{
  "abstract": "Introduction The comparative long-term survival benefit of coronary artery bypass grafting with single arterial grafts (SAG-CABG) versus percutaneous coronary intervention with drug-eluting stents (DES-PCI) in multivessel coronary artery disease remains incompletely characterized. We aimed to compare 20-year all-cause mortality between DES-PCI and SAG-CABG in patients with multivessel coronary artery disease to quantify the magnitude of long-term survival differences attributable to revascularization strategy.Methods We conducted a retrospective observational cohort study of consecutive adults undergoing first coronary revascularization for multivessel disease (≥2 vessels with significant stenosis) at a single tertiary cardiac center between October 2003 and December 2018. Patients received either DES-PCI exclusively or isolated CABG with single arterial graft configuration. The primary outcome was all-cause mortality, with vital status ascertained through national death registry linkage censored May 2, 2024 (maximum follow-up 20.94 years). To address confounding by indication, we employed 1:1 propensity score matching using a greedy nearest-neighbor algorithm without replacement with caliper width 0.2 standard deviations of the logit propensity score. Covariate balance was assessed using standardized mean differences (SMD <0.10 threshold). Survival was compared using Kaplan-Meier methods with stratified log-rank testing and stratified Cox proportional hazards regression accounting for matched pair structure with cluster-robust standard errors. Sensitivity analyses included inverse probability of treatment weighting (IPTW) with doubly robust adjustment in the full cohort, time-stratified Cox regression to address proportional hazards violations, and prespecified subgroup analyses stratified by procedural urgency and extent of coronary disease.Results Of 9491 patients undergoing first revascularization (SAG-CABG n=4798; DES-PCI n=4693), propensity score matching (C-statistic 0.898, 95% CI 0.891–0.904) created 2,100 matched pairs with good covariate balance (19 of 21 covariates SMD <0.10; residual imbalance in 2-vessel and 3-vessel disease SMD 0.203, addressed through multivariable adjustment) ( table 1). The median follow-up in the matched cohort was 11.8 years for SAG-CABG and 5.9 years for DES-PCI; deaths occurred in SAG-CABG 205/2100 (12.1%) versus DES-PCI 413/2100 (19.7%). Kaplan-Meier analysis demonstrated persistent SAG-CABG superiority throughout 20-year follow-up, representing an absolute survival advantage of 11.9% (stratified log-rank P<0.001) (table 2, figure 1). Stratified Cox proportional hazards regression accounting for matched pair structure revealed DES-PCI patients experienced 2.36-fold increased mortality risk compared with SAG-CABG (hazard ratio 2.36, 95% CI 1.96–2.83, P<0.001). This association remained robust across multiple sensitivity analyses: inverse probability treatment weighting in the full cohort HR 2.49 (95% CI 2.11–2.93, P<0.001), and time-stratified analysis demonstrating strongest mortality excess in the initial 5 years (HR 2.49, 95% CI 2.03–3.05, P<0.001) with sustained significance through extended follow-up. Treatment benefit was consistent across procedural urgency categories (urgent procedures HR 2.08, 95% CI 1.68–2.58; elective procedures HR 2.19, 95% CI 1.74–2.77; interaction P=0.64), yet strongly modified by extent of coronary disease: in 2-vessel disease (n=2073) DES-PCI demonstrated HR 1.78 (95% CI 1.41–2.20, P<0.001), whereas in 3-vessel disease (n=1,627) the mortality hazard was markedly amplified to HR 3.31 (95% CI 2.66–4.11, P<0.001). Separate multivariable Cox regression models within each treatment arm (C-statistics: SAG-CABG 0.733, DES-PCI 0.707) revealed distinct mortality determinants: SAG-CABG deaths were predominantly driven by left ventricular dysfunction (LVEF <30% HR 2.75, 95% CI 1.85–4.10) and renal comorbidity (diabetes HR 1.46, renal disease HR 2.19), whereas DES-PCI mortality reflected anatomical complexity (3-vessel disease HR 2.19, 95% CI 1.76–2.71; left main stenosis HR 1.28) and extracardiac vascular disease (cerebrovascular disease HR 2.18, 95% CI 1.38–3.43).Conclusion In this propensity-matched real-world cohort with two-decade follow-up, SAG-CABG demonstrated markedly superior long-term survival compared with DES-PCI in patients with multivessel coronary artery disease. Single arterial surgical revascularization conferred 2.36-fold mortality reduction, translating to an absolute 11.9% survival advantage at 20 years, with benefit magnitude increasing proportionally with extent of coronary disease. The treatment effect remained consistent across elective and urgent settings. Results should inform shared decision-making regarding optimal revascularization strategy when balancing procedural considerations against long-term survival outcomes.Abstract 438 Figure 1Composite kaplan meier curves for CABG-SAG vs DES-PCI survival ratesAbstract 438 Table 1Baselines characteristicsAbstract 438 Table 2Survival probability for unmatched and matched cohorts",
  "authors": [
    {
      "affiliations": [
        "Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, United Kingdom"
      ],
      "name": "Muhammad Saad Asif"
    },
    {
      "affiliations": [
        "Sheikh Zayed Medical College and Hospital, Rahim Yar Khan, Pakistan"
      ],
      "name": "Muhammad Talha Wajid"
    },
    {
      "affiliations": [
        "Department of Cardiology, Harefield Hospital,, London, United Kingdom"
      ],
      "name": "Tito Kabir"
    },
    {
      "affiliations": [
        "Department of Cardiac Surgery, Harefield Hospital, London, London, United Kingdom"
      ],
      "name": "Sunil K Bhudia"
    },
    {
      "affiliations": [
        "Department of Cardiac Surgery, Harefield Hospital, London, United Kingdom, United Kingdom"
      ],
      "name": "Shahzad G Raja"
    }
  ],
  "title": "438 Single arterial CABG vs DES-PCI for multivessel CAD: 20-year survival from propensity-matched cohort",
  "uid": "338640ad-6ba6-5cfd-8a4f-c61b39703e33"
}