Clinical Impact of Diabetes Mellitus After Intravascular Imaging–Guided PCI vs Coronary Artery Bypass Grafting

Background Coronary artery bypass grafting (CABG) is the standard revascularization method for patients with diabetes mellitus (DM) and complex coronary artery disease. However, with significant advances in percutaneous coronary intervention (PCI), particularly the use of intravascular imaging (IVI), it is uncertain whether contemporary IVI-guided PCI can achieve clinical outcomes comparable with those of CABG. Objectives The aim of this study was to compare the clinical outcomes of IVI-guided PCI, angiography-guided PCI, and CABG in DM patients with left main or 3-vessel disease. Methods A total of 3,402 DM patients with left main or 3-vessel disease were included from individual patient-level data of the RENOVATE-COMPLEX-PCI (Randomized Controlled Trial of Intravascular Imaging Guidance Versus Angiography-Guidance on Clinical Outcomes After Complex Percutaneous Coronary Intervention) trial and the institutional registries of Samsung Medical Center (n = 6,962). The primary outcome, which was a composite of all-cause death, nonfatal myocardial infarction, or stroke at 3 years was compared among IVI-guided PCI, angiography-guided PCI, and CABG. Results In the DM population, the cumulative incidence of the primary outcome at 3 years was 20.1% for angiography-guided PCI, 11.4% for IVI-guided PCI, and 12.4% for CABG. PCI was associated with a significantly higher risk for primary outcome (17.0% vs 12.4%; HR: 1.91; 95% CI: 1.50-2.44; P < 0.001). However, the risk for the primary outcome was comparable between the IVI-guided PCI and CABG groups (11.4% vs 12.4%; HR: 0.88; 95% CI: 0.58-1.32; P = 0.525). A propensity score–matched analysis yielded similar results (HR: 0.85; 95% CI: 0.53-1.36; P = 0.507). Conclusions In this hypothesis-generating study, PCI was associated with significantly higher risk for all-cause death, nonfatal myocardial infarction, or stroke at 3 years than CABG in DM patients with left main or 3-vessel disease. However, IVI-guided PCI had comparable risk for clinical events compared with CABG in DM patients. Further randomized controlled trial is needed to confirm this finding.