Abstract
Background: Despite increasing recognition that coronary artery bypass grafting (CABG) compared to percutaneous coronary intervention (PCI) significantly reduces the need for repeat revascularization in multivessel coronary disease (MVD), overall late mortality has been shown comparable for the two strategies. This perception supports PCI as an acceptable alternative to conventional CABG particularly when drug eluting stents (DES) are used. On the other hand, multiple arterial grafting (MAG) confers improved patency and survival benefits compared with conventional CABG utilizing single internal mammary artery. We aimed to investigate whether MAG offers survival benefit over DES-PCI in MVD. Methods and Results: A total of 5686 patients with MVD (≥2 vessel) underwent CABG (n=4256) or PCI (n=1430) at a single institution. MAG was performed in 1264 CABG cases and DES where implanted in 1180 PCI cases. Propensity score adjusted analysis was performed to investigate the potential survival advantage of MAG over PCI. Mean follow-up was 4.6±2.9 years. Risk for late death was comparable after DES-PCI versus conventional CABG in the overall population (adjusted HR 1.11; 95%CI 0.9 to 1.33; P=0.25). However DES-PCI was associated with an increased risk for late death when compared to MAG (HR 1.86; 95% CI 1.45 to 2.40; P<0.0001) and this advantage persisted when elective cases only where included (HR 1.67; 95%CI 1.23 to 2.26, Figure). DES-PCI was associated with a 3.35 fold increased risk for repeat revascularization over MAG (95%CI 2.38 to 4.71; P<0.0001) and 2.94 fold increased risk for repeat revascularization over conventional CABG (95%2.27 to 3.81; P<0.0001). Conclusions: Compared to conventional CABG, MAG improved late survival when compared to DES-PCI. When feasible, MAG should be strongly recommended in patients with MVD.
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