Clinical Brief
Management of Failed Prior Coronary Bypass Surgery
Source: Weintraub WS, et al. Circulation 1997;95:868-877.
Repeat bypass surgery is becoming a large part of coronary bypass surgery practice, yet little is known about the comparative efficacy of repeat bypass surgery vs. angioplasty for failed bypass surgery. Among 4174 patients with prior bypass surgery undergoing revascularization, 2613 had angioplasty and 1561 had repeat bypass surgery. Women more often had angioplasty. Heart failure, prior myocardial infarction (MI) and three vessel or left main coronary disease was more common in the repeat bypass surgery group. Q-wave MI was more common after repeat bypass surgery as compared to angioplasty (5% vs 1%; P < 0.001), as was hospital death (7% vs 1%; P < 0.001).However, 3% of the angioplasty group required in-hospital bypass surgery. Recurrent angina was frequent after four years of follow-up and was more common in the angioplasty group (46% vs 42%; P = 0.03). Long-term survival was better with angioplasty (62% vs 51% at 10 years; P < 0.001), but this difference disappeared when adjusted for baseline variables that affect survival. Analysis of subgroups showed that underlying disease was more closely related to long-term mortality than was type of repeat revascularization. For example, the survival of diabetics was low (< 30% with either therapy at 10 years).
These data, not surprisingly, show that initial mortality and complications are higher after repeat bypass surgery, but long-term survival is more influenced by covariates that affect survival rather than choice of procedure. Although there were more repeat revascularization procedures in the angioplasty group, both groups had a high incidence of cardiovascular events; event-free survival was about 20% at 10 years.
These findings are consistent with other angioplasty vs. surgery studies that showed little difference in outcomes between the two procedures for initial revascularization. The major limitation of this study is that it was not a randomized trial, but none has been done or is planned. Since neither approach was clearly superior, the choice between them for patients post-bypass surgery with recurrent symptoms refractory to medical therapy can be made based upon clinical features, coronary anatomy, and patient preference.
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