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Percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) are both reasonable options for the revascularization of left main coronary artery stenosis of low-to-intermediate complexity, according to newly pooled data.

While the EXCEL and NOBLE trials appeared to be at odds regarding the noninferiority of PCI to CABG, a systematic review and meta-analysis adding SYNTAX and PRECOMBAT into the mix determined that stenting and surgery cohorts shared a on fixed-effect (HR 1.06, 95% CI 0.90-1.24) and random-effects (HR 1.06, 95% CI 0.85-1.32) analyses.

Kaplan-Meier curve reconstruction showed no variations over time between PCI and CABG: over 5 years, the primary endpoint occurred in 18.3% versus 16.9% of patients, respectively (HR 1.05, 95% CI 0.90-1.23), according to Robert A. Byrne, MB BCh, PhD, of the German Heart Centre in Munich, and colleagues.

"The risk of repeat revascularization is the most important difference between techniques, with a higher risk for PCI at long-term follow-up compared with CABG [HR 1.70, 95% CI 1.42-2.05]," they nonetheless noted in JAMA Cardiology.

Participants in the pooled dataset (n=4,394, average age 65, 76.7% men) were enrolled in four trials -- SYNTAX, PRECOMBAT, EXCEL, and NOBLE -- published from 2001 to 2017.

First-generation drug-eluting stents (DES) had long been blamed for PCI's inferiority against CABG in early randomized trials. Then came the , wherein patients who underwent PCI were treated with new-generation DES.

In a separate note, journal editors Ajay Kirtane, MD, and Robert O. Bonow, MD, both of Columbia University Medical Center/New York-Presbyterian Hospital in New York City, called EXCEL and NOBLE "landmark trials, in aggregate representing the largest and most contemporary data that compared PCI and CABG for prognostically important coronary artery disease."

"However, in our analysis, neither the risk of repeat revascularization nor the risk of the primary endpoint between techniques was influenced by DES generation," Byrne's group commented.

The authors acknowledged that they lacked patient-level data allowing for SYNTAX score stratification or additional subgroup analyses. Furthermore, data from EXCEL trial only went as far as 3 years (versus 5 years for the others).

"In aggregate, these findings suggest that, in patients with significant stenosis of the left main coronary artery and predominantly low to intermediate coronary artery disease complexity, both PCI and CABG are valid approaches to revascularization," they concluded.

"Patient preference should be taken into consideration regarding the risks of periprocedural complications of surgery and long-term repeat revascularization after PCI. Patients with low surgical risk may benefit from CABG owing to more sustained effectiveness as evidenced by the reduced incidence of repeat revascularization. However, if a patient is not a good candidate for surgery or wishes to avoid the morbidity associated with surgical revascularization, PCI is a safe and effective alternative," they stated.

"Perhaps most important in this debate of CABG vs PCI for left main disease is the viewpoint of patients, some of whom may view elective repeat revascularization as an inconvenience,while for others it may be a major life event. Short-term complications, bleeding, blood transfusions, wound infections, arrhythmia, length of stay, and recovery times are all in favor of PCI," wrote Subodh Verma, MD, PhD, of St. Michael's Hospital in Toronto, Canada, and colleagues in a viewpoint article.

"Even if a greater degree of benefit with CABG on death is noted on longer-term follow-up in these 2 studies, many patients may still prefer a procedure with lower procedural risks and faster return to usual living," Verma's group suggested.

Kirtane and Bonow agreed with Byrne's group that both will continue to have an important role in treating patients with left main stenosis -- going as far as to say that PCI should be elevated in the guidelines "as an acceptable alternative to CABG in appropriately selected patients when a preference is expressed for a less-invasive approach to coronary revascularization."