Early results of combined carotid endarterectomy and coronary artery bypass grafting in patients with severe coronary and carotid artery disease

The management of patients with carotid artery disease who require coronary artery bypass grafting (CABG) remains controversial. Several published series from the USA (including one with prospective randomization) advocate a combined approach of carotid endarterectomy (CEA) followed immediately by coronary artery bypass surgery. However, experience of combined carotid endarterectomy and coronary bypass grafting has not been previously reported by a centre from the United Kingdom. Between 1986 and 1991 we performed this combined procedure on 18 patients who required myocardial revascularization and had co-existing severe (> 70%) carotid stenosis. Sixteen patients (89%) had angina and 11 patients (61%) had symptomatic carotid artery disease. The perioperative mortality was 5.5% and the ipsilateral perioperative stroke rate was 5.5%. These early results are encouraging and suggest that further evaluation of combined carotid endarterectomy and coronary artery bypass surgery is warranted.     

The effects of pictorial versus tangible stimuli in stimulus-preference assessments

OBJECTIVES: The purpose of this study was to compare 3-year risk-adjusted survival in patients undergoing coronary artery bypass graft (CABG) surgery and percutaneous transluminal coronary angioplasty. BACKGROUND: Coronary artery bypass graft surgery and angioplasty are two common treatments for coronary artery disease. For referral purposes, it is important to know the relative pattern of survival after hospital discharge for these procedures and to identify patient characteristics that are related to survival. METHODS: New York's CABG surgery and angioplasty registries were used to identify New York patients undergoing CABG surgery and angioplasty from January 1, 1993 to December 31, 1995. Mortality within 3 years of undergoing the procedure (adjusted for patient severity of illness) and subsequent revascularization within 3 years were captured. Three-year mortality rates were adjusted using proportional hazards methods to account for baseline differences in patients' severity of illness. RESULTS: Patients with one-vessel disease with the one vessel not involving the left anterior descending artery (LAD) or with less than 70% LAD stenosis had a statistically significantly longer adjusted 3-year survival with angioplasty (95.3%) than with CABG surgery (92.4%). Patients with proximal LAD stenosis of at least 70% had a statistically significantly longer adjusted 3-year survival with CABG surgery than with angioplasty regardless of the number of coronary vessels diseased. Also, patients with three-vessel disease had a statistically significantly longer adjusted 3-year survival with CABG surgery regardless of proximal LAD disease. Patients with other one-vessel or two-vessel disease had no treatment-related differences in survival. CONCLUSIONS: Treatment-related survival benefit at 3-years in patients with ischemic heart disease is predicted by the anatomic extent and specific site of the disease, as well as by the treatment chosen.     

Minimally invasive direct coronary artery bypass grafting (MIDCAB) for re-operation in a 85 year-old patient

An 85-year-old male, who had undergone aorto-coronary bypass grafting to left anterior descending coronary artery (LAD) using saphenous vein graft (SVG) seventeen years before, was operated with minimally invasive direct coronary artery bypass grafting (MIDCAB) without cardiopulmonary bypass. LAD was anastomosed with the in situ left internal thoracic artery through a limited anterior thoracotomy. The postoperative angiography showed patent graft, and the patient has been doing well without any complications. MIDCAB is a useful technique even for re-operation of coronary diseases in selected cases.     

Combined carotid endarterectomy and coronary artery bypass grafting in asymptomatic carotid artery stenosis

The role of combined carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) in patients with severe asymptomatic carotid artery disease and concurrent symptomatic coronary artery disease is controversial. The objective of this report is to investigate the safety of combined CEA/CABG. The medical records of 30 patients who underwent combined CEA/CABG for coexistent asymptomatic carotid and symptomatic coronary artery occlusive disease were reviewed. All patients were scheduled for either elective or urgent myocardial revascularization due to their symptomatic coronary artery disease. Color-flow duplex scanning identified internal carotid artery stenosis of 80 to 99 per cent in 28 patients (93%) and 50 to 79 per cent in 2 patients (7%). Seventeen patients (57%) were male. The mean age was 64 +/- 10 years (range, 42-84 years). Contralateral internal carotid artery occlusion was present in four patients. Severe left main coronary artery disease was present in 12 patients (40%) and 7 patients (23%) had an ejection fraction of less than 50 per cent. There were no perioperative deaths or strokes. One patient suffered a myocardial infarction on postoperative day 1. This study demonstrates the safety of combined CEA/CABG for coexistent coronary and asymptomatic carotid disease. Using this surgical approach for critical coexistent disease may minimize the incidence of perioperative cerebrovascular complications in patients undergoing CABG.     

