Review

Coronary artery bypass grafting: Practice trends and projections

Richard Ramsingh, MD and Faisal G. Bakaeen, MD
Cleveland Clinic Journal of Medicine March 2025, 92 (3) 181-191; DOI: https://doi.org/10.3949/ccjm.92a.23071

Article Figures & Data

Figures

  • Figure 1
    Figure 1

    Surgical incision site located on the left anterior chest wall following a small thoracotomy for minimally invasive coronary artery bypass grafting. An accompanying chest drain incision site is seen inferolaterally.

Tables

  • TABLE 1

    Major CABG trials in multivessel disease

    StudyYearComparisonPrimary end pointKey findings
    BARI-2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes)102009Revascularization (CABG or PCI) plus intensive medical therapy vs intensive medical therapy in patients with diabetesAll-cause mortality at 5 yearsRevascularization with intensive medical therapy not superior to intensive medical therapy alone
    CABG stratum: lower prevalence of myocardial infarction (10% vs 17.6%) and MACCE (22.4% vs 30.5%), no significant difference in all-cause mortality (13.6% vs 16.4%) or cardiac death (8% vs 9%)
    PCI stratum: no significant difference in myocardial infarction, MACCE, all-cause mortality, or cardiac death
    FREEDOM (Future Revascularization Evaluation in Patients With Diabetes Mellitus: Optimal Management of Multivessel Disease)112012CABG vs PCIAll-cause mortality, nonfatal myocardial infarction, or nonfatal strokeCABG superior to PCI: in CABG patients, lower 5-year primary composite end point (18.7% vs 26.6%), lower prevalence of myocardial infarction (6.0% vs 13.9%) and all-cause mortality (10.9% vs 16.3%), higher prevalence of stroke (5.2% vs 2.4%)
    SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery)122013CABG vs PCI (paclitaxel-eluting stents)Composite MACCE (all-cause mortality, stroke, myocardial infarction, and repeat revascularization)PCI inferior and not noninferior to CABG
    Lower 5-year MACCE (26.9% vs 37.3%); lower prevalence of cardiac death (5.3% vs 9%), myocardial infarction (3.8% vs 9.7%), and repeat revascularization (13.7% vs 25.9%); no significant difference in all-cause mortality (11.4% vs 13.9%) or stroke (3.7% vs 2.4%) for CABG and PCI, respectively
    BEST (Randomized Comparison of Coronary Artery Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients With Multivessel Coronary Artery Disease)132015CABG vs PCI (everolimus-eluting stents)Composite of death, myocardial infarction, target-vessel revascularizationNo significant difference in primary composite end point at 2 years (PCI 11% vs CABG 7.9%)
    At longer-term follow-up (median 4.6 years), PCI had significantly higher primary end point (15.3% vs 10.6%) compared with CABG owing to repeat revascularization and spontaneous myocardial infarction
    STICH (Surgical Treatment for Ischemic Heart Failure) and STICHES (STICH Extension Study)92016CABG plus medical therapy vs medical therapy alone in patients with left ventricular ejection fraction ≤ 35%All-cause mortalityNo significant difference in primary end point over 6 years; however, CABG with medical therapy resulted in significant improvement in long-term all-cause mortality out to 10 years compared with medical therapy alone (58.9% vs 66.1%)
    Cardiovascular mortality and morbidity were lower with CABG in both studies
    FAME 3 (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation)142021Fractional flow reserve–guided PCI vs CABG in triple-vessel diseaseMACCE (death from any cause, myocardial infarction, stroke, or repeat revascularization)Fractional flow reserve–guided PCI not consistent with noninferiority to CABG: higher MACCE in fractional flow reserve–guided PCI arm compared with CABG (10.6% vs 6.9%) at 1 year

    • CABG = coronary artery bypass grafting; MACCE = major adverse cardiac or cerebrovascular events; PCI = percutaneous coronary intervention

