Comparing TAVR + PCI vs. SAVR + CABG across short- and mid- to long-term horizons in patients with severe aortic stenosis and concomitant CAD: a systematic review and meta-analysis

Background: The optimal revascularization approach for intermediate- and high-risk individuals with severe aortic stenosis (AS) and concomitant coronary artery disease (CAD) remains uncertain, particularly regarding the comparative short- and mid- to long-term outcomes of transcatheter aortic valve replacement with percutaneous coronary intervention (TAVR + PCI) vs. surgical aortic valve replacement with coronary artery bypass grafting (SAVR + CABG). Methods: A systematic search of major databases was conducted up to March 2025 to identify studies comparing TAVR + PCI vs. SAVR + CABG in this population. Meta-analyses were performed using a random-effects model to estimate pooled odds ratios (ORs) and 95% confidence intervals (CIs). Evidence quality was assessed using the GRADE framework. Results: Thirteen studies comprising 53,869 patients were analyzed. Compared with SAVR + CABG, TAVR + PCI was associated with lower 30-day risks of stroke, myocardial infarction, and acute kidney injury, but higher permanent pacemaker implantation. No differences were found in all-cause mortality, major vascular complications, or major bleeding. In mid- to long-term follow-up (≥2 years), the TAVR + PCI group exhibited increased risks of all-cause mortality, myocardial infarction, and repeat revascularization, with similar stroke rates between strategies. Certainty of evidence ranged from very low to moderate. Conclusions: In intermediate- and high-risk patients with severe AS and concomitant CAD, TAVR + PCI appears to confer short-term safety advantages but may be associated with less favorable mid- to long-term outcomes compared with SAVR + CABG. These findings support individualized revascularization strategies that balance early procedural safety against longer-term risks and highlight the need for further randomized trials with extended follow-up. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/view/CRD420251000317, PROSPERO CRD420251000317.