Multiple arterial coronary bypass grafting is associated with better survival compared to second generation drug-eluting stents in stable multivessel coronary artery disease

Objective — We sought to compare the long-term outcomes of multi-arterial graft (MAG) coronary artery bypass grafting (CABG) vs percutaneous coronary intervention (PCI) with second generation drug-eluting stents (DES) to treat stable multivessel coronary artery disease.

Methods — Multicenter population-based retrospective analysis of all residents of Ontario, Canada, from January 1, 2011 – December 31, 2019. 3,600 cases of elective primary isolated CABG with MAG and 2,187 cases PCI with 2nd generation DES were identified.

Results — Following the application of propensity score-weighting using overlap weights, MAG was associated with better survival over 5-years compared to DES (96.8% vs 94.5%, Hazard Ratios (HR) 0.56 [95% confidence interval (CI) 0.37-0.85]. MAG was also associated with better secondary outcomes including MACCE (composite of death, myocardial infarction (MI), and stroke) (94.3% vs 88.5%, HR 0.49 [95%CI 0.36-0.65]. The rate of MACCE-1 (death, stroke, myocardial infarction, and repeat revascularization) (91.2% vs 70.7%, HR 0.24 [95%CI 0.20-0.30]), and the individual endpoints of MI (1.4% vs 6.9%, HR 0.22 [95%CI 0.13-0.35]), and repeat revascularisation (4.1% vs 24.2%, HR 0.14 [95%CI 0.10-0.18]) were lower with MAG. PCI with 2nd generation DES was associated with lower rate of stroke up to 5-years (0.6% vs 1.8%, HR 3.97 [95%CI 1.45-10.88]).

Conclusions — CABG with MAG was associated with better survival and fewer major cardiac adverse events compared to second generation DES and may be considered the treatment of choice for patients with stable multivessel coronary artery disease. Further randomized controlled trials are needed to confirm this hypothesis.