Urgent coronary reoperation under the beating heart via the left thoracotomy

An 80-year-old female, who had received coronary artery bypass grafting (CABG) 12 years ago was admitted to our hospital because of unstable angina. The vein grafts to the left anterior descending artery (LAD) and circumflex artery (Cx) were both occluded. Chest computerized tomography showed a severely calcified aorta. An intra-aortic balloon pump was inserted and an urgent reoperation was performed. The patient was positioned for an anterolateral left thoracotomy. The chest was entered through the forth intercostal space. The pericardium was opened parallel to the phrenic nerve. Femorofemoral bypass was instituted. Anastomosis of the saphenous vein graft and the diagonal branch and anastomosis of a second saphenous vein to the old SVG just proximal to the anastomotic site of Cx were performed under a beating heart. Proximal anastomosis of the two saphenous veins and the left subclavian artery was then performed. The patient had an uncomplicated postoperative recovery. A postoperative angiogram showed that the new SVG anastomosed to the diagonal branch was patent while the other new SVG anastomosed to the old SVG/Cx was occluded. The patient was discharged and is now free from angina.     

A case report of coronary artery bypass grafting in a patient with ankylosing spondylitis

We reported a case of ankylosing spondylitis who successfully underwent coronary artery bypass grafting (CABG) for unstable angina pectoris. A 67-year-old man was admitted with symptom of anginal pain. Selective coronary angiography revealed coronary artery stenoses; 90% in seg 6, 90% in seg 11, proximal 75%, distal 90% in seg 3, 99% in 4 PD and 99% with delay in 4 AV. The left internal thoracic artery was anastomosed to seg 7 and saphenous vein (SVG) to PL-2, PL-1 sequentially, and another SVG to 4 PD. His postoperative course was uneventful. Cardiac lesions accompanied by ankylosing spondylitis are rare in Japan. Perioperative problems of these lesions therefore, are discussed.     

Aortic valve replacement after previous coronary artery bypass grafting

BACKGROUND: As the population ages, an increasing number of patients with previous coronary artery bypass grafting (CABG) will require subsequent aortic valve replacement (AVR). This study examined outcome of AVR after previous CABG and reviewed possible indications for valve replacement at the time of initial myocardial revascularization. METHODS: Between March 1975 and December 1994, 145 patients had AVR after previous CABG. Sixty-three patients (43%) had their initial CABG elsewhere. Reoperation for AVR was the second cardiac procedure in 137 patients and the third in 8. Redo CABG with AVR was done in 66 (46%). There were 118 men and 27 women. The mean age at CABG was 64 +/- 7.9 years; for AVR this was 71 +/- 7.6 years. RESULTS: In 2 young patients accelerated calcific aortic stenosis occurred in the setting of renal failure. Significant aortic stenosis did not appear to be addressed at initial CABG in 3 patients. Transaortic valvular gradient, as measured by cardiac catheterization, increased by 10.4 +/- 7.0 mm Hg/y. Twenty-four patients (16.6%) died. The mortality for AVR alone or for AVR + redo-CABG was 15 of 125 patients (12%). For patients having more complicated procedures, the mortality was 9 of 20 (45%). Nine patients (6.2%) suffered a postoperative cerebrovascular accident. Low preoperative ejection fraction measured by echocardiography, sternal reentry problems, complexity of operation, and prolonged cross-clamp and bypass times were significant factors associated with mortality. Age at AVR, interval between operations, the extent of underlying native coronary artery disease, the state of the previously placed bypass conduits, and methods of myocardial preservation were not significant predictors of operative mortality. On multivariate analysis there was only one significant value: prolonged cross-clamp time. CONCLUSIONS: Aortic valve replacement after previous CABG is associated with a mortality that is higher than that seen after repeat CABG or repeat AVR. It seems prudent, therefore, to use liberal criteria for AVR in those patients who require coronary revascularization and who, at the same time, have mild or moderate aortic valve disease.     

