Several randomized clinical trials have demonstrated the superiority of coronary artery bypass grafting (CABG) over percutaneous coronary intervention (PCI) in patients with left main coronary artery (LMCA) disease or three-vessel disease. Therefore, current guidelines recommend CABG as the preferred strategy in these patients, provided there is no excessive surgical risk.
In recent decades, due to advances in PCI, studies have explored whether the outcomes of patients undergoing PCI could match or even surpass those treated with CABG. Although second-generation drug-eluting stents (DES) and fractional flow reserve (FFR)-guided PCI significantly improved outcomes, the FAME 3 trial (Fractional Flow Reserve versus Angiography for Multivessel Evaluation) failed to demonstrate the non-inferiority of FFR-guided PCI compared with CABG in multivessel disease.
More recently, the use of intravascular imaging (IVI) in PCI has shown additional potential to further optimize outcomes, particularly in complex coronary lesions. In this context, reassessing the role of IVI-guided PCI versus CABG in patients with LMCA or three-vessel disease is highly relevant to current clinical practice.
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The aim of this study, based on the RENOVATE-COMPLEX-PCI trial (Percutaneous Coronary Intervention Guided by Intravascular Imaging versus Angiography for Complex Coronary Artery Disease) and institutional PCI and CABG registries, was to compare clinical outcomes in patients with LMCA or three-vessel disease treated with IVI-guided PCI versus CABG.
The primary endpoint (PEP) was a composite of all-cause death, nonfatal myocardial infarction (MI), or stroke at 3 years. The secondary endpoint (SEP) included all-cause death, nonfatal MI, stroke, cardiac death, and clinically driven repeat revascularization.
A total of 6962 patients with LMCA or three-vessel disease were analyzed from the RENOVATE-COMPLEX-PCI trial (1639 patients) and the Samsung Medical Center registry (2972 PCI patients and 6600 CABG patients). In the study population, 848 patients underwent IVI-guided PCI, 987 angiography-guided PCI, and 5127 CABG. The mean age was 66 years, and most were male.
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Patients treated with PCI had a significantly higher risk of the primary endpoint compared with those undergoing CABG (13.3% vs. 10.8%; HR: 1.23; 95% CI: 1.05–1.44; p = 0.013). However, the risk of the primary endpoint was comparable between IVI-guided PCI and CABG (8.7% vs. 10.8%; HR: 0.77; 95% CI: 0.59–1.01; p = 0.058). Propensity score analysis showed similar results (9.5% vs. 9.4%; HR: 0.98; 95% CI: 0.69–1.40; p = 0.914).
Conclusion
In patients with LMCA or multivessel disease, PCI was associated with a significantly higher risk of death, nonfatal MI, or stroke compared with CABG. However, IVI-guided PCI showed comparable outcomes to CABG. Further randomized controlled trials are needed to confirm these findings.
Original Title: Intravascular Imaging-Guided PCI vs Coronary Artery Bypass Grafting for Left Main or 3-Vessel Disease.
Reference: Sang Yoon Lee, MD et al JACC Cardiovasc Interv. 2025.
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