From the Guidelines
The most recent and highest quality evidence suggests that CABG is the preferable option for patients with triple vessel disease, particularly those with diabetes and multivessel disease, including the LAD, who have acceptable surgical risk. The 2023 AHA/ACC clinical performance and quality measures for coronary artery revascularization report 1 highlights the survival benefit and decreased repeat revascularizations in patients who undergo CABG with a LIMA to the LAD. Key points to consider include:
- The FREEDOM trial compared CABG with PCI in 1,900 patients with diabetes and multivessel disease, showing a higher all-cause mortality rate in the PCI group than in the CABG group 1.
- A meta-analysis showed consistent results, with a nearly 50% higher 5-y mortality rate among patients treated with PCI compared with CABG 1.
- The benefit of CABG appeared to be unrelated to the complexity of disease, and patients with diabetes and a high surgical risk are now often treated with PCI, but CABG is still the preferable option for those with acceptable surgical risk 1.
- The 2011 ACCF/AHA guideline for coronary artery bypass graft surgery also supports CABG as a reasonable option to improve survival in patients with complex 3-vessel CAD, with or without involvement of the proximal LAD artery, who are good candidates for CABG 1. However, it is essential to consider individual patient factors, such as surgical risk and disease complexity, when making treatment decisions. In terms of specific treatment recommendations, CABG with a LIMA graft is a reasonable option to improve survival in patients with significant (>70% diameter) stenosis in the proximal LAD artery and evidence of extensive ischemia 1. Ultimately, the choice between CABG and PCI should be based on a comprehensive evaluation of the patient's condition, including their medical history, disease severity, and personal preferences.
From the Research
Landmark Study Comparison of CABG vs Stent in Triple Vessel Disease
- The SYNTAX trial 2 compared coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) using drug-eluting stents in patients with triple-vessel disease.
- The study found that CABG resulted in significantly lower rates of major adverse cardiac and cerebrovascular events (MACCE) compared to PCI (24.2% vs 37.5%, P < 0.001).
- The rates of death, myocardial infarction, and repeat revascularization were also lower in the CABG group compared to the PCI group.
Comparison of Outcomes
- A study published in the New England Journal of Medicine 3 found that CABG resulted in lower rates of major adverse cardiac or cerebrovascular events at 12 months compared to PCI (12.4% vs 17.8%, P = 0.002).
- Another study published in the American Journal of Cardiology 4 found that CABG resulted in lower rates of death, myocardial infarction, and stroke at 5 years compared to PCI (24.0% vs 28.2%, P = 0.006).
- A study published in Catheterization and Cardiovascular Interventions 5 found that PCI using sirolimus-eluting stents resulted in comparable 5-year outcomes to CABG in terms of death, myocardial infarction, and stroke, but with a higher risk of repeat revascularization.
Hybrid Revascularization
- A study published in Catheterization and Cardiovascular Interventions 6 compared hybrid revascularization with conventional CABG in patients with complex triple-vessel disease and found that hybrid revascularization was associated with increasing rates of major adverse cardiovascular events during 2 years of follow-up.