The cost of coronary artery revascularization in 6218 patients with and without CKD whose data were available in the Duke database was examined.1251 CABG was an economically attrac- tive alternative to PCI or medical therapy for all patients with left main or 3-vessel CAD without concomitant CKD as well as those with 2-vessel CAD with concomitant CKD. For subjects with 3-vessel CAD and concomitant CKD, 2-vessel CAD without CKD, and 1-vessel CAD regardless of renal function, medical therapy was an economically attractive strategy com- pared with CABG or PCI. This analysis concluded that CABG is most economically attractive compared with PCI and medical therapy in patients to whom it confers the greatest survival advantage and for whom the cost of alternative treatments is greatest (ie, those with the most severe CAD). Although CABG was more expensive than medical therapy for all patients, the survival benefits associated with it were of such magnitude in some subjects that it was economically attractive. The cost-effectiveness of CABG and PCI in high-risk patients was analyzed in the AWESOME (Angina With Extremely Serious Operative Mortality Evaluation) study,446 in which costs were assessed at 3 and 5 years. After 3 years, the average total cost was $63 896 for PCI and $84 364 for CABG, a difference of $20 468. After 5 years, the average total cost was $81 790 for PCI and $100 522 for CABG, a difference of $18 732. The authors concluded that PCI was less costly and at least as effective for urgent revasculariza- tion in high-risk patients with medically refractory angina. 7.1.2. CABG Versus PCI With DES The use of DES for PCI will require a reassessment of cost- effectiveness. 