When can Coronary Artery Bypass Grafting (CABG) be performed after Thoracic Endovascular Aortic Repair (TEVAR)?

Timing of CABG After TEVAR

CABG can be performed immediately or staged after TEVAR depending on clinical urgency, but when both procedures are required and can be safely staged, delaying CABG for at least 3-10 days after TEVAR may reduce perioperative mortality, particularly in high-risk patients.

Clinical Decision Algorithm

Immediate Combined or Staged Approach

The decision to perform CABG after TEVAR depends on several key factors:

When CABG should be performed immediately (same hospitalization):

• Patients with ongoing myocardial ischemia or hemodynamic instability requiring urgent revascularization 1
• Patients with severe coronary disease (left main >50% stenosis or three-vessel disease >70% stenosis) and evidence of active ischemia 1
• Emergency situations such as failed PCI with ongoing ischemia and substantial myocardium at risk 1

When CABG can be safely delayed after TEVAR:

• Hemodynamically stable patients with chronic coronary syndromes 1
• Patients without active myocardial ischemia or acute coronary syndrome 2
• When TEVAR was performed for uncomplicated thoracic aortic disease 3

Optimal Timing Window

If staging is possible, wait at least 3-10 days after TEVAR before performing CABG to minimize perioperative mortality 4. The evidence shows:

• CABG performed <6 hours after acute cardiac events carries 14.8% mortality 4
• CABG at 6 hours-1 day: 10.2% mortality 4
• CABG at 2-3 days: 8.8% mortality 4
• CABG at 4-10 days: 4.2% mortality 4
• CABG at 11-20 days: 2.3% mortality 4
• CABG at 21-30 days: 2.0% mortality (approaching baseline) 4

For high-risk patients (age >70 years or LVEF <30%), the mortality benefit of delaying surgery is even more pronounced, with significantly elevated mortality persisting through 20 days post-acute event 4.

Pre-CABG Cardiac Evaluation After TEVAR

Before proceeding with CABG after TEVAR, ensure adequate cardiac assessment:

• Resting ECG and transthoracic echocardiography are sufficient initial screening for most patients 2
• Cardiac symptom assessment is essential 2
• More extensive workup (stress testing or coronary angiography) is indicated only for unstable symptoms, significantly abnormal ECG/TTE findings, or multiple cardiac risk factors 2
• The perioperative cardiac event rate after TEVAR is low (2.4%), suggesting most patients tolerate staged procedures well 2

Important Caveats

Antiplatelet management considerations:

• If the patient is on clopidogrel or ticagrelor, withhold for at least 5 days before CABG 1
• If on prasugrel, withhold for at least 7 days before CABG 1
• Tirofiban or eptifibatide should be discontinued 2-4 hours before CABG 1
• Abciximab should be discontinued at least 12 hours before CABG 1

Post-TEVAR surveillance before CABG:

• Ensure 1-month post-TEVAR imaging has been completed to assess for endoleaks or complications before proceeding with CABG 1, 5
• Verify hemodynamic stability and absence of TEVAR-related complications 3

Avoid routine prophylactic revascularization:

• Routine coronary angiography and systematic revascularization in patients with chronic coronary syndromes prior to aortic repair is not recommended 1
• CABG should be performed only when clinically indicated based on symptoms, ischemia, or high-risk anatomy 1

Special Circumstances

Emergency CABG after TEVAR may be necessary for:

• Failed PCI with ongoing ischemia 1
• Hemodynamic compromise from acute coronary syndrome 1
• Resuscitated sudden cardiac death with significant CAD and resultant ischemia 1

In these emergency situations, proceed immediately despite increased perioperative risk, as the mortality from untreated acute ischemia exceeds surgical risk 1.