A surgical approach to coexistent coronary and carotid artery disease

OBJECTIVE: To assess the early results of combined coronary artery bypass graft surgery and carotid endarterectomy. DESIGN: Retrospective and ongoing analysis of patients who underwent combined coronary artery bypass graft surgery and carotid endarterectomy. SETTING: Cardiothoracic unit in a London teaching hospital. PATIENTS: From June 1987 to March 1995, 64 patients were identified. They were patients who were scheduled to have coronary artery bypass graft surgery or required urgent coronary revascularisation and who were found to have significant coexistent carotid disease. (Unilateral carotid stenosis > 70%, bilateral carotid stenosis > 50%, or unilateral carotid stenosis > 50% with contralateral occlusion.) INTERVENTIONS: Both procedures were performed during one anaesthesia: the carotid endarterectomy was performed first without cardiopulmonary bypass. After completion of carotid endarterectomy, coronary artery bypass graft surgery was performed. MAIN OUTCOME MEASURES: The incidence of stroke, transient ischaemic attack, and myocardial infarction in the early postoperative period was analysed. RESULTS: Myocardial revascularisation was successful in all 64 patients. There were no perioperative infarcts. In three patients (4.7%) a new neurological deficit developed postoperatively: two recovered fully before hospital discharge. CONCLUSIONS: Combined coronary artery bypass graft surgery and carotid endarterectomy were performed safely and with good results.     

Elimination of cardiopulmonary bypass: a prime goal in reoperative coronary artery bypass surgery

OBJECTIVE: The purpose of this study was to evaluate morbidity and mortality in reoperative coronary artery bypass surgery using the New York State database. METHODS: Patients undergoing reoperative coronary artery bypass between January-1995 and December 1996 were included. Patients were operated using cardiopulmonary bypass (CPB group, n = 184) or without cardiopulmonary bypass (non-CPB group, n = 105) by surgeon preference. Groups were compared for preoperative risk factors, postoperative mortality and major complications. RESULTS: Crude mortality was lower in the non-CPB group, despite a higher expected mortality, resulting in a risk-adjusted mortality of 1.3% versus 2.7% for the CPB group (NS). Of non-CPB patients, 91.4% were without complications, while only 72.1% of CPB patients (P < 0.0001) were complication-free. Major complications were significantly reduced in non-CPB patients compared to CPB patients: stroke 0% versus 3.8% (P < 0.04), cardiovascular complications 4.8% versus 15.8% (P < 0.005), other major complications 1.9% versus 10.4% (P < 0.007). Postoperative IABP support was needed in 1.9% of the non-CPB group patients and in 14.2% of the CPB group (P < 0.0007). CONCLUSIONS: The main object of reoperative CABG is to relieve symptoms, since the survival benefit of the procedure has not been demonstrated. Performance of reoperative coronary artery bypass surgery without cardiopulmonary bypass significantly reduces morbidity. We conclude that cardiopulmonary bypass should be avoided whenever possible in reoperative coronary bypass surgery.     

