Fractional flow reserve guided percutaneous coronary intervention vs coronary artery bypass grafting for multivessel coronary artery disease: A meta-analysis

Abstract

BACKGROUND

Coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are well-established treatments for multivessel coronary artery disease (CAD), a condition where multiple heart arteries are narrowed. A newer approach, fractional flow reserve (FFR)-guided PCI, uses a specialized measurement to select which artery blockages to treat, aiming to enhance patient outcomes. Despite its adoption, the comparative effectiveness of FFR-guided PCI vs CABG remains unclear, particularly regarding key health outcomes such as survival, heart-related complications, and the need for further procedures.

AIM

To evaluate the safety and effectiveness of FFR -guided PCI compared to CABG in patients with multivessel CAD.

METHODS

This meta-analysis followed standard reporting guidelines and included randomized controlled trials (RCTs) comparing FFR-guided PCI with CABG in patients with multivessel CAD. We searched medical databases, including PubMed, EMBASE, ScienceDirect, and ClinicalTrials.gov, from their start to May 2025. We calculated combined risk ratios (RRs) with 95% confidence intervals (95%CIs) to analyze the data.

RESULTS

Three RCTs were analyzed. There was no notable difference in all-cause mortality between FFR-guided PCI and CABG (RR = 1.01, 95%CI: 0.78-1.31, P = 0.93). However, FFR-guided PCI showed higher rates of major adverse cardiac events (MACEs; RR = 1.30, 95%CI: 1.11-1.52, P = 0.001), myocardial infarction (RR = 1.49, 95%CI: 1.11-2.01, P = 0.009), and repeat revascularization (RR = 2.25, 95%CI: 1.78-2.85, P < 0.00001). Stroke rates were comparable between the two treatments (RR = 0.80, 95%CI: 0.54-1.20, P = 0.28).

CONCLUSION

FFR-guided PCI and CABG have similar rates of all-cause mortality and stroke in patients with multivessel CAD. However, CABG results in fewer MACEs, myocardial infarctions, and repeat procedures.

Key Words: Percutaneous coronary intervention; Coronary artery bypass grafting; Fractional flow reserve; Multivessel coronary artery disease; Meta-analysis

Core Tip: This meta-analysis compares fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) with coronary artery bypass grafting (CABG) for multivessel coronary artery disease. While both treatments show similar all-cause mortality and stroke rates, CABG significantly reduces major adverse cardiac events, myocardial infarction, and repeat revascularization. These findings highlight CABG’s superior efficacy in managing complex coronary disease, challenging the broader adoption of FFR-guided PCI. The results underscore the need for tailored treatment strategies and further trials to optimize outcomes in diverse patient populations.

INTRODUCTION

Multivessel coronary artery disease (CAD), defined as significant stenosis (> 70%) in two or more major coronary arteries with a diameter of 2.5 mm or greater, is a prevalent condition encountered in patients undergoing coronary angiography[1]. It poses a significant clinical challenge due to its association with extensive myocardial ischemia, impaired ventricular function, and an increased risk of adverse cardiac events, including myocardial infarction, heart failure, and mortality[1]. The management of multivessel CAD primarily involves two revascularization strategies: Percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). PCI is favored for its minimally invasive nature, offering shorter recovery times and favorable short-term outcomes. At the same time, CABG provides superior long-term durability, reducing the incidence of myocardial infarction and the need for target vessel revascularization[2,3]. The decision between these strategies is complex, influenced by factors such as the extent of coronary involvement, degree of ischemia, patient comorbidities, and individual preferences, often guided by tools like the SYNTAX score[4].

The introduction of fractional flow reserve (FFR) has transformed PCI by providing a physiological assessment of coronary stenoses. FFR measures the ratio of distal coronary pressure to aortic pressure during maximal hyperemia, with a value ≤ 0.80 indicating ischemia that warrants intervention[5]. By identifying functionally significant lesions, FFR-guided PCI reduces unnecessary stent placements and has been shown to lower the composite endpoint of death, nonfatal myocardial infarction, and repeat revascularization compared to angiography-guided PCI alone[6]. This precision has made FFR-guided PCI a cornerstone of modern interventional cardiology, particularly for multivessel CAD, where selective intervention can optimize outcomes[7].

