS 5,000 3 to 5 years Favors CABG Favors 30 days: Favors CABG Cardiovascular/cerebrovascular event were
2014 (24) CABG favours PCI; 1.71 times higher in the DES/PCI
1–5 years: non-
significant

D’Ascenzo 20 RCT; aimed 12,844 30 days to Favors CABG Favors Favors PCI Favors CABG PCI reduces the risk of stroke in female
et al., 2014 at correlating 1 year CABG patients: PCI has increased risk of RR risk in
(26) risk factors women and in those with diabetes

Fanari et al., 6 RCT 5,123 1 and 5 1-year: non- 1 year: non- Favors PCI Favors CABG Increased death in diabetics with PCI

© Annals of Cardiothoracic Surgery. All rights reserved.

2015 (23) years significant; significant;
5-year: favors 5 years:
Annals of cardiothoracic surgery, Vol 7, No 4 July 2018

CABG favours
CABG

Zimarino et al., 28 studies 83,695 4.7 ± 4.3 – – – – CR confers benefit on outcomes more
2016 (28) years evident in diabetics

Benedetto et 5 RCT 4,563 3.4 years Favors CABG Favors Favors PCI Favors CABG PCI increase mortality by 51%; PCI increase
al., 2016 (19) CABG MI by 102%; CABG increase stroke by 29%

Lee et al., 3 RCT; MVD + 3,280 5 years MVD: favors MVD: favors Non-significant Favors CABG Overall CABG educed long-term rates of the
2016 (10) LMD CABG; CABG; composite of all-cause death, myocardial

www.annalscts.com
LMD: non- LMD: favors infarction, or stroke in patients with LMD
significant CABG and MVD

Benefit of CABG more pronounced in MVD

Chang et al., BEST + 1,275 62 months Favors CABG Favors No differences Favors CABG CABG, as compared with DES-PCI educed
2016 (29) SYNTAX in CABG the long-term risk of mortality in nondiabetic
non-diabetics patients with MVD CAD

Cavalcante BEST + 1,166 5 years Favors CABG Favors No differences Favors CABG In MVD with proximal LAD involvement,
et al., 2017 SYNTAX CABG CABG has lower rates of the composite
(30) endpoint of death, MI or stroke

Head et al., 11 RCT; MVD 11,518 5 years Favors CABG – – – CABG benefit restricted to MVD + diabetes
2018 (31) + LMD in complex
MVD and Equivalence for LMD
diabetes; LMD: Equivalence for MVD in non-diabetic
non-significant patients

MVD, multivessel disease; LMD, left main disease; CR, complete revascularization; DES-PCI, Drug-eluting stents percutaneous coronary intervention; OBS, observational;
RCT, randomized controlled trial; CABG, coronary artery bypass grafting; CAD, cardiovascular disease.

