CABG Versus PCI: Greater Benefit in Long-Term Outcomes With Multiple Arterial Bypass Grafting

Abstract

Background: Treatment of multivessel coronary artery disease with traditional single-arterial coronary artery bypass graft (SA-CABG) has been associated with superior intermediate-term survival and reintervention compared with percutaneous coronary intervention (PCI) using either bare-metal stents (BMS) or drug-eluting stents (DES).

Objectives: This study sought to investigate longer-term outcomes including the potential added advantage of multiarterial coronary artery bypass graft (MA-CABG).

Methods: We studied 8,402 single-institution, primary revascularization, multivessel coronary artery disease patients: 2,207 BMS-PCI (age 66.6 ± 11.9 years); 2,381 DES-PCI (age 65.9 ± 11.7 years); 2,289 SA-CABG (age 69.3 ± 9.0 years); and 1,525 MA-CABG (age 58.3 ± 8.7 years). Patients with myocardial infarction within 24 h, shock, or left main stents were excluded. Kaplan-Meier analysis and Cox regression were used to separately compare 9-year all-cause mortality and unplanned reintervention for BMS-PCI and DES-PCI to respective propensity-matched SA-CABG and MA-CABG cohorts.

Results: BMS-PCI was associated with worse survival than SA-CABG, especially from 0 to 7 years (p = 0.015) and to a greater extent than MA-CABG was (9-year follow-up: 76.3% vs. 86.9%; p < 0.001). The surgery-to-BMS-PCI hazard ratios (HR) were as follows: versus SA-CABG, HR: 0.87; and versus MA-CABG, HR: 0.38. DES-PCI showed similar survival to SA-CABG except for a modest 0 to 3 years surgery advantage (HR: 1.06; p = 0.615). Compared with MA-CABG, DES-PCI exhibited worse survival at 5 (86.3% vs. 95.6%) and 9 (82.8% vs. 89.8%) years (HR: 0.45; p <0.001). Reintervention was substantially worse with PCI for all comparisons (all p <0.001).

Conclusions: Multiarterial surgical revascularization, compared with either BMS-PCI or DES-PCI, resulted in substantially enhanced death and reintervention-free survival. Accordingly, MA-CABG represents the optimal therapy for multivessel coronary artery disease and should be enthusiastically adopted by multidisciplinary heart teams as the best evidence-based therapy.

Keywords: arterial grafting; coronary stents; myocardial revascularization; propensity matching.

FIGURE 1. Survival After Percutaneous and Surgical CAD Treatment Modalities

Comparisons of unadjusted 9-year all-cause mortality (A) and unplanned reintervention-free (B) survival shown for all 4 coronary revascularization groups: 2,207 bare-metal stent (BMS) percutaneous coronary intervention (PCI) (age 66.6 ± 11.9 years); 2,381 drug-eluting stent (DES)-PCI (age 65.9 ± 11.7 years); 2,289 single-arterial (SA) coronary artery bypass graft (CABG) (age 69.3 ± 9.0 years); and 1,525 multiarterial (MA)-CABG (age 58.3 ± 8.7 years). The p values were derived by log-rank test. CAD = coronary artery disease.

FIGURE 2. 9-Year Mortality and Reintervention Outcomes for BMS- Versus DES-PCI

Breakdown of 9-year cumulative event rates to their all-cause mortality, planned reinterventions, and unplanned reinterventions for multivessel coronary artery disease patient cohorts treated with intracoronary stenting at their index (first) revascularization procedure: BMS-PCI cohort (A) and DES-PCI cohort (B). *Definition of planned PCI provided under Outcomes and Follow-up in the Methods section. Abbreviations as in Figure 1.

FIGURE 3. Pairwise PCI Versus CABG Comparisons of Match-Adjusted Unplanned Reintervention

Comparison of 9-year propensity-matched reintervention-free survival data for both PCI treatment cohorts with each separately compared with SA-CABG and MA-CABG surgery: (A) BMS-PCI versus SA-CABG; (B) BMS-PCI versus MA-CABG; (C) DES-PCI versus SA-CABG; and (D) DES-PCI versus MA-CABG. The p values were derived by log-rank test. Abbreviations as in Figure 1.

FIGURE 4. Pairwise Adjusted Hazard Ratios of CABG Versus PCI Modalities

Risk-adjusted 9-year all-cause mortality CABG-to-PCI hazard ratios derived for both the BMS-PCI and DES-PCI treatment cohorts when each is compared with the SA-CABG and MA-CABG surgical treatments. Solid squares reflect hazard ratios derived in matched patient cohorts (*additional adjustment for left main disease, which was not included in propensity models). Open squares reflect hazard ratios derived from all available patients using forced risk-adjustments (22 factors) via proportional hazard Cox regression. Pts = patients; other abbreviations as in Figure 1.

CENTRAL ILLUSTRATION. Optimal Revascularization of Multivessel CAD: Comparison of 9-Year Propensity Matched All-Cause Mortality Survival Data for Both PCI Treatment Cohorts

Each cohort is separately compared to single-arterial (SA) and multiarterial (MA) coronary artery bypass graft (CABG) surgery: (A) bare-metal stent (BMS) percutaneous coronary intervention (PCI) versus SA-CABG; (B) BMS-PCI versus MA-CABG; (C) drug-eluting stent (DES)-PCI versus SA-CABG; and (D) DES-PCI versus MA-CABG. The p values were derived by log-rank test. CAD = coronary artery disease.