Revascularization strategy for left main coronary artery disease comparing percutaneous coronary intervention versus coronary artery bypass grafting

Ryaan El-Andari; Jimmy Kang; Nicholas Fialka; Yongzhe Hong; Finlay A McAlister; Jeevan Nagendran; Jayan Nagendran

doi:10.1038/s43856-025-01098-w

Revascularization strategy for left main coronary artery disease comparing percutaneous coronary intervention versus coronary artery bypass grafting

Commun Med (Lond). 2025 Sep 29;5(1):402. doi: 10.1038/s43856-025-01098-w.

Authors

Ryaan El-Andari¹, Jimmy Kang², Nicholas Fialka², Yongzhe Hong², Finlay A McAlister³, Jeevan Nagendran², Jayan Nagendran⁴

Affiliations

¹ Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada. elandari@ualberta.ca.
² Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada.
³ Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.
⁴ Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada. jayan@ualberta.ca.

Abstract

Background: Coronary artery bypass grafting(CABG) has long been the preferred treatment for left main coronary artery disease(LMCAD), although percutaneous coronary intervention(PCI) has been increasingly utilized. Despite numerous investigations seeking to identify the optimal revascularization strategy for LMCAD, limitations in sample size or follow-up duration have hindered definitive conclusions. Herein, we compare the long-term outcomes up to 14 years after CABG or PCI for patients with LMCAD.

Methods: Data was retrospectively collected from a provincial database. The inclusion criteria is patients ≥18 years old, with LMCAD, and revascularization with CABG or PCI. The primary outcome is all-cause mortality. Secondary outcomes are any rehospitalization, myocardial infarction (MI), stroke, or repeat revascularization. Outcomes are adjusted for age, sex, and clinical comorbidities. The average age of the patients was 67 ± 9 years for the CABG patients and 71 ± 11 years for the PCI patients. 84.7% of the CABG patients and 71.5% of the PCI patients were male.

Results: 5580 patients are identified with LMCAD between 2009 and 2018. 1706 patients (1180 CABG; 526 PCI) are included in the final analysis and followed until March 31, 2023. Rates of mortality at longest follow-up of 14 years are 40.0% for CABG and 58.4% for PCI (adjusted hazard ratio(aHR) 0.58, 95% confidence interval(CI) 0.48-0.70, p < 0.001). Rates of MI (10.7% vs 22.3%, aHR 0.40, 95% CI 0.29-0.55, p < 0.001) and repeat revascularization (5.4%vs16.3%, aHR 0.25, 95% CI 0.18-0.36, p < 0.001) favor CABG over PCI.

Conclusions: Patients with LMCAD undergoing CABG experience significant benefit over PCI in terms of long-term mortality, MI, and required repeat revascularization. These finding suggest CABG should remain the preferred revascularization strategy for patients with LMCAD and acceptable surgical risk. Future studies should explore evolving PCI techniques and their impact on long-term outcomes.

Plain language summary

Coronary artery bypass grafting (CABG) or bypass surgery involves using vessels to bypass blockages in heart arteries. CABG is the preferred treatment for left main coronary artery disease (LMCAD), disease of one of the major arteries that supplies blood to a large area of the heart, although percutaneous coronary intervention (PCI) which involves artery stenting has been increasingly utilized. Previous studies comparing the two treatments in LMCAD have been limited in sample size or follow-up duration. This study compared the long-term outcomes up to 14 years after CABG or PCI for patients with LMCAD. 1706 patients (1180 CABG; 526 PCI) were compared. At longest follow-up, rates of death, heart attack, and repeat procedures were significantly lower for CABG compared to PCI. These finding suggest CABG should remain the preferred revascularization strategy for patients with LMCAD and acceptable surgical risk.