Long term outcomes of different revascularization strategies in left main coronary artery: a network meta-analysis

Background: The comparative effectiveness of angiography-guided versus imaging–guided PCI relative to coronary artery bypass grafting (CABG) in left main coronary artery (LMCA) disease remains uncertain. Methods: We performed a network meta-analysis of randomized controlled trials (RCTs) including patients undergoing LMCA revascularization. Pooled incidence rate ratios (IRRs) with 95% confidence intervals (CIs) were computed. Co-primary endpoints were major adverse cardiovascular events (MACE) by trial definition and all-cause death. Secondary endpoints included myocardial infarction (MI), stroke, target vessel revascularization (TVR), repeat revascularization, and stent thrombosis or graft occlusion. Results: Seventeen RCTs encompassing 7700 patients (median follow-up 2 years) were included. Angiography-guided PCI was associated with a higher risk of MACE compared with both imaging-guided PCI (IRR 1.34, 95%CI 1.05–1.72) and CABG (IRR 1.49, 95%CI 1.10–2.03). Compared with imaging-guided PCI, neither CABG (IRR 1.00 95%CI 0.81–1.24) nor angiography-guided PCI (IRR 1.04, 95%CI 0.77–1.40) differed in all-cause death. CABG was associated with a lower risk of MI, TVR and repeat revascularization, but at the expense of an increased stent thrombosis or graft occlusion. Angiography-guided PCI was associated with higher risks of TVR compared with imaging-guided PCI and a lower risk of stroke compared to both CABG and imaging-guidance. Conclusions: In patients with LMCA disease, no significant differences in MACE were observed between imaging-guided PCI and CABG, whereas angiography-guided PCI was associated with a higher risk of MACE compared either with imaging-guided PCI and CABG. PCI, regardless of guidance, achieved all-cause death comparable to surgery. Imaging guidance reduced stent thrombosis or graft occlusion, whereas CABG reduced MI and repeat revascularization.PROSPERO registration number: CRD420261283126.