What are the conditions in Coronary Artery Disease (CAD) where Percutaneous Coronary Intervention (PCI) is preferred and where Coronary Artery Bypass Grafting (CABG) is preferred?

Conditions in CAD Where PCI vs. CABG is Preferred

In coronary artery disease, CABG is generally preferred over PCI for patients with complex multivessel disease, diabetes, or left main disease with high SYNTAX scores, while PCI is preferred for less complex disease, high surgical risk patients, and single-vessel disease not involving the proximal LAD. 1

Left Main Coronary Artery Disease

CABG Preferred:

• Left main disease with high anatomical complexity (SYNTAX score >22) 1
• Left main disease with concomitant multivessel disease 1
• Left main disease in patients who are good surgical candidates 1

PCI Preferred:

• Left main disease with low anatomical complexity (SYNTAX score ≤22) 1
• Left main disease in patients with high surgical risk (STS-predicted risk of operative mortality >5%) 1
• Unstable angina/NSTEMI patients who are not CABG candidates 1
• STEMI with distal coronary flow TIMI grade 3 when PCI can be performed more rapidly and safely than CABG 1
• Ostial or trunk left main lesions (rather than bifurcation) 1

Multivessel Coronary Artery Disease

CABG Preferred:

• Three-vessel disease, especially with complex anatomy (SYNTAX score >22) 1, 2
• Multivessel disease with diabetes mellitus 1, 3
• Multivessel disease with left ventricular dysfunction (EF 35-50%) 1
• Multivessel disease with proximal LAD involvement 1
• Complex coronary anatomy with heavy calcification, severe tortuosity, or complex bifurcations 1

PCI Preferred:

• Three-vessel disease with low anatomical complexity (SYNTAX score ≤22) 1, 2
• Multivessel disease in patients with high surgical risk (moderate-severe COPD, disability from prior stroke, prior cardiac surgery) 1
• Multivessel disease in patients who are poor candidates for surgery 1

Single or Double Vessel Disease

CABG Preferred:

• Complex single or double-vessel disease involving the proximal LAD that is less amenable to PCI 1
• Single-vessel proximal LAD disease when LIMA graft can be used (for long-term benefit) 1

PCI Preferred:

• Single or double-vessel disease not involving the proximal LAD 1
• Single-vessel disease (except proximal LAD) 1
• Previous CABG with graft failure and suitable anatomy for PCI 1

Special Clinical Scenarios

CABG Preferred:

• Survivors of sudden cardiac death with presumed ischemia-mediated ventricular tachycardia 1
• Severe LV dysfunction (EF <35%) when viable myocardium is present 1
• Extensive ischemia (>20% of myocardium) 1

PCI Preferred:

• Acute STEMI requiring immediate reperfusion 4
• High bleeding risk patients who cannot tolerate prolonged dual antiplatelet therapy 1
• Patients with anatomically complex lesions when guided by intracoronary imaging (IVUS or OCT) 1

Decision-Making Algorithm

1. Assess anatomical complexity:

   • Calculate SYNTAX score (low ≤22, intermediate 23-32, high ≥33)
   • Evaluate specific lesion characteristics (calcification, bifurcations, tortuosity)

2. Evaluate patient factors:

   • Diabetes status (favors CABG)
   • Left ventricular function (EF <35% generally favors CABG if viable myocardium)
   • Surgical risk (STS score >5% may favor PCI)
   • Comorbidities (COPD, prior stroke, renal dysfunction)

3. Apply evidence-based recommendations:

   • Left main disease: CABG for complex anatomy, PCI for simple anatomy
   • Three-vessel disease: CABG generally preferred, especially with diabetes
   • Single/double vessel: PCI generally preferred unless proximal LAD involved

Important Considerations

• Heart Team approach is strongly recommended for complex cases 1
• Complete revascularization is an important goal with either strategy 1
• Stroke risk is generally higher with CABG, while repeat revascularization risk is higher with PCI 3, 5
• Functional assessment of lesions using FFR/iFR is recommended to guide PCI decision-making in multivessel disease 1
• Intracoronary imaging (IVUS/OCT) should be used for complex PCI, particularly left main interventions 1

The choice between PCI and CABG should be based on a structured assessment of coronary anatomy, clinical factors, and patient preferences, with the Heart Team playing a crucial role in complex cases to optimize outcomes related to mortality, morbidity, and quality of life.