CABG Bests FFR-Guided PCI for Three-Vessel CAD

The advantages of coronary artery bypass graft (CABG) over percutaneous coronary intervention (PCI) have been most apparent in patients with the most-complex coronary artery disease (CAD). In this contemporary comparison, investigators assessed whether PCI with current drug-eluting stents and guided by fractional flow reserve (FFR) assessment could narrow this gap.

The industry-funded trial included 1500 patients with three-vessel CAD (without left main involvement) randomly assigned to CABG or FFR-guided PCI with zotarolimus-eluting stents. Their mean age was 65 years, 18% were women, 29% had diabetes, and 39% had acute coronary syndrome. Patients had an average of 4.3 lesions (22% of patients had at least 1 chronic total occlusion) and a mean SYNTAX score of 26. The mean numbers of stents (PCI) and distal anastomoses (CABG) received were 3.7 and 3.4, respectively.

At 1 year, the primary endpoint of death, myocardial infarction (MI), stroke, or repeat revascularization occurred in 10.6% of PCI patients and 6.9% of CABG patients. A secondary endpoint of death, MI, or stroke occurred in 7.3% and 5.2%, respectively. There was a trend toward better outcomes with PCI compared with surgery among patients with the lowest SYNTAX scores (<23). Patients undergoing CABG had higher rates of major bleeding, arrhythmia, acute kidney injury, and rehospitalization.