Long-term outcomes comparison between surgical and percutaneous coronary revascularization in patients with multivessel coronary disease or left main disease. A systematic review and study level meta-analysis of randomized trials.

Recent randomized trials comparing coronary artery bypass graft (CABG) with percutaneous coronary intervention (PCI) utilizing drug-eluting stents in patients with left main (LMD) disease and/or multivessel disease (MVD), reported conflicting results. We performed a study level meta-analysis comparing the two interventions for the treatment of LMD or MVD. Using electronic databases, we retrieved 6 trials, between January, 2010 and December, 2022. Five-years Kaplan-Meier curves of endpoints where reconstructed. Comparisons were made by Cox-linear regression frailty model and by landmark analysis. A random-effect method was applied. 8269 patients were included and randomly assigned to CABG (n=4135) or PCI (n=4134). During 5-years follow-up, PCI showed a higher incidence of all-cause mortality [hazard ratio (HR) 1.28; 95% confidence interval (CI), 1.11-1.47; p<0.0001)], spontaneous myocardial infarction (MI) (HR 1.84; 95% CI, 1.54-2.19; p<0.0001) and repeat coronary revascularization (HR 1.96; 95% CI, 1.72-2.24; p<0.0001). There was no long-term difference between the two interventions for cardiovascular death (p=0.14) and stroke (p=0.20), although the incidence of stroke was higher with CABG within 30-days from intervention (p<0.0001). PCI was associated with an increased risk for composite endpoints (p<0.0001) and major cerebral and cardiovascular events. (p<0.0001). In conclusion, at 5-year follow-up, in patients with LMD and/or MVD there was a significant higher incidence of all-cause mortality, spontaneous MI and repeat revascularization with PCI compared to CABG. The incidence of stroke was higher with CABG during the post-procedural period, but no difference was found during 5-years follow-up. Longer follow-up is mandatory to better define outcome difference between the two interventions.