This study compared the perioperative and longitudinal risk-adjusted outcomes of patients aged 65 and older with severe aortic stenosis and concomitant coronary artery disease undergoing either coronary artery bypass grafting with surgical aortic valve replacement (CABG+SAVR) or percutaneous coronary intervention with transcatheter aortic valve replacement (PCI+TAVR) from 2018 to 2022. While PCI+TAVR was associated with lower procedural morality, it had higher rates of vascular complications and new permanent pacemaker implantation; however, the five-year composite endpoint favored CABG+SAVR, which resulted in lower rates of stroke, myocardial infarction, valve reintervention, and death. The findings suggest that among Medicare beneficiaries, CABG+SAVR may provide better long-term outcomes compared to PCI+TAVR despite higher procedural morality.