Revascularization in patients with prior coronary bypass surgery

Increasingly over the past several years, patients have returned after coronary surgery for reintervention procedures. This reflects immediate postsurgical complications and the relentless progression of coronary artery disease in the native circulation and in the bypass grafts. Although there are randomized comparative data for coronary bypass surgery (CABG) versus percutaneous transluminal coronary angioplasty (PTCA) and medical therapy, these trials have always excluded patients with previous (GABG). OBJECTIVES: We attempted to compare the 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). METHODS AND RESULTS: This study examines follow up data (15.4 +/- 11.0 months) from 130 patients with previous CABG, who required either PTCA (Group A, n = 73) or re-CABG (Group B; n = 57) at a single center from 1994 to 1997. Follow up data were obtained from subsequent office visits and telephone calls. The PTCA and re-CABG groups were similar with respect to gender (86% vs 94% males), mean age (62 +/- 9 vs 59 +/- 10 years), angina CCS classes 3 and 4 (73% vs 69%), diminished left ventricular function (23% vs 26%), risk factors such as diabetes (19% vs 17%), hypercolesterolemia (49% vs 45%) and smoking (48% vs 39%) and three-vessel native coronary artery disease (67% vs 72%). The symptomatic status prior to the revascularization procedure was similar in both groups. Complete and functional revascularization was achieved in 85% of the PTCA group and in 92% of those with re-CABG (p = NS). During the hospital stay the complication rates were lower in the PTCA group. Actuarial survival was different at follow up (p = 0.04). Both PTCA and re-CABG groups resulted in equivalent event-free survival (freedom from death, myocardial infarction, unstable angina and urgent revascularization). The need for repeat revascularization at follow up was significantly higher in the PTCA group (PTCA 28% vs re-CABG 10%, p < 0.01). CONCLUSIONS: In this non-randomized study of patients with previous CABG requiring revascularization procedures, PTCA resulted in lower procedural morbidity and mortality risks. At follow up, both PTCA or CABG were similar for event-free survival; PTCA offered lower overall mortality, although it is associated to a greater need for subsequent revascularization procedures.     

Quantitative analysis of stool losses in adult celiac disease: use of near-infrared analysis reconsidered

Reoperative coronary artery bypass grafting (CABG) are still associated with higher mortality than primary CABG. This is due in part to the potential for cardiac and patent graft injury during their dissection and the reopening of the sternum. Therefore, in two patients with recurrent angina attributable to occlusion of the old vein graft to the LAD, we performed reoperative CABG by the minimally invasive direct coronary artery bypass (MIDCAB) procedures. The left internal thoracic artery was anastomosed to the LAD through small anterolateral thoracotomy without cardiopulmonary bypass. Both patients recovered fast and underwent postoperative angiogram, showing the new grafts widely patent. About two weeks later, both discharged in the conditions of nearly normal activities. The reoperative MIDCAB grafting might be expected to be as safe and promising as the primary one.     

A case of coronary artery bypass grafting for single coronary artery complicated by angina pectoris

A case of coronary artery bypass grafting (CABG) for single coronary artery complicated by angina pectoris (AP) was reported. The patient was a 74-year-old male, complained of anginal discomforts. His single coronary artery originated in left coronary sinus, bifurcated to the left anterior descending artery (LAD) and the circumflex artery (CX), and then, an abnormal communicating branch, passing in front of the right ventricular outflow, was branched from the proximal region of LAD; it showed a route corresponding to the proximal region of the right coronary artery (RCA). The distal region of RCA and the posterior descending artery were angiographed in continuity from CX. Other findings included 75%-stenosis at LAD-#6 and 90%-stenosis at CX-#13. Using two saphenous vein grafts, CABG operation was carried out on those regions at LAD-#7 and distal CX corresponding to #3 normally. Postoperatively, anginal discomforts disappeared, and favorable results were obtained.     

Conformations of cis- and trans-2,3-methanomethionine stereoisomers in the tripeptide mimic system Ac[cyclo-M]NHiPr

Coronary artery bypass grafting (CABG) is the most common procedure performed in adult cardiovascular surgery today. In our Department of Surgery at Baylor College of Medicine, we have experienced, as have most large programs, a trend to older patients, more comorbidity, worse ventricular function, and more redo CABG procedures. Along with this shift has come an evolution in surgical techniques, cardioplegia and choice of coronary bypass graft conduits. The benefit of using an internal mammary artery (IMA) to the left anterior descending coronary artery (LAD) appears irrefutable at this time. Data for multiple arterial grafts is still evolving and conduit choice for other than the IMA to LAD graft is often debated. The purpose of this article is to review the current literature on conduit choice and to allow a rational, data driven approach to graft choice.     

Tracking the MEN1 gene

Combined carotid endarterectomy and coronary artery bypass grafting was performed in 52 patients between January 1982 and September 1994. Forty-nine patients had stable or unstable angina and three had symptom-free coronary artery disease detected by stress testing. Thirty-one patients had triple-vessel disease and 17 had left main trunk or left main equivalent coronary artery disease. Five patients had symptom-free carotid artery disease, 12 had non-specific neurological symptoms, and 35 had transient ischaemic attacks. Carotid endarterectomy was performed first, followed by coronary artery bypass grafting. There were three postoperative deaths, two cardiac and one neurological, for a mortality rate of 5.8%. One patient suffered a permanent neurological deficit (1.9%). It is concluded that combined carotid endarterectomy/coronary artery bypass grafting can be performed in selected patients with acceptable neurological morbidity, although cardiac mortality was not eliminated by the combined approach.     

