Patients with obstructive left main coronary artery disease (LMCAD) have often been treated with coronary artery bypass grafting (CABG). The EXCEL trial has; however, shown that percutaneous coronary intervention (PCI) with everolimus-eluting stent is a suitable and less invasive option in patients with a SYNTAX score <32. There was a major difference between PCI and CABG in terms of 30-day incidence of procedural myocardial infarction (MI).

A systematic review and meta-analysis suggested that in patients with significant LMCA stenosis and predominantly low to intermediate CAD complexity, both PCI and CABG may be reasonable approaches to revascularization. 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; however, if a patient is not a good candidate for surgery or wishes to avoid the morbidity associated with CABG, PCI appears to be a reasonable option.

The EXCEL trial randomly assigned 1905 patients with left main CAD of low or intermediate anatomical complexity (SYNTAX score of 32 or lower) to either PCI (with a goal of complete revascularization) with everolimus-eluting stents or CABG.

The primary endpoint, a composite of death from any cause, stroke, or MI at three years, occurred at a similar rate in both groups (15.4% versus 14.7%; hazard ratio 1, 95% CI 0.79-1.26). There were no significant between-group differences in the three-year rates of the components of the primary endpoint. The secondary endpoint of death, stroke, or MI at 30 days occurred less often in patients in the PCI group (4.9% versus 7.9%) due mainly to a lower rate of MI. The secondary endpoint of death, stroke, MI, or ischemia-driven revascularization at three years occurred more often with PCI (23.1% versus 19.1%).