Long-term survival after multiple arterial coronary artery bypass grafting compared with percutaneous coronary intervention: a systematic review and meta-analysis

Background: Multiple arterial coronary artery bypass grafting (CABG) has been associated with superior long-term outcomes compared with single arterial CABG. However, randomized trials comparing percutaneous coronary intervention (PCI) with CABG have largely evaluated single arterial grafting strategies, leaving evidence comparing multiple arterial CABG with PCI limited. Methods: This systematic review and meta-analysis was registered prospectively in PROSPERO (CRD42025106759). MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched for studies published from inception through September 30, 2025, that compared outcomes between multiple arterial CABG and PCI in patients with multivessel coronary artery disease. Study-level meta-analyses and reconstructed individual patient data (IPD) meta-analyses were performed. The primary outcome was all-cause mortality, and the secondary outcome was major adverse cardiovascular and cerebrovascular events (MACCE). Results: Ten observational studies were included. Study-level meta-analysis showed higher all-cause mortality with PCI (hazard ratio [HR] 1.78, 95% confidence interval [CI] 1.51–2.09), consistent with reconstructed IPD analysis (HR 2.05, 95% CI 1.86–2.27). PCI was also associated with increased MACCE (study-level HR 2.48, 95% CI 1.91–3.21; IPD HR 2.94, 95% CI 2.56–3.39). Conclusion: In multivessel coronary artery disease, multiple arterial CABG was associated with significantly lower long-term mortality and MACCE than PCI, supporting its consideration in heart team decision-making.