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  • Review Article
  • Published:

Contemporary coronary artery bypass graft surgery and subsequent percutaneous revascularization

Nature Reviews Cardiology volume 19, pages 195–208 (2022)Cite this article

Subjects

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.

Key points

  • 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.

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Fig. 1: Common pathophysiology in SVG conduits after coronary artery bypass graft surgery.
Fig. 2: Intervention modalities in patients who have undergone CABG surgery.
Fig. 3: SVG PCI and potential complications.

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Acknowledgements

M.F.L.G. has received institutional grant/research support from the NIH and the Canadian Institutes of Health Research.

Review criteria

A search was performed for original articles published between 1980 and 2021 focusing on contemporary practices in both coronary artery bypass graft surgery as well as follow-up percutaneous coronary interventions in patients who have previously undergone coronary artery bypass graft surgery. The search terms used were ‘prior coronary artery bypass graft’, ‘saphenous vein graft’, ‘radial artery graft’, ‘bilateral internal thoracic artery’, ‘right internal thoracic artery’, ‘multiple artery grafting’, ‘total arterial revascularization’, ‘venous graft failure’, ‘arterial graft failure’, ‘perioperative graft failure’, ‘prior CABG revascularization’, ‘prior CABG medical treatment’, ‘saphenous vein graft PCI’, ‘native vessel PCI prior CABG’, ‘arterial graft PCI’, ‘repeat CABG surgery’, ‘radial PCI prior CABG’, ‘femoral PCI prior CABG’, ‘stent selection prior CABG’ and ‘EPD graft PCI’, alone and in combination. All articles identified were English-language, full-text papers. The reference lists of identified articles were also searched for further relevant papers.

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Authors and Affiliations

  1. Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA

    Frans J. Beerkens

  2. The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA

    Frans J. Beerkens, Bimmer E. Claessen, Roxana Mehran & George D. Dangas

  3. Department of Cardiology, Amsterdam University Medical Center, Amsterdam, Netherlands

    Bimmer E. Claessen & José P. S. Henriques

  4. Department of Ophthalmology, MedStar Georgetown University/Washington Hospital Center, Washington, DC, USA

    Marielle Mahan

  5. Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA

    Mario F. L. Gaudino

  6. Division of Cardiac Surgery, University of Toronto, Toronto, ON, Canada

    Derrick Y. Tam

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  1. Frans J. Beerkens
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Contributions

All the authors researched data for the article, contributed to discussions of its content, wrote the article, and reviewed and/or edited the manuscript before submission.

Corresponding author

Correspondence to George D. Dangas.

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Competing interests

R.M. and G.D.D. have received institutional grant/research support from Abbott Laboratories, AstraZeneca, Boston Scientific, Daiichi-Sankyo and Medtronic; have served as consultants for Biosensors; and have received speaker honoraria from Chiesi. The other authors declare no competing interests.

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Nature Reviews Cardiology thanks Y. Jang and C. Juergens for their contribution to the peer review of this work.

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Beerkens, F.J., Claessen, B.E., Mahan, M. et al. Contemporary coronary artery bypass graft surgery and subsequent percutaneous revascularization. Nat Rev Cardiol 19, 195–208 (2022). https://doi.org/10.1038/s41569-021-00612-6

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