Ann Cardiothorac Surg 2018;7(4):506-515

511
512 Spadaccio and Benedetto. CABG vs. PCI

endpoint of mortality (32). Even the most recent study by territories, therefore restoring the function of ungrafted
Head et al. (31) with a sample size of more than 11,500 regions (39).
patients, despite confirming the superiority of CABG for This hypothesis finds a clinical correlate in the analysis
MVD in diabetic patients, is not in agreement with the of the NICOR registry, in which large territories that are
meta-analyses published immediately prior by Chang et al. (29) tributaries of the right coronary artery or the circumflex
and Cavalcante et al. (30). artery remain unrevascularized leading to a reduction in late
An interesting point that is emerging from the survival (35). More ad hoc studies are required to elucidate
analysis of the literature is that of the issue of incomplete the pathophysiological mechanisms and the consequent
revascularization in the two modes of revascularization. optimal strategy to be adopted in these circumstances.
Very recently, Hannan et al. reported the results of an Another point of discussion centers on the fact that
interesting registry analysis on the outcomes of incomplete the currently available RCTs are comparing the newest
revascularization in PCI in a very large cohort of generation of stenting technology with a relatively “old-
patients (33). The results of the study somehow echo the fashioned” operation; the patency rate and durability of
conclusion of the most recent follow-up of the SYNTAX venous grafts is widely known to be limited. On account
study by Milojevic et al., in which authors demonstrated of the evidence testifying to the longer-term durability of
that incomplete revascularization was an independent CABG performed with a total arterial technique, a more
predictor of mortality in the PCI group. Interestingly, in adequate comparison would be performed among the
the SYNTAX trial, incomplete revascularization did not newest stenting technology and more modern grafting
increase the risk of death or cardiac adverse events in the strategies (i.e., total arterial revascularization).
CABG arm of the study (34). These results reflect the This point is even more significant when noting that
findings of an analysis of the NICOR database including the majority of the trials and reviews, despite showing
13,701 patients who underwent CABG. After propensity non-inferiority of PCI with respect to CABG for the
score matching, incomplete revascularization did not safety endpoints in the immediate postoperative period,
increase all-cause death in the group (35). The mechanisms fail to demonstrate a sustained benefit of percutaneous
underlying this apparent inefficacy of PCI in incomplete interventions over the long-term. CABG seems to
revascularization still remains unsolved. Chronic total outperform PCI in the long-term with conduits known
occlusion—which is difficult to manage percutaneously— to have a limited life. We could imagine that even more
and post-procedural MI exacerbate the already incomplete compelling results would arise from the comparison of the
revascularization, have been advocated as culprit factors in long-term data of multiple arterial grafting trials, such as
determining mortality in PCI (36). the ART trial (40), with the long-term durability of the
These events might similarly occur in surgical settings, newest generation DES.
however, they do not constitute a significant risk factor Summarizing the current evidence from the largest
for CABG patients. From the BARI trial, we learnt that RCTs, SYNTAX demonstrated superiority of CABG
grafting left internal mammary artery (LIMA) to LAD in cases of SYNTAX scores >22 (15). The BEST (13)
determines survival independently of the presence of other and FREEDOM (17) trials showed the same superiority,
grafts and that it seems that there is no direct numeric irrespective of the SYNTAX score. A large patient level
correlation between grafts and coronary lesions to achieve meta-analysis, combining the results of SYNTAX and
clinical benefit (37). On the other hand, arterial grafts have BEST trials, concluded that CABG offers improved
been shown to release high quantities of nitric oxide (NO), outcomes when compared to DES-PCI in both and non-
a known inducer of angiogenesis, and this is thought to be diabetic and in MVD (2 or 3 vessels involved) with proximal
one of the factors at the crux of the superior outcomes of LAD involvement (30).
these conduits in CABG (38). It has been hypothesized that In conclusion, CABG remains the best revascularization
intramyocardial delivery of NO through the graft, together strategy in MVD, conferring reduced mortality and repeat
with the neoangiogenic drive initiated by the reperfusion, revascularization risk. The absolute risk increases in stroke
may account for the creation of a progressively spreading associated with CABG does not outweigh the benefit in
microvascular network of neocapillaries within the affected the long-term survival achievable with this technique of
myocardium. These territorially expand from the region revascularization.
directly subjected to revascularization to the adjacent The conclusions reached by the currently available

© Annals of Cardiothoracic Surgery. All rights reserved. www.annalscts.com Ann Cardiothorac Surg 2018;7(4):506-515
Annals of cardiothoracic surgery, Vol 7, No 4 July 2018 513

