The Current State of Coronary Revascularization: Percutaneous Coronary Intervention versus Coronary Artery Bypass Graft Surgery

The question of percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) surgery remains among the most important questions in the treatment of coronary artery disease. The leading North American and European societies largely agree on the current guidelines for the revascularization of unprotected left-main disease (ULMD) and multivessel disease (MVD) which are largely supported by the outcomes of several large randomized trials including SYNTAX, PRECOMBAT, NOBLE, and EXCEL. While these trials are of the highest quality, currently available, they suffer several limitations, including the use of bare metal and/or first-generation drug-eluting stents in early trials and lack of updated surgical outcomes data. The objective of this review is to briefly discuss these key early trials, as well as explore contemporary studies, to provide insight on the current state of coronary revascularization. Evidence suggests that in ULMD and MVD, there are similar mortality rates for CABG and PCI but PCI is associated with fewer "early" strokes, whereas CABG is associated with fewer "late" strokes, myocardial infarctions, and lower need for repeat revascularization. Additionally, studies suggest that CABG remains superior to PCI in patients with intermediate/high SYNTAX scores and in MVD with concomitant proximal left anterior descending (pLAD) artery stenosis. Despite the preceding research and its basis for our current guidelines, there remains significant variation in care that has yet to be quantified. Emerging studies evaluating second-generation drug-eluting stents, specific lesion anatomy, and minimally invasive and hybrid approaches to CABG may lend itself to more individualized patient care.