CABG is Superior to PTCA for Triple Vessel Disease
For patients with coronary artery disease and triple vessel disease, CABG is the recommended treatment over PCI (modern term for PTCA), as it significantly reduces mortality, myocardial infarction, and repeat revascularization compared to percutaneous intervention. 1
Primary Recommendation Based on Disease Complexity
CABG is mandatory for all patients with three-vessel disease when anatomic complexity is intermediate to high (SYNTAX score >22). 1 The 2024 ESC Guidelines provide Class I, Level A evidence that CABG improves symptoms, survival, and other outcomes in patients with significant three-vessel disease, preserved LVEF, no diabetes, and insufficient response to guideline-directed medical therapy. 1
When PCI Becomes Acceptable (Narrow Exception)
PCI is only recommended as an alternative when ALL of the following criteria are met: 1
- Low-to-intermediate anatomic complexity (SYNTAX score ≤22)
- PCI can provide equivalent completeness of revascularization to CABG
- Preserved left ventricular ejection fraction
- No diabetes mellitus
- Patient is at low surgical risk
This represents a Class I, Level A recommendation, but the guidelines emphasize this is acceptable "given its lower invasiveness and generally non-inferior survival" - not because it is superior. 1
Mortality and Morbidity Outcomes
The SYNTAX trial at 5-year follow-up demonstrated that PCI resulted in significantly higher rates of major adverse cardiac and cerebrovascular events (37.5% vs. 24.2%, P < 0.001) compared to CABG. 2 More specifically:
- All-cause death: 14.6% (PCI) vs. 9.2% (CABG), P = 0.006 2
- Myocardial infarction: 9.2% (PCI) vs. 4.0% (CABG), P = 0.001 2
- Repeat revascularization: 25.4% (PCI) vs. 12.6% (CABG), P < 0.001 2
- Stroke rates were similar: 3.0% (PCI) vs. 3.5% (CABG), P = 0.66 2
A 2013 meta-analysis confirmed that CABG should be recommended in patients with multivessel CAD if the severity of coronary disease is deemed complex (SYNTAX >22) due to lower cardiac events. 3
Special Population: Diabetes Mellitus
For patients with diabetes and triple vessel disease, CABG is mandatory over both medical therapy and PCI, regardless of anatomic complexity. 1 This is a Class I, Level A recommendation. The 2024 ESC Guidelines state that CABG improves symptoms and outcomes in diabetic patients with multivessel disease. 1
The SYNTAX trial subgroup analysis showed differences in major adverse events between PCI and CABG were larger in diabetics (hazard ratio = 2.30) than non-diabetics (hazard ratio = 1.51). 2 A meta-analysis demonstrated 5-year MACCE of 18.7% for CABG vs. 26.6% for PCI in diabetic patients (P = 0.005). 3
Special Population: Left Ventricular Dysfunction
In patients with triple vessel disease and LVEF ≤35%, CABG is recommended over medical therapy alone to improve long-term survival. 1, 4 This is a Class I, Level B recommendation from the 2024 ESC Guidelines. 1
The American College of Cardiology confirms that CABG is a Class I treatment for all patients with three-vessel disease, with the survival benefit being even greater when left ventricular ejection fraction is less than 0.50. 5
Quality of Life Considerations
CABG provides superior angina relief compared to PCI at 5-year follow-up, particularly in patients with high SYNTAX scores. 6 The SYNTAX trial quality-of-life analysis showed that CABG was superior to DES-PCI on several Seattle Angina Questionnaire domains including angina frequency and physical function. 6
The interaction between angiographic complexity and angina relief was significant: mean difference in SAQ angina frequency score for CABG vs. PCI was -0.9,3.3, and 3.9 points for low, intermediate, and high SYNTAX score patients, respectively (P = 0.048 for interaction). 6
Critical Contraindications to PCI in Triple Vessel Disease
PCI should NOT be performed in patients with high SYNTAX scores (≥33) and three-vessel disease - this is a Class III recommendation (contraindicated). 5 The evidence demonstrates clear CABG superiority in terms of MACCE, death, MI, and repeat revascularization in intermediate (23-32) or high (≥33) SYNTAX score terciles. 2
Common Pitfalls to Avoid
Do not defer CABG in asymptomatic or mildly symptomatic patients with triple vessel disease. 5 The survival benefit exists regardless of symptom severity in three-vessel disease. 5
Do not withhold CABG in elderly patients based on age alone. 5 The benefit-to-risk ratio remains favorable when surgical risk is acceptable. 5
Do not perform emergency CABG within 3-7 days of acute MI unless there is ongoing ischemia with hemodynamic compromise. 5 Surgical mortality is elevated during this window. 5
Do not select PCI simply because it is "less invasive" when CABG is indicated. 1 While PCI has shorter hospital stays and recovery times, the long-term outcomes favor CABG in most triple vessel disease patients. 2, 3
Heart Team Approach
It is recommended that physicians select the most appropriate revascularization modality based on patient profile, coronary anatomy, procedural factors, LVEF, preferences, and outcome expectations through a Heart Team discussion. 1 However, this does not mean equipoise exists - the guidelines clearly favor CABG for most triple vessel disease patients. 1
Calculation of the SYNTAX score is recommended to assess the anatomical complexity of disease in patients with multivessel obstructive CAD. 1 This is a Class I, Level B recommendation. 1
Surgical Technique Considerations
The left internal mammary artery (LIMA) to the left anterior descending (LAD) artery is mandatory in every CABG procedure, with long-term patency rates exceeding 90% at 10 years. 5 The 2022 ACC/AHA Guidelines recommend using a radial artery as a surgical revascularization conduit in preference to a saphenous vein conduit for the second most important target vessel. 1