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Lawton et al 2021 ACC/AHA/SCAI Coronary Revascularization Guideline

January 18, 2022 Circulation. 2022;145:e18–e114. DOI: 10.1161/CIR.0000000000001038 e46

CLINICAL STATEMENTS AND GUIDELINES 2.	 Patients with diabetes who are at high surgical risk and require coronary revascularization are more likely to be treated with PCI in current practice.9 In an observational registry that included high-risk patients with refractory ischemia, 5-year survival rates were similar among those treated with CABG and PCI.10

3.	 There are no RCTs specifically comparing PCI with CABG in patients with diabetes and left main CAD. However, a large RCT exclusively enrolled patients with left main CAD, and the subgroup analysis of patients with diabetes informs this recommendation.13 In the EXCEL trial, which included patients with left main CAD and low- or intermediate-complexity CAD, approximately 30% of patients had diabetes. At 3 years, the composite of death, stroke, or MI was not significantly different between PCI and CABG among patients with diabetes. However, the all-cause mortality rate was almost 2 times higher in the PCI group. There was no interaction between diabetes status and revascularization modality.

8.3 Patients With Previous CABG

Recommendations for Patients With Previous CABG Referenced studies that support the recommendations are summarized in Online Data Supplement 15.

COR LOE Recommendations

2a B-NR 1.	 In patients with previous CABG with a patent LIMA to the LAD who need repeat revascularization, if PCI is feasible, it is reasonable to choose PCI over CABG.1,2

2a C-LD 2.	 In patients with previous CABG and refractory angina on GDMT that is attributable to LAD disease, it is reasonable to choose CABG over PCI when an internal mammary artery (IMA) can be used as a conduit to the LAD.3,4

2b B-NR 3.	 In patients with previous CABG and complex CAD, it may be reasonable to choose CABG over PCI when an IMA can be used as a conduit to the LAD.3,4

Synopsis A Heart Team approach and shared decision-making are important in patients who require repeat revascularization after CABG. There are no randomized trials comparing medical therapy with revascularization in patients with previous CABG. PCI and repeat CABG in patients with previous CABG are associated with higher rates of procedural failure and complications5,6 and worse outcomes than those of patients without previous CABG.6-8 The need for any repeat revascularization after PCI or CABG is itself an independent predictor of higher mortality risk.9 Factors that influence the choice of revascularization modal- ity include the availability of the IMA for grafting, a patent graft to the LAD, comorbid conditions, patient factors and preferences, the quality of the target vessels, anatomic complexity of the native and graft disease, and the feasibility and risks of the revascularization method.

Recommendation-Specific Supportive Text

1.	 In patients with previous CABG, percutaneous intervention of a native vessel or a saphenous vein graft (SVG) is probably indicated in preference to redo CABG, particularly if a LIMA-LAD is not planned or if the patient already has a patent LIMA-LAD, which increases the risk of a redo sternotomy. Randomized and retrospective comparisons of PCI versus repeat CABG show lower in-hospital stroke and mortality rates associated with PCI,2,3 although long-term mortality rates appeared similar. In circumstances of acute graft closure, PCI of the native vessel is often performed in preference to redo CABG10 or treating an acutely thrombosed graft with fresh suture lines.11 2.	 A patient with previous CABG faces increased risk during revascularization via CABG,9 including higher rates of in-hospital death and stroke, compared with patients who undergo revascularization via PCI.2,3 Observational data suggest that the use of CABG over PCI may result in improved longterm outcomes; however, results are inconsistent and not supported by high-quality RCTs.3,12,13 If PCI is not an option, if a patent IMA to LAD is not present, or if an IMA is available to be used as a conduit for the LAD, CABG is often chosen as the revascularization strategy in patients with previous CABG and refractory angina who are at an acceptable risk for reoperation.3,4 3.	 Two large observational studies with propensity matching in patients with previous CABG and complex CAD inform decisions about revascularization. The first noted that current clinical practice favored redo CABG over PCI for patients at higher risk and with fewer functional grafts, more CTOs, and lower systolic function, whereas PCI was favored in patients with a patent LIMA and amenable anatomy.3 The second noted that LIMA grafting to the LAD confers a long-term survival advantage.4 Thus, decisions about revascularization should involve consideration of factors that may favor repeat CABG, such as the availability of an IMA for LAD grafting, ability to provide left main revascularization, recurrent restenosis of stents, or high-complexity PCI, in such patients.

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