In which patient scenarios is CABG preferred over PCI according to guidelines?

• A. Single-vessel disease with no comorbidity
• B. Multivessel disease, left main disease, diabetes with multivessel disease, prior PCI failure or high-risk anatomy, and the desire for durable complete revascularization
• C. When PCI is technically feasible
• D. In pediatric patients

Answer: (B)

CABG is favored when the goal is durable, complete revascularization in the setting of complex coronary disease. This is most clearly beneficial in patients with multivessel disease or left main disease, where bypassing multiple blocked arteries with grafts tends to provide better long-term patency and survival and reduces the need for future procedures. Diabetes with multivessel disease is a particularly strong scenario for CABG, because trials have shown superior long-term outcomes and fewer repeat revascularizations with surgery compared to PCI. CABG is also preferred if PCI has previously failed or if the anatomy is high-risk for PCI—such as diffuse disease, small or heavily calcified vessels—since bypassing the diseased segments with grafts offers a more reliable path to revascularization. The underlying reason is the durable complete revascularization that grafts can achieve, often lasting longer and requiring fewer repeat interventions than PCI in these contexts. In contrast, when disease is limited to a single vessel, or when PCI is technically feasible and likely to achieve good revascularization with lower immediate risk, PCI is typically appropriate. Pediatric patients follow different considerations, and guidelines for adults don’t directly translate to that population.