studies should be considered carefully when translating the 7. Putzu A, Gallo M, Martino EA, et al. Coronary artery
results to the real-life scenarios, which are often inclusive bypass graft surgery versus percutaneous coronary
of variegate case mixes with multiple comorbidities. In this intervention with drug-eluting stents for left main
context, the importance of the Heart Team is profound. coronary artery disease: A meta-analysis of randomized
trials. Int J Cardiol 2017;241:142-8.
8. De Rosa S, Polimeni A, Sabatino J, et al. Long-term
Acknowledgements
outcomes of coronary artery bypass grafting versus stent-
None. PCI for unprotected left main disease: a meta-analysis.
BMC Cardiovasc Disord 2017;17:240
9. Garg A, Rao SV, Agrawal S, et al. Meta-Analysis of
Footnote
Randomized Controlled Trials of Percutaneous Coronary
Conflicts of Interest: The authors have no conflicts of interest Intervention with Drug-Eluting Stents Versus Coronary
to declare. Artery Bypass Grafting in Left Main Coronary Artery
Disease. Am J Cardiol 2017;119:1942-8.
10. Lee CW, Ahn JM, Cavalcante R, et al. Coronary Artery
References
Bypass Surgery Versus Drug-Eluting Stent Implantation
1. Authors/Task Force members, Windecker S, Kolh P, for Left Main or Multivessel Coronary Artery Disease:
et al. 2014 ESC/EACTS Guidelines on myocardial A Meta-Analysis of Individual Patient Data. JACC
revascularization: The Task Force on Myocardial Cardiovasc Interv 2016;9:2481-9.
Revascularization of the European Society of Cardiology 11. Nerlekar N, Ha FJ, Verma KP, et al. Percutaneous
(ESC) and the European Association for Cardio- Coronary Intervention Using Drug-Eluting Stents Versus
Thoracic Surgery (EACTS)Developed with the special Coronary Artery Bypass Grafting for Unprotected Left
contribution of the European Association of Percutaneous Main Coronary Artery Stenosis: A Meta-Analysis of
Cardiovascular Interventions (EAPCI). Eur Heart J Randomized Trials. Circ Cardiovasc Interv 2016;9.
2014;35:2541-619. 12. Palmerini T, Benedetto U, Biondi-Zoccai G, et al. Long-
2. Makikallio T, Holm NR, Lindsay M, et al. Percutaneous Term Safety of Drug-Eluting and Bare-Metal Stents:
coronary angioplasty versus coronary artery bypass grafting Evidence From a Comprehensive Network Meta-Analysis.
in treatment of unprotected left main stenosis (NOBLE): a J Am Coll Cardiol 2015;65:2496-507.
prospective, randomised, open-label, non-inferiority trial. 13. Park SJ, Ahn JM, Kim YH, et al. Trial of everolimus-
Lancet 2016;388:2743-52. eluting stents or bypass surgery for coronary disease. N
3. Stone GW, Sabik JF, Serruys PW, et al. Everolimus- Engl J Med 2015;372:1204-12.
Eluting Stents or Bypass Surgery for Left Main Coronary 14. Serruys PW, Morice MC, Kappetein AP, et al.
Artery Disease. N Engl J Med 2016;375:2223-35. Percutaneous coronary intervention versus coronary-artery
4. Buszman PE, Buszman PP, Banasiewicz-Szkrobka I, bypass grafting for severe coronary artery disease. N Engl
et al. Left Main Stenting in Comparison with Surgical J Med 2009;360:961-72.
Revascularization: 10-Year Outcomes of the (Left Main 15. Head SJ, Davierwala PM, Serruys PW, et al. Coronary
Coronary Artery Stenting) LE MANS Trial. JACC artery bypass grafting vs. percutaneous coronary
Cardiovasc Interv 2016;9:318-27. intervention for patients with three-vessel disease: final
5. Ahn JM, Roh JH, Kim YH, et al. Randomized Trial of five-year follow-up of the SYNTAX trial. Eur Heart J
Stents Versus Bypass Surgery for Left Main Coronary 2014;35:2821-30.
Artery Disease: 5-Year Outcomes of the PRECOMBAT 16. Kapur A, Hall RJ, Malik IS, et al. Randomized
Study. J Am Coll Cardiol. 2015;65:2198-206. comparison of percutaneous coronary intervention with
6. Morice MC, Serruys PW, Kappetein AP, et al. Five-year coronary artery bypass grafting in diabetic patients.
outcomes in patients with left main disease treated with 1-year results of the CARDia (Coronary Artery
either percutaneous coronary intervention or coronary Revascularization in Diabetes) trial. J Am Coll Cardiol
artery bypass grafting in the synergy between percutaneous 2010;55:432-40.
coronary intervention with taxus and cardiac surgery trial. 17. Farkouh ME, Domanski M, Sleeper LA, et al. Strategies
Circulation 2014;129:2388-94. for multivessel revascularization in patients with diabetes.

© Annals of Cardiothoracic Surgery. All rights reserved. www.annalscts.com Ann Cardiothorac Surg 2018;7(4):506-515
514 Spadaccio and Benedetto. CABG vs. PCI

N Engl J Med 2012;367:2375-84. with multivessel coronary artery disease: a meta-analysis

