Ischemic events after coronary artery bypass grafting: when to treat interventionally, medically or surgically?

Purpose of review: All revascularization modalities in patients with prior coronary artery bypass grafting (CABG) have been shown to have higher rates of procedural complications and worse outcomes compared to patients without prior CABG. However, patients' clinical presentations often necessitate revascularization. This review outlines the different treatment options for patients with prior CABG presenting with ischemia depending on clinical presentation, focusing on the advantages and challenges of different techniques and emerging evidence.

Recent findings: While still high risk, recent studies have shown improvement in outcomes in both surgical and interventional revascularization options in post-CABG patients. Redo CABG, still recommended in patients with left anterior descending disease and an available internal mammary conduit, has had improved outcomes over the past two decades. Percutaneous coronary intervention (PCI) is preferred in most cases, with native-vessel PCI generally preferred over vein-graft PCI when feasible. Bypassed arteries often have high rates of chronic total occlusions, and the vein grafts themselves can be useful in retrograde approaches.

Summary: Revascularization in patients with prior CABG remains high risk and should be reserved for high-risk ischemia or symptoms refractory to medical management. The choice of intervention is often dictated by the clinical presentation and coronary anatomy, with specific techniques available to improve both native-vessel and saphenous vein graft PCI success rates.