Multiple randomized clinical trials have demonstrated superior outcomes with coronary artery bypass grafting (CABG) vs. percutaneous coronary intervention (PCI) in patients with left main coronary artery (LMCA) disease or three-vessel disease. This is why the current guidelines recommend CABG for LMCA or multivessel disease patients unless surgical risk is exceedingly high.
However, over the past decades, major advances in PCI have prompted studies evaluating whether PCI outcomes could surpass those of CABG. Although second-generation drug-eluting stents (DES) and fractional flow reserve (FFR)-guided PCI have led to significant improved clinical outcomes, the FAME 3 trial (Fractional Flow Reserve versus Angiography for Multivessel Evaluation) failed to show non-inferiority for FFR-guided PCI vs. CABG in multivessel disease.
More recently, the introduction of intravascular imaging (IVI) has shown additional potential to improve clinical outcomes after PCI, particularly in complex coronary lesions. Considering these advances, reassessing the impact of IVI-guided PCI in LMCA or three-vessel disease patients, vs. CABG, is highly relevant to the current clinical practice.
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The aim of this study — based on the RENOVATE-COMPLEX-PCI trial (Intravascular Imaging-Guided PCI versus Angiography-Guided PCI for Complex Coronary Artery Disease) and PCI and CABG institutional registries — was to compare clinical outcomes in LMCA or three-vessel disease patients undergoing IVI-guided PCI vs. CABG.
The primary endpoint was a composite of all-cause death, nonfatal myocardial infarction (MI), or stroke at 3 years. The secondary endpoint included all-cause death, nonfatal MI, stroke, cardiac death, and clinically driven repeat revascularization.
6,962 patients with left main or 3-vessel disease from the RENOVATE-COMPLEX-PCI trial (n = 1,639) and the institutional registry of Samsung Medical Center (2,972 patients underwent PCI and 6,600 patients underwent CABG) were analyzed. Overall, 848 patients received IVI-guided PCI, 987 angiography-guided PCI, and 5,127 CABG. Patients were mostly men, mean age 66.
PCI patients showed a significantly higher risk vs CABG patients (13.3% vs. 10.8%; HR 1.23; 95% CI 1.05–1.44; P = 0.013). However, risk 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 between IVI-guided PCI and CABG (9.5% vs. 9.4%; HR 0.98; 95% CI 0.69–1.40; P = 0.914).
Conclusion
In this study, patients with LMCA or multivessel disease undergoing PCI had a significantly higher risk of all-cause death, nonfatal MI, or stroke vs patients undergoing CABG. However, IVI-guided PCI showed comparable clinical risk similar vs. CABG. Additional randomized clinical trials are required 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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