Mid-term results in coronary revascularization using the right gastroepiploic artery graft

We studied the mid-term results in 191 patients (including emergent operation in 27 patients) who have performed coronary artery bypass grafting (CABG) using the right gastroepiploic artery (REGA) for 74 months (mean follow up period was 37 months). We evaluated the postoperative results in terms of 1. mortality and survival rate, 2. graft angiography, 3. cardiac event free rate and 4. abdominal complications. We had operative death in 6 patients (3.1%) including 3 patients of emergent operations. Late deaths were found in 11 patients (5.9%): 2 patients were cardiac death and 9 were non-cardiac. The actual survival rates were 94.2% at one year, 90.0% at three years and 85.9% at five years. Early patency rate of the RGEA was 98.9% (n = 178). However flow competition between the RGEA and native coronary artery was seen in 42 patients (24.0%). Mid-term patency rate was 96.4% (n = 28). According to mid-term graft angiography, 1 patient improved and 5 patients got worse in comparison with early control. Cardiac event free rates were 98.2% at 1 year, 94.8% at 3 years and 92.7% at 5 years. Abdominal complications were observed in 5 patients (1 patient of bleeding from the RGEA, 1 of gastric perforation, 2 of bleeding from gastric ulcer and 1 of pyloric stenosis) at early period and in 7 patients (2 patients of incisional hernia and 5 of gastric cancer) at long-term period. Early and mid-term results of CABG using the RGEA were quite good. However, the RGEA had a tendency of flow competition against native coronary artery and a problem of gastric cancer after the operation.     

Importance of intraoperative transesophageal echocardiography during coronary artery surgery without cardiopulmonary bypass

The goal of this study was to assess left ventricular segmental wall motion (SWM) abnormalities during coronary artery bypass grafting (CABG) without cardiopulmonary bypass (CPB), and its impact on the immediate postoperative outcome. Transesophageal echocardiography was used intraoperatively in 27 patients (mean age 57 years) who had CABG without CPB. Images obtained with a 5-MHz biplane transesophageal echocardiographic probe in the transgastric and transesophageal planes were recorded before, during, and after 48 coronary artery clampings for saphenous vein or internal mammary artery anastomosis. Transthoracic echocardiography was performed 1 day before surgery and on the seventh postoperative day. During the 48 coronary artery clampings, 31 (64%) new SWM abnormalities were found. At the time of chest closure, complete recovery occurred in 16 (50%) segments, partial recovery in 10 (33%), and no recovery in 5 (17%). On the seventh postoperative day the new SWM abnormalities persisted in all 5 segments without recovery at the end of the surgery and in 2 of 10 (20%)segments with partial recovery (group 1). Group 1 had higher variation on the echocardiographic point score index between the beginning and end of surgery, higher enzymatic levels, more ST-T changes on the electrocardiogram, and more clinical problems than group 2 (patients without new SWM abnormalities on the seventh postoperative day) (P < .05). We concluded that new SWM abnormalities of the left ventricle occur during CABG without CPB as assessed by intraoperative transesophageal echocardiography. Persistence of these abnormalities at the end of surgery may be a predictor of SWM dysfunction and clinical problems in the immediate postoperative period.     

