Stenting of the Left Main Artery Is Noninferior to Bypass Surgery

Unprotected left main (LM) coronary artery disease (CAD) has traditionally been treated surgically with coronary-artery bypass grafting (CABG), although the SYNTAX trial suggested similar outcomes with percutaneous coronary intervention (PCI) using first-generation stents in a subset of patients with low or intermediate CAD burden. Now, the manufacturer-funded, randomized, noninferiority EXCEL trial has compared PCI using a contemporary drug-eluting stent to CABG using contemporary techniques in 2905 patients with angiographic LM lesions ≥70% or hemodynamically significant lesions ≥50% (mean baseline age, 66; men, 77%; diabetes, 29%; distal LM bifurcation lesions, 80%; 2- or 3-vessel disease, 51%). Overall CAD burden was low or intermediate (i.e., SYNTAX score, ≤32; 60.5% and 39.5%, respectively).

Patients received a mean of either 2.4 stents or 2.6 grafts (internal thoracic artery grafts, 99%). Intravascular ultrasound guidance was used in nearly 80% of PCI patients. After a median follow-up of 3 years, the primary composite endpoint (death, stroke, or myocardial infarction) occurred in 15.4% of PCI patients and 14.7% of CABG patients, showing noninferiority; the endpoint also did not differ in prespecified subgroups including diabetics and patients with angiographically-determined high SYNTAX scores (24%). A composite outcome at 30 days occurred significantly less frequently with PCI than with CABG (4.9% vs. 7.9%). Ischemia-driven revascularization was more frequent after PCI (12.6% vs. 7.5%); definite stent thrombosis post-PCI was less frequent than symptomatic graft occlusion post-CABG (0.7% vs. 5.4%).