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Surgical Swine Model of Chronic Cardiac Ischemia Treated by Off-Pump Coronary Artery Bypass Graft Surgery
Published on: March 27, 2018
Repeat Coronary Bypass Surgery or Percutaneous Coronary Intervention After Previous Surgical Revascularization
Chaim Locker1, Lawrence E Greiten1, Malcolm R Bell2
1Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN.
Insights
Repeat coronary artery bypass grafting (RCABG) offers improved long-term survival compared to percutaneous coronary intervention (PCI) after prior CABG. Arterial grafts and drug-eluting stents further enhance outcomes in these complex cardiac patients.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiac Surgery
Background:
- Patients with previous coronary artery bypass grafting (CABG) often require revascularization.
- Repeat coronary artery bypass grafting (RCABG) and percutaneous coronary intervention (PCI) are options for managing recurrent or progressive coronary artery disease after initial CABG.
- Long-term survival data comparing RCABG and PCI in this specific patient population are crucial for treatment decisions.
Purpose of the Study:
- To assess and compare long-term survival rates between repeat coronary artery bypass grafting (RCABG) and percutaneous coronary intervention (PCI) in patients who have previously undergone CABG.
- To evaluate the impact of graft type (saphenous vein vs. arterial grafts) in RCABG and stent type (bare metal vs. drug-eluting stents) in PCI on survival outcomes.
- To analyze survival differences based on the target of intervention (native coronary arteries vs. bypass grafts).
Main Methods:
- Retrospective analysis of 1612 patients who underwent RCABG (n=215) or PCI (n=1397) after previous CABG between 2000 and 2013.
- Subgroup analysis based on graft type for RCABG and stent type for PCI.
- Multivariable regression and propensity score matching (n=280) were employed to adjust for baseline differences and compare survival outcomes.
Main Results:
- While 30-day mortality was higher with RCABG, overall survival after 30 days significantly improved with RCABG compared to PCI (HR, 0.72).
- The use of internal mammary arteries in RCABG and drug-eluting stents in PCI was associated with improved long-term survival.
- In propensity score-matched patients, RCABG demonstrated superior late survival (48% vs. 33%) compared to PCI. PCI involving bypass grafts showed increased late mortality compared to RCABG.
Conclusions:
- Repeat coronary artery bypass grafting (RCABG) is associated with improved long-term survival in patients with previous CABG.
- RCABG demonstrates a survival benefit over percutaneous coronary intervention (PCI), particularly when compared to PCI targeting bypass grafts.
- The choice of arterial grafts for RCABG and drug-eluting stents for PCI can positively influence long-term outcomes.
Objective:
To assess long-term survival with repeat coronary artery bypass grafting (RCABG) or percutaneous coronary intervention (PCI) in patients with previous CABG.
Methods:
From January 1, 2000, through December 31, 2013, 1612 Mayo Clinic patients underwent RCABG (n=215) or PCI (n=1397) after previous CABG. The RCABG cohort was grouped by use of saphenous vein grafts only (n=75), or with additional arterial grafts (n=140); the PCI cohort by, bare metal stents (BMS; n=628), or drug-eluting stents (DES; n=769), and by the treated target into native coronary artery (n=943), bypass grafts only (n=338), or both (n=116). Multivariable regression and propensity score analysis (n=280 matched patients) were used.
Results:
In multivariable analysis, the 30-day mortality was increased in RCABG versus PCI patients (hazard ratio [HR], 5.32; 95%CI, 2.34-12.08; P<.001), but overall survival after 30 days improved with RCABG (HR, 0.72; 95% CI, 0.55-0.94; P=.01). Internal mammary arteries were used in 61% (129 of 215) of previous CABG patients and improved survival (HR, 0.82; 95% CI, 0.69-0.98; P=.03). Patients treated with drug-eluting stent had better 10-year survival (HR, 0.74; 95% CI, 0.59-0.91; P=.001) than those with bare metal stent alone. In matched patients, RCABG had improved late survival over PCI: 48% vs 33% (HR, 0.57; 95% CI, 0.35-0.91; P=.02). Compared with RCABG, patients with PCI involving bypass grafts (n=60) had increased late mortality (HR, 1.62; 95% CI, 1.10-2.37; P=.01), whereas those having PCI of native coronary arteries (n=80) did not (HR, 1.09; 95% CI, 0.75-1.59; P=.65).
Conclusion:
RCABG is associated with improved long-term survival after previous CABG, especially compared with PCI involving bypass grafts.
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