A number of randomized clinical trials have compared PCI and CABG in patients with multivessel CAD who were suitable technically for both procedures. The redevelopment of angina requiring repeat coronary angiography and repeat revascularization is higher with PCI. This is a result of restenosis in the stented segment (a problem largely solved with drug-eluting stents) and the development of new stenoses in unstented portions of the coronary vasculature. It has been argued that PCI with stenting focuses on culprit lesions while a bypass graft to the target vessel also provides a conduit around future culprit lesions proximal to the anastomosis of the graft to the native vessel.
Comparison of mortality rates in patients treated with CABG versus PCI is a complex issue. There is an early increased risk of mortality with CABG, but when considering a longer time horizon, such as 5 years, mortality is lower with CABG compared with PCI.
Based on available evidence, it is now recommended that patients with an unacceptable level of angina despite optimal medical management be considered for coronary revascularization. Patients with single- or two-vessel disease with normal LV function and anatomically suitable lesions are ordinarily advised to undergo PCI (Chap. 240). Patients with three-vessel disease (or two-vessel disease that includes the proximal left descending coronary artery) and impaired global LV function (LVEF <50%) or diabetes mellitus or those with left main coronary artery disease or other lesions unsuitable for catheter-based procedures should be considered for CABG as the initial method of revascularization.
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