**5. Outcomes of coronary-artery bypass grafting versus bare metal stent implantation**

The New York's cardiac registries were one of the largest studies which identify 37,212 patients with multivessel disease who underwent CABG and 22,102 patients with multivessel disease who underwent PCI using BMS from January 1, 1997, to December 31, 2000. They determined the rates of death and subsequent revascularization within three years after the procedure in various groups of patients according to the number of diseased vessels and presence or absence of involvement of the left anterior descending coronary artery LAD.

Risk-adjusted survival rates were significantly higher among patients who underwent CABG than among those who received a stent in all of the anatomical subgroups studied. For example, the adjusted hazard ratio for the long-term risk of death after CABG relative to stent implan‐ tation was 0.64 (95 percent confidence interval, 0.56 to 0.74) for patients with three-vessel disease with involvement of the proximal LAD and 0.76 (95 percent confidence interval, 0.60 to 0.96) for patients with two-vessel disease with involvement of the non-proximal LAD. Also, the three-year rates of revascularization were considerably higher in the stenting group than in the CABG group (7.8 percent vs. 0.3 percent for subsequent CABG and 27.3 percent vs. 4.6 percent for subsequent PCI), [13].

Texas Heart Institute Cardiovascular Research Database retrospectively identified patients who had undergone their 1st revascularization procedure with coronary artery bypass surgery (CABG; n=2,826) or coronary stenting (n=2,793) between January 1995 and December 1999. They have found that in-hospital mortality was significantly greater in patients undergoing CABG than in those undergoing stenting (3.6% vs 0.75%; adjusted OR 8.4; *P* <0.0001). At a mean 2.5-year follow-up, risk-adjusted survival was equivalent (CABG 91%, stenting 95%; adjusted OR 1.26; *P* = 0.06). When subgroups matched for severity of disease were compared, no differences in risk-adjusted survival were seen, [14].

end point of death, myocardial infarction, or stroke (OR 1.25, 95% CI 0.86 to 1.82). The risk for target vessel revascularization was significantly lower in the CABG group com‐ pared to the PCI group (OR 0.44, 95% CI 0.32 to 0.59). In conclusion, PCI with DES is safe and could represent a good alternative to CABG for selected cases in patients with

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In the SYNTAX trial, 1,800 patients with three-vessel and/or LM disease were random‐ ized to either CABG or PCI; of these, 271 LM patients were prospectively assigned to receive a 15-month angiogram. The primary endpoint for the CABG arm was the ratio of ≥50% to <100% obstructed/occluded grafts bypassing LM lesions to the number placed. The primary endpoint for the PCI arm was the proportion of patients with ≤50% diameter stenosis ('patent' stents) of treated LM lesions. Per protocol, no formal comparison between CABG and PCI arms was intended based on the differing primary endpoints. Available 15-month angiograms were analyzed for 114 CABG and 149 PCI patients. At 15 months, 9.9% (26/263) of CABG grafts were 100% occluded and an addi‐ tional 5.7% (15/263) were ≥50% to <100% occluded. Overall, 27.2% (31/114) of patients had ≥1 obstructed/occluded graft. The 15-month CABG MACCE rate was 8.8% (10/114) and MACCE at 15 months was not significantly associated with graft obstruction/occlu‐ sion (p=0.85). In the PCI arm, 92.4% (134/145) of patients had ≤50% diameter LM steno‐ sis at 15 months (89.7% [87/97] distal LM lesions and 97.9% [47/48] non-distal LM lesions). The 15-month PCI MACCE rate was 12.8% (20/156) and this was significantly associated with lack of stent patency at 15 months (p<0.001), mainly due to repeated re‐

The results of the SYNTAX trial confirm that at 3 years CABG remains the treatment of choice for most patients with three-vessel and LMS disease and especially in those with the most severe disease. SYNTAX will have a profound effect on practice recommendations for the foreseeable future and has already had a major effect on the new European Society for Cardiology/European Association for Cardiothoracic Surgery guidelines for myocardial

At four years follow-up of SYNTAX trial which presented at TCT in 2011, there was no difference in MACCE between CABG and PCI in those with a SYNTAX score of 0 to 22, (26.1% vs 28.6%; p=0.57). This is good, and would legitimize the use of PCI in this kind of patient". But for those with an intermediate SYNTAX score of 23 to 32, "You see immediately a highly significant difference" in MACCE rate (21.5% for CABG vs 32% for PCI; p=0.006). For those with a high SYNTAX score (≥33), "mortality is double in the PCI group compared with CABG (16.1% vs 8.4%; p=0.04) in addition to MI is two to three times higher with PCI than with CABG

In this highest-risk group, even the end point of death/stroke/MI becomes significantly higher with PCI, (22.7% vs 14.6%; p=0.01), and MACCE were much higher (40.1% vs 23.6%; p<0.001), driven in large part by a 17% higher rate of revascularization in this high-risk group at four

ULMCA disease, [18].

vascularization. [19].

revascularization, [20].

(9.3% vs 3.9%; p=0.01).

years. Figures 6& 7
