Intravascular Imaging‐Guided Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting for Unprotected Left Main Stenosis

Background Randomized clinical trials comparing percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) for left main coronary artery (LMCA) stenosis have indicated lower repeat revascularization after CABG. Aim This multi‐center study aimed to investigate outcomes of intravascular imaging (IVI)‐guided PCI compared with CABG for treating LMCA stenosis. Methods Analysis included 855 patients (396 PCI) from 18 centers. The primary composite endpoint was major adverse cardiac and cerebrovascular events (MACCE: cardiovascular death, myocardial infarction, stroke, and target vessel revascularization at 2 years). Propensity score matching (PSM) analysis was used to limit differences among the groups. Cox regression event rates were calculated for matched groups. Results In the overall cohort, no difference in MACCE was observed (HR 0.97, 95% CI 0.72–1.32, p = 0.84). PSM resulted in 230 pairs, with no significant differences in baseline, procedural characteristics, and SYNTAX score between the two groups. The matched cohorts had no significant differences for the primary endpoint (HR 0.85, 95% CI 0.65–1.43, p = 0.85). No differences for all‐cause mortality rates between the two groups were found at 2 years (10% in the PCI and 11% in the CABG arm, p = 0.65). During follow‐up, patients undergoing CABG had lower rates of myocardial infarction (8.7% vs. 14.8%, p = 0.04). More frequent stroke incidence was noticed (8.7% vs. 0%, p < 0.001). There was no significant difference in the incidence of target vessel revascularization between PCI and CABG (3.91% vs. 2.61%, p = 0.43). Conclusions IVI‐guided PCI for LMCA stenosis provides similar 2‐year outcomes to CABG. Lower MACCE rates with PCI were observed in patients with lower anatomic complexity.