Is coronary artery bypass graft (CABG) recommended for patients with triple vessel disease in the left coronary artery?

CABG is Strongly Recommended for Triple Vessel Disease

For patients with triple vessel disease involving the left coronary artery system, coronary artery bypass grafting (CABG) is the definitive treatment of choice and should be performed to improve survival, reduce myocardial infarction, and decrease the need for repeat revascularization.

Primary Recommendation

CABG is a Class I recommendation (highest level) for all patients with three-vessel disease, with the survival benefit being even greater when left ventricular ejection fraction is less than 0.50. 1

The evidence supporting CABG over medical therapy alone or percutaneous coronary intervention (PCI) is robust:

• CABG significantly reduces mortality compared to PCI in three-vessel disease patients, with 5-year all-cause death rates of 9.2% for CABG versus 14.6% for PCI 2
• CABG reduces myocardial infarction risk (4.0% vs 9.2% with PCI at 5 years) 2
• CABG dramatically lowers repeat revascularization rates (12.6% vs 25.4% with PCI) 2
• Stroke rates are equivalent between CABG and PCI (3.5% vs 3.0%), eliminating this as a deciding factor 2

Clinical Context Matters

For Patients with Preserved LVEF and No Diabetes

CABG remains the preferred strategy, though PCI becomes an acceptable alternative only in patients with low-to-intermediate anatomic complexity (SYNTAX score ≤22) where complete revascularization can be achieved. 1

The SYNTAX trial demonstrated that in patients with low SYNTAX scores (0-22), CABG and PCI had similar major adverse cardiac and cerebrovascular event rates (26.8% vs 33.3%), though PCI still required significantly more repeat revascularization 2, 3

For Patients with Diabetes

CABG is mandatory over both medical therapy and PCI in diabetic patients with three-vessel disease. 1 The mortality benefit is substantially amplified in diabetics, with hazard ratios showing more than double the benefit compared to non-diabetics 2

For Patients with Reduced LVEF (≤35%)

CABG should be performed when significant viable myocardium is present, particularly with proximal LAD involvement or two- to three-vessel disease. 1 The survival benefit of CABG is greatest in this population 1

Anatomic Complexity Determines Urgency

For patients with intermediate (SYNTAX score 23-32) or high (≥33) anatomic complexity, CABG demonstrates clear and unequivocal superiority with major adverse event rates of 25.8% vs 36.0% (intermediate) and 26.8% vs 44.0% (high) for CABG vs PCI respectively 3

PCI should not be performed in patients with high SYNTAX scores (≥33) and three-vessel disease - this is a Class III recommendation (contraindicated) 1

Surgical Technique Considerations

The left internal mammary artery (LIMA) to the left anterior descending (LAD) artery is mandatory in every CABG procedure - this is a Class I recommendation with the highest long-term patency rates exceeding 90% at 10 years 1, 4, 5

Multiple arterial grafting (MAG) provides superior long-term survival compared to single arterial grafting (SAG) in three-vessel disease, with adjusted hazard ratios of 0.55 for MAG versus 0.68 for SAG when compared to PCI 6

Common Pitfalls to Avoid

• Do not defer CABG in asymptomatic or mildly symptomatic patients - the survival benefit exists regardless of symptom severity in three-vessel disease 1
• Do not choose PCI based solely on patient preference for "less invasive" treatment when anatomic complexity is intermediate or high - the mortality difference is substantial 2, 3
• Do not perform emergency CABG within 3-7 days of acute MI unless there is ongoing ischemia with hemodynamic compromise, as surgical mortality is elevated during this window 1
• Do not withhold CABG in elderly patients based on age alone - the benefit-to-risk ratio remains favorable when surgical risk is acceptable 1

When PCI May Be Considered

PCI is only an acceptable alternative in the narrow subset of patients who meet ALL of the following criteria:

• Low SYNTAX score (0-22) 1
• No diabetes 1
• Preserved LVEF 1
• Complete revascularization achievable with PCI 1
• Patient acceptance of significantly higher repeat revascularization rates 2

Even in this select group, CABG remains the preferred option and should be recommended first. 1