Do I need a stent after Coronary Artery Bypass Grafting (CABG)?

Stent Requirements After CABG

After coronary artery bypass grafting (CABG), stents are generally not routinely needed unless specific clinical indications arise such as graft failure, recurrent ischemia, or progression of native coronary artery disease.

Indications for PCI/Stenting After CABG

Early Post-CABG Period (< 30 days)

• Early ischemia after CABG (within 30 days) should be treated with PCI when technically feasible 1
• Urgent coronary angiography is indicated to define the anatomic cause of early post-operative ischemia 1
• Common causes include:
  • Graft thrombosis (can occur in both venous and arterial grafts)
  • Incomplete revascularization
  • Unbypassed native vessel stenoses

Late Post-CABG Period (> 30 days)

PCI is reasonable in the following situations:

• Ischemia occurring 1-3 years after CABG with preserved LV function and discrete lesions in graft conduits 1
• Disabling angina due to new disease in native coronary circulation after CABG 1
• Diseased vein grafts more than 3 years after CABG 1
• When technically feasible in patients with patent left internal mammary artery graft who have clinically significant obstructions in other vessels 1

Contraindications for PCI/Stenting After CABG

PCI is not recommended in the following scenarios:

• Chronic total vein graft occlusions 1
• Multiple target lesions with multivessel disease, failure of multiple SVGs, and impaired LV function (unless repeat CABG poses excessive risk) 1
• In the absence of ischemia 1
• When revascularization is impossible due to target anatomy or no-reflow state 1

Graft Considerations

Understanding graft patency is important when considering the need for future interventions:

Graft Patency Rates

• Saphenous vein grafts (SVGs): >90% at 1 year, 65-80% at 4-5 years, 25-50% at 10-15 years 1
• Left internal thoracic artery (ITA): >91% at 1 year, 88% at both 4-5 and 10-15 years 1
• Right ITA: 96% at 4-5 years, 65% at 10-15 years 1
• Radial artery: 86-96% at 1 year, 89% at 4-5 years 1

The superior long-term patency of arterial grafts (particularly the left ITA) means patients with these grafts are less likely to require subsequent stenting.

Decision-Making Process

When ischemia occurs after CABG, the Heart Team should make the decision between redo CABG or PCI 1. The following algorithm can help guide decision-making:

1. Assess for symptoms or objective evidence of ischemia

   • If no ischemia is present → no revascularization needed

2. If ischemia is present, evaluate:

   • Timing since CABG
   • Graft patency status
   • Native coronary anatomy
   • Location of stenosis/occlusion

3. For early graft failure with ischemia:

   • PCI is superior to re-operation 1
   • Preferred target: native vessel or ITA graft (not freshly occluded SVG) 1

4. For late graft failure with ischemia:

   • PCI is recommended as first choice over redo CABG 1
   • PCI of the bypassed native artery is preferred when stenosed grafts are >3 years old 1

Important Considerations

• Higher complication risk: Post-CABG patients have a high rate of embolization of atherosclerotic material from friable grafts during PCI, making procedures more difficult with higher complication rates 1

• Less favorable outcomes: Post-CABG patients have less favorable outcomes with repeat revascularization than patients who have not undergone previous CABG 1

• Embolic protection: When PCI of SVGs is performed, distal embolic protection devices should be used when technically feasible 1

• Long-term survival: For patients with multivessel disease, CABG is associated with higher adjusted rates of long-term survival than stenting 2

Conclusion

While stents are not routinely needed after CABG, they play an important role in managing specific complications or disease progression. The decision should be based on clinical presentation, timing since CABG, graft type and patency, and the specific coronary anatomy involved.