A meta-analysis presented at EuroPCR 2026 found no significant difference in 10-year mortality between patients with left main coronary artery disease (LMCAD) who underwent percutaneous coronary intervention (PCI) with drug-eluting stents and those with LMCAD who underwent coronary artery bypass grafting (CABG).

“These findings suggest that PCI with drug-eluting stents and CABG may both be considered for left main coronary artery revascularization in patients deemed suitable candidates for either approach by a multidisciplinary Heart Team,” said Brian Bergmark, MD, cardiologist at Brigham and Women’s Hospital, Harvard Medical School in Boston, who participated in the study.

LMCAD is one of the most serious forms of CAD. The introduction of drug-eluting stents, which substantially reduced restenosis rates, established PCI as a practical alternative to CABG. However, long-term comparative data were limited.

Long-Standing Debate

Since 2018, clinical guidelines have supported the consideration of PCI with drug-eluting stents as a revascularization option for selected patients with LMCAD. Nevertheless, the optimal revascularization strategy remains the subject of considerable debate among interventional cardiologists and cardiac surgeons.

The controversy intensified following the publication of the 5-year results from the EXCEL trial, which compared PCI and CABG in patients with left main disease. Although no significant differences were seen in the primary composite endpoints of all-cause mortality, myocardial infarction, and stroke, PCI was associated with higher all-cause mortality.

Additional concerns emerged in 2019 after BBC Newsnight’s investigations alleged that the full study results had not been reported. Critics have argued that the rates of myocardial ischemic complications associated with stent use may have been underestimated.

In response, the European Association for Cardio-Thoracic Surgery temporarily withdrew support for recommendations regarding the management of LMCAD, citing concerns about the safety of PCI in this setting.

5-Year Findings Reassure Clinicians

The debate eased somewhat in 2021 after a meta-analysis of randomized trials reported no significant difference in 5-year all-cause mortality between PCI and CABG, with mortality rates of 11.2% and 10.2%.

That analysis included data from the SYNTAX, PRECOMBAT, NOBLE, and EXCEL trials, all of which compared the two revascularization strategies in patients with LMCAD.

The key unanswered question was whether differences in mortality would emerge beyond 5 years. To address this issue, investigators performed a new meta-analysis incorporating 10-year follow-up data from SYNTAX, PRECOMBAT, and NOBLE, while including the available 5-year data from EXCEL.

No Mortality Difference at 10 Years

The analysis included 4394 patients with LMCAD who were eligible for either PCI or CABG. The mean age of the patients was 66 years and 77% were men.

Among the participants, 16% had isolated left main disease, while 66% had additional involvement of one or two coronary vessels. The mean SYNTAX score was 25.

After 10 years, all-cause mortality was 23.5% among patients treated with PCI, who received an average of two stents per patient, compared with 23.1% among patients treated with CABG.

When the analysis was restricted to the three trials with complete 10-year follow-up, mortality rates remained similar at 22.3% and 23.3%, respectively.

Consistent Across Subgroups

No significant differences were seen across the various subgroups analyzed, including categories defined by age, sex, and baseline SYNTAX scores (≤ 22, 23-32, and ≥ 33).

Similarly, analyses examining outcomes during the first 5 years and between 5 and 10 years after revascularization showed comparable mortality rates between PCI and CABG.

During the discussion, David Hildick Smith, MD, from University Hospitals Sussex in Brighton, England, noted that the choice between PCI and CABG applies only to a subset of patients, as most participants in the included trials had low to intermediate SYNTAX scores. He added that surgery is often preferred in patients with more extensive left main disease.

Martin Leon, MD, cardiologist from Columbia University Irving Medical Center in New York City, meanwhile, highlighted the lack of long-term data on outcomes beyond mortality, including stroke, repeat revascularization, and rehospitalization. He acknowledged the challenges of collecting such information over extended follow-up periods but expressed hope that future follow-up assessments would capture these major clinical events, which could help inform treatment decisions beyond mortality alone, particularly in younger patients.

Bergmark reported having relationships with Pfizer, Ionis, Abbott Vascular, Inari Medical, now part of Stryker, AstraZeneca/MedImmune, and Amgen. He also reported consulting fees or personal compensation from Philips, Abbott Vascular, Abiomed, Boston Scientific, Teleflex, Bolt Medical, Endovascular Engineering, SpectraWAVE, and the Boston Clinical Research Institute.

Hildick-Smith and Leon reported having relevant conflicts of interest.

This story was translated from Medscape’s French edition.