18. Kamalesh M, Sharp TG, Tang XC, et al. Percutaneous of 89,883 patients enrolled in randomized clinical
coronary intervention versus coronary bypass surgery in trials and observational studies. J Am Coll Cardiol
United States veterans with diabetes. J Am Coll Cardiol 2013;62:1421-31.
2013;61:808-16. 28. Zimarino M, Ricci F, Romanello M, et al. Complete
19. Benedetto U, Gaudino M, Ng C, et al. Coronary surgery myocardial revascularization confers a larger clinical
is superior to drug eluting stents in multivessel disease. benefit when performed with state-of-the-art techniques in
Systematic review and meta-analysis of contemporary high-risk patients with multivessel coronary artery disease:
randomized controlled trials. Int J Cardiol 2016;210:19-24. A meta-analysis of randomized and observational studies.
20. Al Ali J, Franck C, Filion KB, et al. Coronary artery bypass Catheter Cardiovasc Interv 2016;87:3-12.
graft surgery versus percutaneous coronary intervention 29. Chang M, Ahn JM, Lee CW, et al. Long-Term
with first-generation drug-eluting stents: a meta-analysis Mortality After Coronary Revascularization in
of randomized controlled trials. JACC Cardiovasc Interv Nondiabetic Patients with Multivessel Disease. J Am
2014;7:497-506. Coll Cardiol 2016;68:29-36.
21. Sipahi I, Akay MH, Dagdelen S, et al. Coronary artery 30. Cavalcante R, Sotomi Y, Zeng Y, et al. Coronary bypass
bypass grafting vs percutaneous coronary intervention surgery versus stenting in multivessel disease involving the
and long-term mortality and morbidity in multivessel proximal left anterior descending coronary artery. Heart
disease: meta-analysis of randomized clinical trials of 2017;103:428-33.
the arterial grafting and stenting era. JAMA Intern Med 31. Head SJ, Milojevic M, Daemen J, et al. Mortality after
2014;174:223-30. coronary artery bypass grafting versus percutaneous
22. Boudriot E, Thiele H, Walther T, et al. Randomized coronary intervention with stenting for coronary artery
comparison of percutaneous coronary intervention with disease: a pooled analysis of individual patient data. Lancet
sirolimus-eluting stents versus coronary artery bypass 2018;391:939-48.
grafting in unprotected left main stem stenosis. J Am Coll 32. Bhatt DL. CABG the clear choice for patients with
Cardiol 2011;57:538-45. diabetes and multivessel disease. Lancet 2018;391:913-4.
23. Fanari Z, Weiss SA, Zhang W, et al. Comparison of 33. Hannan EL, Zhong Y, Berger PB, et al. Association
percutaneous coronary intervention with drug eluting of Coronary Vessel Characteristics With Outcome in
stents versus coronary artery bypass grafting in patients Patients With Percutaneous Coronary Interventions
with multivessel coronary artery disease: Meta-analysis With Incomplete Revascularization. JAMA Cardiol
of six randomized controlled trials. Cardiovasc Revasc 2018;3:123-30.
Med 2015;16:70-7. Erratum in: J Am Coll Cardiol 34. Milojevic M, Head SJ, Parasca CA, et al. Causes of
2011;57:1792. Death Following PCI Versus CABG in Complex CAD:
24. Lim JY, Deo SV, Kim WS, et al. Drug-eluting stents 5-Year Follow-Up of SYNTAX. J Am Coll Cardiol
versus coronary artery bypass grafting in diabetic patients 2016;67:42-55.
with multi-vessel disease: a meta-analysis. Heart Lung Circ 35. Benedetto U, Gaudino M, Di Franco A, et al. Incomplete
2014;23:717-25. revascularization and long-term survival after coronary
25. Hakeem A, Garg N, Bhatti S, et al. Effectiveness of artery bypass surgery. Int J Cardiol 2018;254:59-63.
percutaneous coronary intervention with drug-eluting 36. Nappi F, Sutherland FW, Al-Attar N, et al. Incomplete
stents compared with bypass surgery in diabetics with Revascularization in PCI and CABG: When Two
multivessel coronary disease: comprehensive systematic Plus Two Does Not Make Four. J Am Coll Cardiol
review and meta-analysis of randomized clinical data. J Am 2016;68:877-8.
Heart Assoc 2013;2:e000354. 37. Rastan AJ, Walther T, Falk V, et al. Does reasonable
26. D'Ascenzo F, Barbero U, Moretti C, et al. Percutaneous incomplete surgical revascularization affect early or
coronary intervention versus coronary artery bypass graft long-term survival in patients with multivessel coronary
for stable angina: meta-regression of randomized trials. artery disease receiving left internal mammary artery
Contemp Clin Trials 2014;38:51-8. bypass to left anterior descending artery? Circulation
27. Garcia S, Sandoval Y, Roukoz H, et al. Outcomes after 2009;120:S70-7.
complete versus incomplete revascularization of patients 38. Tarr FI, Sasvari M, Tarr M, et al. Evidence of nitric oxide

© Annals of Cardiothoracic Surgery. All rights reserved. www.annalscts.com Ann Cardiothorac Surg 2018;7(4):506-515
Annals of cardiothoracic surgery, Vol 7, No 4 July 2018 515

produced by the internal mammary artery graft in venous Int J Cardiol 2016;224:295-8.
drainage of the recipient coronary artery. Ann Thorac 40. Taggart DP, Altman DG, Gray AM, et al. Randomized
Surg 2005;80:1728-31. Trial of Bilateral versus Single Internal-Thoracic-Artery
39. Spadaccio C, Nappi F, Nenna A, et al. Is it time to change Grafts. N Engl J Med 2016;375:2540-9.
how we think about incomplete coronary revascularization?

Cite this article as: Spadaccio C, Benedetto U. Coronary

artery bypass grafting (CABG) vs. percutaneous coronary
intervention (PCI) in the treatment of multivessel coronary
disease: quo vadis? —a review of the evidences on coronary
artery disease. Ann Cardiothorac Surg 2018;7(4):506-515. doi:
10.21037/acs.2018.05.17

© Annals of Cardiothoracic Surgery. All rights reserved. www.annalscts.com Ann Cardiothorac Surg 2018;7(4):506-515