Despite these advancements, the optimal revascularization strategy for multivessel CAD remains a subject of ongoing debate[8]. CABG, which bypasses both flow-limiting and angiographically mild lesions using arterial or venous grafts, has been associated with better long-term survival and lower rates of repeat revascularization, particularly in patients with higher SYNTAX scores or complex disease[9,10]. In contrast, FFR-guided PCI offers comparable outcomes in terms of mortality and major adverse cardiac events (MACEs) in certain populations, as demonstrated by the FFR vs angiography for multivessel evaluation 3 trial. This trial reported no significant difference in the composite endpoint of death, myocardial infarction, or stroke between FFR-guided PCI with contemporary drug-eluting stents and CABG at a 5-year follow-up. However, CABG was associated with a lower rate of repeat revascularization[8]. The subgroup analyses further complicate the decision-making process, revealing that patient-specific factors, such as diabetes or the presence of bifurcation lesions, may influence the relative benefits of each strategy. For instance, diabetic patients on insulin therapy experienced a significantly higher risk of repeat revascularization with FFR-guided PCI compared to CABG[11].

The conflicting results from individual randomized controlled trials (RCTs) and observational studies highlight significant clinical uncertainty[12]. Limitations such as small sample sizes, lack of randomization in subgroup analyses, and variability in patient populations (e.g., exclusion of left main disease or differences in SYNTAX scores) underscore the need for a comprehensive synthesis of evidence[13]. Moreover, advancements in medical technology, including newer-generation drug-eluting stents and improved surgical techniques, have altered the treatment landscape, necessitating updated comparisons[14]. A meta-analysis is, therefore, timely and essential to pool data from multiple studies, enhancing statistical power and providing robust estimates of treatment effects across diverse patient populations.

A meta-analysis is, therefore, timely and essential to pool data from multiple studies, enhancing statistical power and providing robust estimates of treatment effects across diverse patient populations. This meta-analysis aims to systematically compare the efficacy and safety of FFR-guided PCI vs CABG in patients with multivessel CAD, focusing on key clinical outcomes such as all-cause mortality, myocardial infarction, stroke, and the need for repeat revascularization. By addressing heterogeneity across studies and incorporating contemporary data, this study seeks to clarify the optimal revascularization strategy, inform clinical guidelines, and support patient-centered decision-making for this high-risk population.

MATERIALS AND METHODS

This systematic review and meta-analysis were conducted per the PRISMA 2020 guidelines[15,16]. The protocol is registered on PROSPERO CRD420251077550.

Eligibility criteria

Inclusion criteria: The inclusion criteria for this systematic review and meta-analysis included studies involving adult patients aged 18 years or older who were diagnosed with multivessel CAD, defined as at least a 50% diameter stenosis in two or more major epicardial vessels, with or without diabetes mellitus. Eligible studies compared FFR-guided PCI using contemporary drug-eluting stents with CABG, including both on-pump and off-pump techniques. Studies were required to report at least one of the following outcomes with a minimum follow-up of 3 years, prioritizing 5-year data when available: All-cause mortality (primary outcome), MACEs, myocardial infarction, repeat revascularization, or stroke, as defined by individual studies. Only RCTs and observational cohort studies published in English with full-text availability were included, with no restrictions on publication year.

Exclusion criteria: The exclusion criteria encompassed studies involving patients with single-vessel disease or isolated left main disease, those including patients presenting with acute coronary syndromes other than stable or unstable angina (e.g., ST-elevation myocardial infarction), and studies that did not employ FFR guidance for PCI. Additionally, non-comparative studies, case reports, editorials, expert opinions, and duplicates were excluded.

