CABG and PCI are certainly better options for severe three vessel disease compared to optimal medical treatment. PCI is a good option in LMCA disease with TVD and long term mortality is comparable to CABG in those with relatively low SYNTAX score ( below 34). CABG is a better option in those with higher Syntax score. Many other modifications of the scoring system (PCI risk Vs surgical risk) are available. Compared to CABG with LIMA and arterial conduits, PCI especially with BMS is associated with higher requirement for repeat revacularisation procedures. Risk of stroke may be marginally higher with CABG compared to PCI.

Downstream disease progression may be slightly less with LIMA grafts but proximal disease (coronary upstream) progression tend to be more. PCI at a later date can be more challenging because of the accelerated progression of proximal disease. Redo CABG is always difficult and often such patients are offered PCI for the native vessels.

Hence, it may not be wise to advise CABG to a young patient with TVD and low SYNTAX score who will do exceedingly well with PCI. Now with better hardware, stents and newer anti platelets the long term out look is excellent. Even if a repeat procedure is required, it can very often be performed safely.

Dear Prof, Thank you so much for your enlightenment. I understand besides Syntax score, physician individualise management may varies in coronary revascularization. Can i conclude, PCI is comparable to CABG in all cause mortality outcome but CABG have slight edge on less likely needing repeated revascularisation in future? For premature TVD with lesion at LMS/ bifurcation, would we advocate for CABG (if fits for surgery) or proceed with PCI?

For premature TVD with LM and good anatomy (Low SYNTAX score), I would prefer PCI over CABG ( certainly after discussion with the patient and relatives - heart team). Coronary physiology is more "physiological" following PCI and often more acceptable to patients.

Hi, Kelvin,, very interesting question. Thanks Dr koshy for nice elaborate answar. PCI definitely could be a better option in these situations where syntax score is low. However patency of LIMA graft is better than stent. So long term results of CABG can be better. Now a days CABG can be done with very small thoracotomy with excellent long term results and with fewer complication. So treatment strategy to be individualised and patients choice is also very important.. Thanks

I am sorry. What does TVD mean?

Three vessel disease meaning significant disease involving LAD, RCA and left cicumflex.

In all TVD variants, CABG is better than PCI. Its advantages in morbimortalide are demonstrated. there is also less need for future revascularization procedures. in addition CABG decreases disease progression in native vessels.

Dear colleagues, its also important to take into account if disease is progredient and cabg is likely to be a future option, a vessel is a lot more difficult to be operated if stented prior (less option for anastomosis)

Studies 30+ years ago found half of grafts excluded at 8-10years. All arterial graphs did not exist then and LIMAs were not the rule. Even many arterial grafts fail. Multivessel PCI allows for risk reduction and with current meds should be able to prevent further progression. Should that fail CABG still available to buy another 10 years. Achilles heel of PCI are 2 issues: instent restenosis and stent thrombosis. I propose 1) check ASA platelet suppression and platelet inhibition by plavix, and all new agents on every patient after PCI. 2) Take up orbital athectomy, currently listed as improper, for instent restenosis, which has an outcome far better in animal studies than other treatment. Can currently be used off label and should be much safer than use of rotational atherectomy that we used for years to treat instent restenosis. With those two actions PCI should be far preferable. I did the animal studies and did use it for instent restenosis prior to retirement.