  • TABLE 2

    Major CABG trials in left main coronary artery disease

    StudyYearComparisonPrimary end pointKey findings
    PRECOMBAT (Premier of Randomized Comparison of Bypass Surgery versus Angioplasty Using Sirolimus-Eluting Stent in Patients with Left Main Coronary Artery Disease)152011CABG vs PCI (sirolimus-eluting stents)MACCE (death from any cause, myocardial infarction, stroke, or ischemia-driven target-vessel revascularization)No significant difference in primary end point at 2 years
    Higher ischemia-driven target-vessel revascularization in PCI group (9% vs 4.2%)
    SYNTAX left main coronary artery subgroup162014CABG vs PCI (paclitaxel-eluting stents)Composite MACCE (all-cause mortality, stroke, myocardial infarction, and repeat revascularization)No significant difference in primary end point at 5 years
    Increased stroke in CABG arm (4.3% vs 1.5%), higher repeat revascularization in PCI arm (26.7% vs 15.5%), and higher MACCE at 5 years in PCI with SYNTAX score ≥ 33 (46.5% vs 29.7%)
    EXCEL (Evaluation of Xience Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization)172019CABG vs PCI (everolimus-eluting stents)Composite of death, stroke, myocardial infarctionPCI was noninferior to CABG for primary end point at 3 years, survival curves favored CABG at 5 years (22.0% vs 19.2%), and ischemia-driven revascularization was more frequent after PCI (16.9% vs 10%)
    NOBLE (Nordic-Baltic-British Left Main Revascularization)182020CABG vs PCIComposite MACCE (all-cause mortality, nonprocedural myocardial infarction, repeat revascularization, and stroke)CABG superior to PCI
    Lower MACCE for CABG (19% vs 28%) at 5 years, driven by lower nonprocedural myocardial infarction (3% vs 8%) and lower repeat revascularization in CABG patients (10% vs 17%)

    • CABG = coronary artery bypass grafting; MACCE = major adverse cardiac or cerebrovascular events; PCI = percutaneous coronary intervention; SYNTAX = Synergy Between PCI With Taxus Stents and Cardiac Surgery

  • TABLE 3

    2021 American College of Cardiology, American Heart Association, Society for Cardiovascular Angiography and Interventions recommendations for CABG vs PCI

    IndicationCriteria and recommendationClass strength and level of evidence
    Complex diseaseSignificant left main coronary artery disease with high complexity
    CABG is recommended over PCI to improve survival    		Class 1, level B-R
    Multivessel disease with complex or diffuse coronary artery disease (SYNTAX score ≥ 33)
    It is reasonable to choose CABG over PCI to confer survival advantage    		Class 2a, level B-R
    DiabetesMultivessel disease with LAD involvement
    CABG with left IMA to LAD is preferred to PCI to reduce mortality and repeat revascularizations    		Class 1, level A
    Multivessel disease amenable to PCI, indication for revascularization, and poor candidate for surgery
    PCI can be useful to reduce long-term ischemic outcomes    		Class 2a, level B-NR
    Left main coronary artery stenosis and low- or intermediate-complexity coronary artery disease in the rest of coronary anatomy
    Consider PCI as alternative to CABG to reduce major adverse cardiovascular outcomes    		Class 2b, level B-R
    Previous CABGRefractory angina on guideline-directed medical therapy attributable to LAD disease
    CABG over PCI when IMA can be used as conduit to the LAD    		Class 2a, level C-LD
    Complex coronary artery disease
    CABG over PCI when IMA can be used as a conduit to the LAD    		Class 2b, level B-NR
    Nonadherence to dual antiplatelet therapyMultivessel disease amenable to treatment with either PCI or CABG
    CABG is preferred to PCI    		Class 2a, level B-NR

    • CABG = coronary artery bypass grafting; IMA = internal mammary (thoracic) artery; LAD = left anterior descending coronary artery; LD = limited data; NR = nonrandomized; PCI = percutaneous coronary intervention; R = randomized; SYNTAX = Synergy Between PCI With Taxus Stents and Cardiac Surgery

    • Data from reference 8.

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