Draft Key Questions
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Archived: This report was assessed in May 2013 and some conclusions were considered out of date. Findings may be used for research purposes, but should not be considered current.
Atherosclerosis develops in a patchy, discontinuous fashion within coronary arteries. Therefore, it is possible to treat the discrete areas of obstruction that most impede coronary blood flow to the myocardium. The mechanical approaches to coronary revascularization fall broadly into two categories: coronary artery bypass grafting surgery (CABG) and catheter-based percutaneous coronary interventions (PCI). Together, these coronary revascularization methods are among the most common major medical procedures performed in North America and Europe.
Coronary bypass surgery and coronary angioplasty (with or without stents) are alternative approaches to mechanical coronary revascularization, so their comparative effectiveness in terms of patient outcomes has been of great interest. The comparative effectiveness of bypass surgery and angioplasty is an open question primarily for those patients for whom either procedure would be technically feasible and whose coronary disease is neither too limited nor too extensive.
CABG is generally preferred for patients with left main coronary artery disease or severe triple-vessel disease with reduced left ventricular function because it has been previously shown in randomized trials to improve survival compared with medical therapy. In contrast, PCI is generally preferred for patients with most forms of single-vessel disease when symptoms warrant coronary revascularization, in light of its lower procedural risk and the evidence that PCI reduces angina and myocardial ischemia in this subset of patients.
The choice between PCI and CABG is most relevant for patients whose coronary artery disease (CAD) lies in between these extremes, namely patients with single-vessel disease of the proximal left anterior descending artery (LAD), most forms of double-vessel CAD, and less extensive forms of triple-vessel CAD. Most randomized controlled clinical trials (RCTs) of angioplasty and surgery have been conducted in this middle segment of the patient population with CAD.
The purpose of this report is to evaluate the evidence for the comparative effectiveness of PCI and CABG in this population of patients with CAD.