Contemporary coronary artery bypass graft surgery and subsequent percutaneous revascularization

Abstract

Patients who have undergone coronary artery bypass graft (CABG) surgery are susceptible to bypass graft failure and progression of native coronary artery disease. Although the saphenous vein graft (SVG) was traditionally the most-used conduit, arterial grafts (including the left and right internal thoracic arteries and the radial artery) have improved patency rates. However, the need for secondary revascularization remains common, and percutaneous coronary intervention (PCI) has become the most common modality of secondary revascularization after CABG surgery. Procedural characteristics and clinical outcomes differ considerably from those associated with PCI in patients without previous CABG surgery, owing to altered coronary anatomy and differences in conduit pathophysiology. In particular, SVG PCI carries an increased risk of complications, and operators are shifting their focus towards embolic protection strategies and complex native-vessel interventions, increasingly using SVGs as conduits to facilitate native-vessel PCI rather than pursuing SVG PCI. In this Review, we discuss the differences in conduit pathophysiology, changes in CABG surgery techniques, and the latest evidence in terms of PCI in patients with previous CABG surgery, with a particular emphasis on safety and long-term efficacy. We explore the subject of contemporary CABG surgery and subsequent percutaneous revascularization in this complex patient population. In this Review, Dangas and colleagues explore changes in coronary artery bypass graft (CABG) surgical techniques, differences in conduit vessel pathophysiology and the latest evidence for percutaneous coronary intervention in patients with previous CABG surgery. Coronary artery bypass graft (CABG) surgery has evolved over the years because saphenous vein graft harvesting techniques and expanded use of arterial grafts have improved graft patency. Peri-operative graft failure is a rare complication that can be difficult to recognize during CABG surgery. Venous and arterial grafts vary in pathophysiology, which leads to differences in graft failure modes and relevant considerations in percutaneous coronary revascularization techniques. The need for subsequent revascularization after CABG surgery might occur; the choice of revascularization method depends on patient anatomy and characteristics, with percutaneous coronary intervention being the main treatment modality. Coronary artery bypass graft (CABG) surgery has evolved over the years because saphenous vein graft harvesting techniques and expanded use of arterial grafts have improved graft patency. Peri-operative graft failure is a rare complication that can be difficult to recognize during CABG surgery. Venous and arterial grafts vary in pathophysiology, which leads to differences in graft failure modes and relevant considerations in percutaneous coronary revascularization techniques. The need for subsequent revascularization after CABG surgery might occur; the choice of revascularization method depends on patient anatomy and characteristics, with percutaneous coronary intervention being the main treatment modality.