Coronary revascularization strategies: From PCI versus CABG to an individualized approach

Background: Coronary revascularization by percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) remains a cornerstone in the management of complex coronary artery disease, particularly in patients with left main coronary artery disease and multivessel disease. Major randomized trials, including SYNTAX, EXCEL, NOBLE, and FREEDOM, have provided substantial evidence comparing these two strategies; however, their findings indicate that no single approach is optimal for all patients. Coronary revascularization strategies should therefore be individualized according to anatomical complexity, surgical risk, the feasibility of complete revascularization, comorbidities, age, left ventricular function, and, importantly, patient preferences. Decision-support tools such as the SYNTAX Score II 2020, STS score, and EuroSCORE II, together with physiological and intracoronary imaging modalities including FFR/iFFR and IVUS/OCT, as well as multidisciplinary Hear Team discussion, are increasingly important in guiding treatment decisions. Accordingly, this review aims to summarize contemporary evidence on PCI and CABG, identify key factors supporting individualized coronary revascularization, and discuss their applicability in clinical practice in Vietnam. Methods: To provide a narrative review of randomized controlled trials, meta-analyses, and clinical practice guidelines published between 2019 and 2026, with a focus on: (1) short-and long-term outcomes of PCI versus CABG in clinically relevant patient subgroups; (2) the role of SYNTAX Score II 2020, STS/EuroSCORE II, FFR/iFR, and IVUS/OCT in guiding revascularization strategy; (3) the clinical relevance of complete revascularization and staged revascularization strategies; (4) the role of the Heart Team in treatment decision-making; and (5) the applicability of individualized revascularization principles in the Vietnamese healthcare setting. Evidence: Major randomized trials have demonstrated that the choice between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) should be guided by individual anatomical characteristics and clinical risk. In appropriately selected patients undergoing coronary angiography, long-term mortality appears broadly comparable between PCI and CABG; however, PCI is associated with higher rates of spontaneous myocardial infarction (8% vs. 3%) and repeat revascularization (17% vs. 10%). Over long-term follow-up, CABG has been associated with a 30–40% reduction in the risk of myocardial infarction and a 50–60% reduction in the need for repeat revascularization. In patients with multivessel coronary artery disease, particularly those with diabetes mellitus or complex coronary anatomy, CABG provides greater protection against major cardiovascular events (10.9% vs. 16.3%) and reduces the need for long-term repeat revascularization (6.0% vs. 13.9%). Contemporary revascularization decision-making should integrate the SYNTAX Score II 2020, STS/EuroSCORE II, the likelihood of achieving complete revascularization, physiological lesion assessment with FFR/iFR, intracoronary imaging with IVUS/OCT, and multidisciplinary Heart Team discussion. In Vietnam, complex PCI and CABG, as well as FFR/iFR and IVUS/OCT, are increasingly available at major cardiovascular centers. Nevertheless, access to these technologies, their integration into a multimodality decision-making strategy, treatment costs, and institutional expertise remain heterogeneous. Therefore, coronary revascularization strategies should be individualized according to each patient’s clinical and anatomical profile as well as the real-world capabilities of the treating institution. Conclusion: No single revascularization strategy is optimal for all patients. The choice between PCI and CABG should be based on coronary anatomy, clinical risk, the feasibility of complete revascularization, comorbidities, and patient preferences. In the Vietnamese healthcare setting, treatment decisions should also take into account access to advanced technologies, treatment costs, adherence to long-term medical therapy, and institutional expertise. The Heart Team should remain central to the individualized selection of the optimal coronary revascularization strategy