Information sources and search strategy

The search strategy for this meta-analysis was designed to retrieve studies from PubMed, EMBASE, ScienceDirect, and ClinicalTrials.gov, using MeSH and free-text keywords aligned with the PICOS framework. The search strategy for PubMed combined medical subject headings (MeSHs) terms is as follows ((((Fractional Flow Reserve, Myocardial[Mesh]) OR (Myocardial Fractional Flow Reserve)) AND ((((((((((((Percutaneous Coronary Intervention[Mesh]) OR (Coronary Intervention, Percutaneous)) OR (Coronary Interventions, Percutaneous)) OR (Intervention, Percutaneous Coronary)) OR (Interventions, Percutaneous Coronary)) OR (Percutaneous Coronary Interventions)) OR (Percutaneous Coronary Revascularization)) OR (Coronary Revascularization, Percutaneous)) OR (Coronary Revascularizations, Percutaneous)) OR (Percutaneous Coronary Revascularizations)) OR (Revascularization, Percutaneous Coronary)) OR (Revascularizations, Percutaneous Coronary))) AND (((((((((((((Coronary Artery Bypass[Mesh]) OR (Artery Bypass, Coronary)) OR (Artery Bypasses, Coronary)) OR (Bypasses, Coronary Artery)) OR (Coronary Artery Bypasses)) OR (Coronary Artery Bypass Grafting)) OR (Coronary Artery Bypass Surgery)) OR (Aortocoronary Bypass)) OR (Aortocoronary Bypasses)) OR (Bypass, Aortocoronary)) OR (Bypasses, Aortocoronary)) OR (Bypass Surgery, Coronary Artery)) OR (Bypass, Coronary Artery))) AND ((((((((((Coronary Stenosis[Mesh]) OR (Stenoses, Coronary)) OR (Stenosis, Coronary)) OR (Coronary Stenoses)) OR (Coronary Artery Stenosis)) OR (Artery Stenoses, Coronary)) OR (Artery Stenosis, Coronary)) OR (Coronary Artery Stenoses)) OR (Stenoses, Coronary Artery)) OR (Stenosis, Coronary Artery)) with free-text keywords, including “Fractional Flow Reserve, Myocardial,” “Percutaneous Coronary Intervention,” “Coronary Artery Bypass,” and “Coronary Stenosis”. Boolean operators (AND, OR) were used to combine terms. "Fractional Flow Reserve, Myocardial" OR "Myocardial Fractional Flow Reserve" was paired with "Percutaneous Coronary Intervention" OR synonyms (e.g., "Coronary Revascularization, Percutaneous") using AND, then combined with "Coronary Artery Bypass" OR synonyms (e.g., "Coronary Artery Bypass Grafting") using AND, and finally with "Coronary Stenosis" OR synonyms (e.g., "Coronary Artery Stenosis") using AND. The NOT operator was not used. These terms were tailored to each database to identify studies based on predefined population, intervention, comparison, and outcome criteria. Manual searches of bibliographies and grey literature, including conference proceedings, abstracts, and preprints, were performed to ensure comprehensive data collection.

Study selection

All identified citations were imported into Zotero reference management software for duplicate removal. Two independent reviewers (Kataveni S and Ellahi E) conducted a two-stage screening process. First, titles and abstracts were screened for relevance based on the predefined inclusion and exclusion criteria. Second, full texts of potentially eligible studies were retrieved and assessed for final inclusion. Disagreements were resolved through discussion, with a third reviewer (Dhir B). No studies were excluded based on the risk of bias; the risk of bias assessment was used to evaluate the quality of evidence for included studies, as detailed in the risk of bias and Grading of Recommendations Assessment, Development, and Evaluation (GRADE) assessments. The study selection process was documented using a PRISMA flow diagram.

Data extraction

Data were extracted independently by two reviewers (Sabarish S and Kvn M) using a standardized, pre-piloted Google Sheets form. Extracted data included study characteristics (author, year, country, study design), participant demographics (e.g., age, sex, comorbidities), intervention details, and outcome measures (all-cause mortality, MI, stroke, MACE, repeat revascularization). For each study, outcome data from the longest available follow-up period (at least 3 years) were extracted, with a preference for 5-year data when available. Discrepancies between reviewers were resolved through discussion, and corresponding authors were contacted via email for clarification of missing or ambiguous data, with a two-week response period and follow-up if necessary.

Risk of bias assessment

The risk of bias for RCTs was assessed using the Cochrane Risk of Bias 2 (RoB 2) tool, which evaluates domains such as randomization process, deviations from intended interventions, missing outcome data, measurement of the outcome, and selection of reported results[17].

Although eligibility criteria allowed for observational cohort studies, none were included; however, had they been included, the Newcastle-Ottawa Scale (NOS) would have been used to assess bias, evaluating three domains: Selection of study groups (e.g., representativeness, selection of controls), comparability of groups (e.g., adjustment for confounders), and ascertainment of outcomes (e.g., adequacy of follow-up), with a maximum score of 9 stars indicating high quality. The RoB 2 tool is designed explicitly for RCTs, focusing on randomization-related biases, whereas NOS is suited for observational studies, addressing confounding and selection biases.