Coronary artery bypass graft surgery in dialysis patient

To determine the operative outcome of coronary artery bypass graft surgery (CABG) for severe coronary artery disease in long-term hemodialysis patients, we analyzed a group of 16 patients who underwent CABG over a ten-year period in our institution. Hospital mortality was 12.5% (2 of 16 patients). These two patients died of ischemic colitis and perioperative myocardial infarction, respectively. There were five late deaths: one patient died from myocardial infarction, one from uremia, one from gastro-intestinal bleeding, one from gastric cancer and one from unknown cause. There were four significant postoperative complications (morbidity 25%), consisted of one pulmonary tuberculosis, one sternal dehiscence secondary to mediastinitis, one mediastinal hematoma secondary to late bleeding from the LITA dissection area and one A-V shunt trouble. Graft patency rate within the first two months was 93% (30 to 42 in 13 patients). Hospital survivors experienced complete relief from angina. Actuarial survival was 68.8% at 3 years, 57.3% at 5 years and 28.6% at 7 years. This rate is not significantly different from the survival of all dialysis patients, but seems to be better than that of dialysis patients with not operated coronary artery disease. We concluded that CABG in dialysis patients can be accomplished with acceptable morbidity and mortality and effective relief of symptoms.     

An evaluation of the use made of cosmetic and functional prostheses by unilateral upper limb amputees

PURPOSE: To review the available data on the treatment of chronic stable angina and formulate a rational approach to the use of pharmacologic therapy, percutaneous transluminal coronary angioplasty (PTCA), and coronary artery bypass graft surgery (CABG). DATA SOURCES: A MEDLINE search of English-language literature published between 1976 and 1996 and the bibliographies of relevant articles. STUDY SELECTION: Primary research articles, meta-analyses, and meeting abstracts related to the management of chronic stable angina with an emphasis on comparisons of medical therapy, PTCA, and CABG. DATA EXTRACTION: Three trials comparing medical therapy with PTCA, seven trials comparing medical therapy with CABG, and nine trials comparing PTCA with CABG. DATA SYNTHESIS: Low-risk patients with single-vessel coronary artery disease and normal left ventricular function had greater alleviation of symptoms with PTCA than with medical treatment; mortality rates and rates of myocardial infarction were unchanged. In high-risk patients (risk was defined by severity of ischemia, number of diseased vessels, and presence of left ventricular dysfunction), improvement of survival was greater with CABG than with medical therapy. In moderate-risk patients with multivessel coronary artery disease (most had two-vessel disease and normal left ventricular function), PTCA and CABG produced equivalent mortality rates and rates of myocardial infarction. CONCLUSIONS: In low-risk patients, a strategy of initial medical therapy is reasonable. In moderate-risk patients, PTCA and CABG produce similar mortality rates and rates of myocardial infarction but PTCA-treated patients require more revascularization procedures. In high-risk patients, CABG is usually preferred.     

Minimally invasive coronary artery bypass grafting without cardiopulmonary bypass

To determine the feasibility and the effectiveness of minimally invasive direct coronary artery bypass without cardiopulmonary bypass (MICABG) in patients with left anterior descending (LAD) coronary artery disease, we evaluated 90 consecutive patients who underwent MICABG at the University Hospital of Groningen. PATIENTS: Between January 1995 and December 1996, 50 patients (mean age 60 +/- 10.3 years) with documented myocardial ischemia and isolated stenosis of the LAD were selected for MICABG. Patients with any associated cardiac disease or with acute or evolving myocardial infarction were excluded. METHODS: A small left antero-lateral thoracotomy in the 5th intercostal space was made in all patients, anastomosing the left internal mammary artery (LIMA) to the LAD. A short-term (3 days) postoperative rehabilitation programme was used. Emotional stress (STAY-DY-1 score), wound pain (VAS: visual analogue score) and O2-saturation after a 6 min walking test were measured during hospitalisation and at the first follow-up examination (2.5 week after discharge). RESULTS: Mean operative time was 92 +/- 25 min (range 60-170). We recorded 1 (1.1%) in-hospital death and three cases (3.3%) of perioperative myocardial infarction. In two cases the MICABG was converted to the midline sternotomy. One patient underwent urgent reoperation on postoperative day 1 via midline sternotomy. Mean hospital stay was 4.4 +/- 2 days. Emotional stress was significantly reduced during and after hospitalisation, compared with the admission day. Wound pain was mild (3.5/10 VAS) on postoperative day 1 and reduced significantly during hospitalisation and at first follow-up examination. O2-saturation after a 6 min walking test had significantly improved at the first follow-up examination. CONCLUSION: These results indicate that MICABG is feasible and effective in patients with LAD stenosis and leads to a fast psycho-physical recovery.     

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 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.