Coronary angioplasty versus repeat coronary artery bypass grafting for patients with previous bypass surgery

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 dat for CABG versus medical therapy and, more recently, versus PTCA, these studies have excluded patients with previous CABG. Methods. We retrospectively analyzed dat from 632 patients with previous CABG who required either elective re-CABG (n = 164) or PTC (n = 468) at single center during 1987 through 1988. The PTC 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 angin (70% vs. 63%) and three-vessel coronary artery disease (77% vs. 74%). Results. Complete revascularization was achieved in 38% of patients with PTC and 92% of those with re-CABG (p < 0.0001). The in-hospital complication rates were significantly lower in the PTC 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 (PTC 95% vs. re-CABG 91%) and 6 years (PTC 74% vs. re-CABG 73%) of follow-up (p = 0.32). Both procedures resulted in equivalent event-free survival (freedom from death 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 PTC group (PTC 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 PTC or re-CABG resulted in equivalent overall survival, event-free survival and relief of angina. PTC offers lower procedural morbidity and mortality risks, although it is associated with less complete revascularization and greater need for subsequent revascularization procedures.