Statistical analysis

For each outcome, the number of events and the total number of patients in the FFR-guided PCI and CABG groups were extracted. These data were pooled using risk ratios (RRs) with 95% confidence intervals (95%CIs) calculated via the Mantel-Haenszel method. Heterogeneity was assessed using I². For each outcome, a forest plot was constructed to visually analyze the data, and funnel plots were generated to check the publication bias. All statistical analyses were performed using Review Manager (RevMan) version 5.4. Following the statistical analysis, the quality of evidence for each outcome was evaluated using the GRADE approach, assessing domains such as risk of bias, inconsistency, imprecision, indirectness, and effect size to determine the certainty of evidence.

RESULTS

Study selection

The PRISMA statement flowchart outlines the literature screening process and study selection. The initial search across multiple databases yielded 532 articles: PubMed (n = 118), EMBASE (n = 23), ScienceDirect (n = 389), and ClinicalTrials.gov (n = 2). After removing duplicates, 412 unique records were screened. From these, 36 full-text articles were retrieved for detailed assessment. Ultimately, 3 studies[8,18,19] met the eligibility criteria and were included in both the qualitative and quantitative meta-analyses. All included studies were RCTs (n = 3); no observational cohort studies met the inclusion criteria (Figure 1).

Figure 1  PRISMA flowchart outlining the literature screening process, study selection, and exclusion criteria.

Baseline characteristics

The meta-analysis included three RCTs comparing FFR-guided PCI vs CABG in patients with multivessel CAD, with baseline characteristics summarized across 3412 participants (1719 PCI, 1693 CABG). Sample sizes ranged from 205 to 757 for PCI and 207 to 743 for CABG. Mean ages were comparable, ranging from 65.33 to 67.43 years, with a slight male predominance (75.2%-83% male). Body mass index was reported in two studies, averaging 28.1-29.35 kg/m², indicating similar obesity profiles. Diabetes prevalence was approximately 28%-29% in one study, while hypertension was consistently high (70.1%-75%). Family history of CAD varied (21.6%-33%), and previous myocardial infarction was reported in 10.7%-34% of patients. The proportion of patients with left ventricular ejection fraction ≤ 50% was notably higher in Gioia et al[13] (2020; 66.2%-66.5%) compared to Fearon et al[8] (2025; 18%). Dillen et al[14] (2025) did not report most baseline characteristics, limiting comparisons. Overall, baseline characteristics were broadly similar across groups, supporting the comparability of PCI and CABG cohorts, though incomplete data in one study constrained comprehensive assessment (Table 1).

Table 1 Study characteristics and patient baseline demographics.

Ref.	Study design	Sample size		Age (years)		Sex (male/female)		BMI (kg/m²)		Diabetes		Hypertension		Family history of CAD		Previous (MI)		LVEF ≤ 50% (%)
		PCI	CABG	PCI	CABG	PCI	CABG	PCI	CABG	PCI	CABG	PCI	CABG	PCI	CABG	PCI	CABG	PCI	CABG
Dillen et al[14], 2025	RCT	757	743	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA
Fearon et al[8] 2025	RCT	757	743	65.67 ± 9.66	65.33 ± 8.91	81/19	83/17	28.3	28.1	28	29	71	75	33	29	33	34	18	18
Gioia et al[13], 2020	RCT	205	207	67.35 ± 9.96	67.43 ± 8.35	75.9/24.1	75.2/24.8	29.35	29.09	NA	NA	70.5	70.1	21.6	22.6	11.5	10.7	66.5	66.2

BMI: Body mass index; CAD: Coronary artery disease; LVEF: Left ventricular ejection fraction; MI: Myocardial infarction; PCI: Percutaneous coronary intervention; CABG: Coronary artery bypass grafting; RCT: Randomized controlled trial; NA: Not Applicable.

