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  • Review Article
  • Published:

Secondary revascularization after CABG surgery

Nature Reviews Cardiology volume 9, pages 540–549 (2012)Cite this article

Subjects

Abstract

CABG surgery is an effective way to improve symptoms and prognosis in patients with advanced coronary atherosclerotic disease. Despite multiple improvements in surgical technique and patient treatment, graft failure after CABG surgery occurs in a time-dependent fashion, particularly in the second decade after the intervention, in a substantial number of patients because of atherosclerotic progression and saphenous-vein graft (SVG) disease. Until 2010, repeat revascularization by either percutaneous coronary intervention (PCI) or surgical techniques was performed in these high-risk patients in the absence of specific recommendations in clinical practice guidelines, and within a culture of inadequate communication between cardiac surgeons and interventional cardiologists. Indeed, some of the specific technologies developed to reduce procedural risk, such as embolic protection devices for SVG interventions, are largely underused. Additionally, the implementation of secondary prevention, which reduces the need for reintervention in these patients, is still suboptimal. In this Review, graft failure after CABG surgery is examined as a clinical problem from the perspective of holistic patient management. Issues such as the substrate and epidemiology of graft failure, the choice of revascularization modality, the specific problems inherent in repeat CABG surgery and PCI, and the importance of secondary prevention are discussed.

Key Points

  • Patients who have previously undergone CABG surgery can require early or late repeat revascularization with PCI or CABG surgery because of graft failure or disease progression in native coronary arteries

  • Obtaining evidence on repeat revascularization in patients with a history of CABG surgery from randomized clinical trials is difficult; recommendations on secondary revascularization were absent from clinical guidelines until 2010

  • Particular surgical and interventional techniques have been developed to circumvent the high procedural risk associated with repeat interventions performed in either native vessels or surgical grafts

  • Adequate implementation of diagnostic (for example, multidetector angiography) and therapeutic (embolic protection devices) techniques in patients who have previously undergone CABG surgery remains suboptimal

  • Optimization of secondary prevention in patients with a history of CABG surgery reduces the need for repeat revascularization by slowing the progression of atherosclerosis, and prolonging the patency of grafts

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Figure 1: Time-related graft patency (or freedom from graft occlusion) for ITA grafts and SVG.12
Figure 2: Assessment of the results of CABG surgery with FFR.
Figure 3: EPDs used in percutaneous revascularization of saphenous vein grafts.
Figure 4: Efficacy and safety of DES implantation in stenoses of saphenous-vein grafts.

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Acknowledgements

The author acknowledges Professor Jean Marco and Dr Wiliam Wijns (chairmen of PCR and EuroPCR, respectively), the European Association of Percutaneous Cardiovascular Interventions, the European Association of Cardiothoracic Surgery, and the ESC Working Group on Cardiovascular Surgery for their important and continued support of the concept of secondary revascularization made in institutional scientific programs over the past 4 years.

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  1. Cardiovascular Institute, Hospital Clínico San Carlos, Calle del Profesor Martín Lagos s/n, Madrid, 28040, Spain

    Javier Escaned

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Escaned, J. Secondary revascularization after CABG surgery. Nat Rev Cardiol 9, 540–549 (2012). https://doi.org/10.1038/nrcardio.2012.100

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