Research in context
Evidence before this study
We searched PubMed for articles published in English between database inception and July 24, 2019, with the following search terms: “percutaneous coronary intervention”, “stents”, “coronary artery bypass grafting”, and “random*”. Randomised controlled trials and meta-analyses comparing percutaneous coronary intervention (PCI) using stents versus coronary artery bypass grafting (CABG) in patients with three-vessel or left main coronary artery disease were included. An individual patient data meta-analysis reported that mortality outcomes favoured CABG over PCI at 5-year follow-up in patients with multivessel disease, particularly those with diabetes and more complex coronary artery disease, whereas no significant difference was identified in patients with left main coronary artery disease. It was concluded that longer-term follow-up would be required to better define mortality differences between revascularisation strategies. In our search, we only found two randomised controlled trials reporting survival outcomes at 10 years after PCI versus CABG. In the MASS II trial, patients with multivessel disease had a 10-year all-cause death rate of 24·9% after PCI versus 25·1% after CABG (p=0·089). However, PCI was done with bare metal stents and about 40% of patients had two-vessel disease, and no patients with left main coronary artery disease were included. In the LE MANS trial, which included only patients with left main coronary artery disease (n=105), 10-year all-cause death was 21·6% after PCI versus 30·2% after CABG (p=0·41). However, the sample size was small and only 35% of PCI procedures were performed with (first-generation) drug-eluting stents. The search did not identify studies reporting outcomes in patients with de-novo three-vessel and left main coronary artery disease randomly assigned to PCI with drug-eluting stents or CABG.
Added value of this study
The current study is the first randomised trial that reports complete 10-year data on all-cause death in patients with de-novo three-vessel and left main coronary artery disease after PCI with drug-eluting stents versus CABG. It provides important insights into the relative effectiveness of PCI versus CABG regarding the most robust and clinically relevant outcome—all-cause death. At 10 years, no significant difference was found in all-cause death between PCI using first-generation paclitaxel-eluting stents and CABG. However, CABG provided a significant survival benefit in patients with three-vessel disease, but not in patients with left main coronary artery disease. These findings can aid decision making for patients with coronary artery disease who require PCI or CABG, accounting for differences in cardiovascular risk factors, coronary lesion complexity (eg, SYNTAX score), and the presence of three-vessel or left main coronary artery disease.
Implications of all the available evidence
Patients with complex, three-vessel coronary artery disease who require revascularisation should undergo CABG as it results in significantly lower all-cause death than PCI. In selected patients with left main coronary artery disease, PCI is a suitable alternative to CABG and provides similar 10-year survival.