Quality assessment

Using the ROB 2.0 tool, we assessed the risk of bias across five domains (D1: Randomization, D2: Intervention deviations, D3: Missing outcome data, D4: Outcome measurement, D5: Result selection) for three studies. Dillen et al[14] (2025) exhibited some concerns in D1 and D2, resulting in an overall rating of some concerns, despite low risk in D3, D4, and D5. Fearon et al[8] (2025) showed some concerns in D2 but achieved an overall low risk rating, with all other domains rated low. Similarly, Gioia et al[13] (2020) had some concerns in D5 but was rated low risk overall, with low risk in D1, D2, D3, and D4. In summary, Fearon et al[8] and Gioia et al[13] demonstrated robust methodological quality with low overall bias, while Dillen et al[14] raised moderate concerns due to issues in randomization and intervention adherence (Supplementary Figures 1 and 2).

Clinical outcomes

Forest plots for all clinical outcomes are presented in Figure 2. Three studies, with baseline characteristics summarized in Table 1, reported all-cause mortality, showing no significant difference between FFR-guided percutaneous coronary intervention and CABG (pooled relative risk1.01, 95%CI: 0.78-1.31, P = 0.93), with no heterogeneity (I² = 0%). Three studies reported MACEs, indicating a significantly higher rate with FFR-guided percutaneous coronary intervention compared to CABG (pooled relative risk 1.30, 95%CI: 1.11-1.52, P = 0.001), with no heterogeneity (I² = 0%). Three studies reported myocardial infarction, demonstrating a significantly higher rate with FFR-guided PCI compared to CABG (pooled relative risk 1.49, 95%CI: 1.11-2.01, P = 0.009), with low heterogeneity (I² = 25%). Three studies reported repeat revascularization, revealing a significantly higher rate with FFR-guided PCI compared to CABG (pooled relative risk 2.25, 95%CI: 1.78-2.85, P < 0.00001), with no heterogeneity (I² = 0%). Three studies reported stroke, showing no significant difference between FFR-guided PCI and CABG (pooled relative risk 0.80, 95%CI: 0.54-1.20, P = 0.28), with no heterogeneity (I² = 0%).

Figure 2 Forest plots comparing outcomes between fractional flow reserve-guided percutaneous coronary intervention and coronary artery bypass grafting in multivessel coronary artery disease patients. A: All-cause mortality; B: Major adverse cardiac event; C: Myocardial infarction; D: Revascularization; E: Stroke.

Publication bias

Publication bias was evaluated using funnel plots for all clinical outcomes, including target lesion revascularization, major adverse cardiovascular events, stent thrombosis, all-cause mortality, cardiac mortality, and myocardial infarction. The plots displayed symmetrical distributions of effect sizes around the pooled estimates, with no notable asymmetry observed across the included studies. This symmetry suggests the absence of significant publication bias, indicating that the meta-analysis results are unlikely to be skewed by selective reporting or non-publication of smaller studies with non-significant findings (Supplementary Figure 3).

GRADE assessment

The GRADE assessment evaluated the certainty of evidence for five clinical outcomes from three RCTs comparing FFR-guided PCI with CABG. All-cause mortality and stroke showed low certainty due to serious risks of bias (one study with some concerns in randomization and intervention adherence) and imprecision (wide confidence intervals: RR = 1.01, 95%CI: 0.78-1.31 for mortality; RR = 0.80, 95%CI: 0.54-1.20 for stroke). MACE, myocardial infarction, and repeat revascularization achieved moderate certainty, downgraded only for serious risk of bias (RR = 1.30, 95%CI: 1.11-1.52; RR = 1.49, 95%CI: 1.11-2.01; RR = 2.25, 95%CI: 1.78-2.85, respectively). No heterogeneity (I² = 0%-25%) or publication bias was detected across outcomes, and indirectness was not a concern (Supplementary Table 1).

DISCUSSION

This meta-analysis of three RCTs, involving 1918 patients with multivessel CAD, compared FFR-guided PCI with CABG reveals key insights into their relative safety and efficacy. No significant differences were observed in all-cause mortality or stroke between the two strategies, indicating comparable outcomes for these critical endpoints. The primary findings indicate that both strategies yield comparable outcomes in terms of long-term survival and stroke risk, suggesting that FFR-PCI can be a viable alternative to CABG for certain patients, particularly those with less complex disease. However, CABG demonstrates a clear advantage in reducing the incidence of myocardial infarction, major adverse cardiac and cerebrovascular events (MACCE), and the need for repeat revascularization. These results underscore CABG’s superior durability in managing complex coronary disease, aligning with its ability to provide more complete revascularization compared to the targeted approach of FFR-PCI[8,9].

