Intravascular Imaging-Guided PCI vs Coronary Artery Bypass Grafting for Left Main or 3-Vessel Disease

Background: Previous trials have shown that coronary artery bypass graft (CABG) has better clinical outcomes compared with percutaneous coronary intervention (PCI) for patients with left main coronary artery or 3-vessel disease. However, it is unclear whether intravascular imaging (IVI)-guided PCI would reduce the difference in clinical events compared to CABG. Objectives: The present study sought to compare the clinical outcomes of patients with left main or 3-vessel disease who underwent IVI-guided PCI with those who underwent CABG. Methods: A total of 6,962 patients with left main or 3-vessel disease from the RENOVATE-COMPLEX-PCI trial (n = 1,639) and the institutional registry of Samsung Medical Center (2,972 patients underwent PCI and 6,600 patients underwent CABG) were analyzed. The primary outcome was a composite of death from any cause, nonfatal myocardial infarction, or stroke at 3 years. Results: Among the study population, 848 patients underwent IVI-guided PCI, 987 patients underwent angiography-guided PCI, and 5,127 patients underwent CABG. Patients treated with PCI had significantly higher risk of primary outcome than patients who underwent CABG (13.3% vs 10.8%; HR: 1.23; 95% CI: 1.05-1.44; P = 0.013). However, the risk of primary outcome was comparable between IVI-guided PCI and CABG (8.7% vs 10.8%; HR: 0.77; 95% CI: 0.59-1.01; P = 0.058). The propensity score–matched analysis showed similar results between IVI-guided PCI and CABG (9.5% vs 9.4%; HR: 0.98; 95% CI: 0.69-1.40; P = 0.914). Conclusions: In this hypothesis-generating study, PCI had significantly higher risk of a composite of death, nonfatal myocardial infarction, or stroke than CABG. However, IVI-guided PCI had comparable risk of clinical events compared with CABG.