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Coronary angioplasty versus repeat coronary artery bypass grafting for patients with previous bypass surgery
W J Stephan1, J H O'Keefe, J M Piehler
1Mid American Heart Institute, Saint Luke's Hospital, Kansas City, Missouri, USA.
Insights
Percutaneous transluminal coronary angioplasty (PTCA) and repeat coronary artery bypass grafting (re-CABG) offer similar survival and angina relief for patients with prior bypass surgery. PTCA has lower initial risks but requires more repeat procedures.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiac Surgery
Background:
- Increasing need for repeat revascularization in patients with prior coronary artery bypass grafting (CABG).
- Limited comparative data for revascularization strategies in patients with previous CABG.
Purpose of the Study:
- To compare the relative risks and benefits of percutaneous transluminal coronary angioplasty (PTCA) versus repeat coronary artery bypass grafting (re-CABG) in patients with prior CABG.
Main Methods:
- Retrospective analysis of 632 patients with previous CABG undergoing elective re-CABG (n=164) or PTCA (n=468).
- Analysis of in-hospital complications, procedural success, long-term survival, event-free survival, and need for repeat revascularization.
Main Results:
- PTCA achieved lower in-hospital mortality (0.3% vs 7.3%) and myocardial infarction rates (0.9% vs 6.1%) compared to re-CABG.
- Equivalent 1-year and 6-year survival rates (95% vs 91% at 1 year, 74% vs 73% at 6 years) were observed.
- PTCA resulted in less complete revascularization (38% vs 92%) and a significantly higher need for repeat revascularization by 6 years (64% vs 8%).
Conclusions:
- Both PTCA and re-CABG provide comparable long-term survival, event-free survival, and angina relief in patients with prior CABG.
- PTCA is associated with lower procedural morbidity and mortality but necessitates more frequent repeat revascularization procedures.
Objectives:
We attempted to determine the relative risks and benefits of percutaneous transluminal coronary angioplasty (PTCA) and repeat coronary artery bypass grafting (re-CABG) in patients with previous coronary bypass surgery (CABG).
Background:
Due to an expanding population of patients with surgically treated coronary artery disease and the natural progression of atherosclerosis, an increasing number of patients with previous CABG require repeat revascularization procedures. Although there are randomized comparative data for CABG versus medical therapy and, more recently, versus PTCA, these studies have excluded patients with previous CABG.
Methods:
We retrospectively analyzed data from 632 patients with previous CABG who required either elective re-CABG (n = 164) or PTCA (n = 468) at a single center during 1987 through 1988. The PTCA and re-CABG groups were similar with respect to gender (83% vs. 85% male), age > 70 years (21% vs. 23%), mean left ventricular ejection fraction (46% vs. 48%), presence of class III or IV angina (70% vs. 63%) and three-vessel coronary artery disease (77% vs. 74%).
Results:
Complete revascularization was achieved in 38% of patients with PTCA and 92% of those with re-CABG (p < 0.0001). The in-hospital complication rates were significantly lower in the PTCA group: death (0.3% vs. 7.3%, p < 0.0001) and Q wave myocardial infarction (MI) (0.9% vs. 6.1%, p < 0.0001). Actuarial survival was equivalent at 1 year (PTCA 95% vs. re-CABG 91%) and 6 years (PTCA 74% vs. re-CABG 73%) of follow-up (p = 0.32). Both procedures resulted in equivalent event-free survival (freedom from dealth or Q wave MI) and relief of angina; however, the need for repeat percutaneous or surgical revascularization, or both, by 6 years was significantly higher in the PTCA group (PTCA 64% vs. re-CABG 8%, p < 0.0001). Multivariate analysis identified age > 70 years, left ventricular ejection fraction < 40%, unstable angina, number of diseased vessels and diabetes mellitus as independent correlates of mortality for the entire group.
Conclusions:
In this nonrandomized series of patients with previous CABG requiring revascularization, an initial stategy of either PTCA or re-CABG resulted in equivalent overall survival, event-free survival and relief of angina. PTCA offers lower procedural morbidity and mortality risks, although it is associated with less complete revascularization and a greater need for subsequent revascularization procedures.