When examining individual outcomes, the lack of difference in all-cause mortality and stroke between FFR-PCI and CABG highlights the safety of both procedures in appropriately selected patients. This equivalence may reflect advancements in PCI techniques, such as the use of second-generation drug-eluting stents, and improvements in surgical methods, including arterial grafting and off-pump CABG, which have reduced perioperative complications[20,21]. However, the higher rates of myocardial infarction in the FFR-PCI group suggest that stents may not offer the same level of ischemic protection as surgical bypass, potentially due to residual ischemia or disease progression in untreated vessels[22]. Similarly, the increased need for repeat revascularization with FFR-PCI points to the limitations of stents in maintaining long-term patency compared to the robust durability of surgical grafts, particularly internal mammary artery grafts[23,24]. The elevated MACCE rates in the PCI group further reinforce CABG’s advantage in preventing adverse events, especially in patients with high anatomical complexity or comorbidities like diabetes[13].

Comparing these findings to prior studies, the results are consistent with landmark trials that have established CABG as the preferred strategy for complex multivessel CAD. For instance, earlier trials demonstrated higher revascularization rates with PCI compared to CABG, a trend that persists even with FFR guidance, which optimizes lesion selection[23,24]. However, unlike older studies that relied on angiography-guided PCI, this meta-analysis reflects contemporary practice by focusing on physiologically guided interventions, offering a more relevant comparison. The findings also align with studies in high-risk populations, such as diabetic patients, where CABG has consistently shown better long-term outcomes[25]. Discrepancies with some studies, particularly those involving lower SYNTAX scores, may be attributed to differences in patient selection, lesion complexity, or follow-up duration[26].

Several factors may explain the observed differences between FFR-PCI and CABG. FFR-guided PCI targets only ischemia-causing lesions, potentially leaving non-flow-limiting but vulnerable plaques untreated, which can progress and cause future events[27]. In contrast, CABG bypasses entire diseased segments, providing a more comprehensive solution that mitigates the risk of ischemia from both culprit and non-culprit lesions[28]. Additionally, lesion complexity, such as calcified or bifurcated plaques, poses challenges for PCI, whereas CABG overcomes these by grafting beyond the lesion[29]. Advances in surgical techniques, including the use of arterial grafts and improved perioperative care, further enhance CABG’s long-term efficacy[30].

To prevent future myocardial infarction, MACCEs, and repeat revascularization, several strategies are recommended. Hybrid revascularization, combining FFR-guided PCI for non-complex lesions with CABG for complex disease, could optimize outcomes[31]. Advanced stent technologies, such as newer-generation drug-eluting stents or bioresorbable scaffolds, may reduce stent-related complications[32,33]. Optimized medical therapy, including dual antiplatelet therapy, statins, and risk factor modification (e.g., diabetes control, smoking cessation), can prevent disease progression in untreated vessels[34].

Strengths and limitations

This meta-analysis has several strengths, including its exclusive use of RCTs, rigorous bias assessment using the Cochrane Risk of Bias 2 tool, and low heterogeneity across outcomes (I² = 0%-25%), which enhances the reliability of the findings. The focus on contemporary FFR-guided PCI and CABG practices ensures relevance to current clinical decision-making. However, limitations include the small number of included studies (three RCTs), which may limit the generalizability of the findings. Incomplete baseline data in one study[14] constrained a comprehensive assessment of patient characteristics. The lack of subgroup analyses for specific populations, such as diabetic patients or those with varying SYNTAX scores, limits our understanding of tailored treatment effects. These limitations highlight the need for larger, more diverse trials to refine treatment strategies.

CONCLUSION

In conclusion, this meta-analysis demonstrates that FFR-guided PCI and CABG yield comparable all-cause mortality and stroke rates in patients with multivessel CAD. However, CABG is superior in reducing myocardial infarction, MACCEs, and repeat revascularization, supporting its preference for complex disease, particularly in high-risk patients like those with diabetes or high SYNTAX scores. Recommended strategies to prevent future adverse events include hybrid revascularization, advanced stent technologies, optimized medical therapy, patient selection with risk stratification tools, and structured long-term follow-up. Future research should focus on large-scale trials exploring these strategies, novel stent designs, and subgroup-specific outcomes to optimize patient-centered care and inform clinical guidelines.