Timing for Hybrid CABG and PCI
When performing staged hybrid coronary revascularization, CABG should be performed before PCI, with the procedures separated by hours to 2 days but typically completed during the same hospital stay. 1
Rationale for CABG-First Approach
The CABG-first sequence is strongly preferred for two critical safety reasons:
Graft patency verification: Performing CABG first allows the interventional cardiologist to angiographically confirm patency of the LIMA-to-LAD graft before attempting PCI of other vessels 1
Bleeding risk minimization: This sequence avoids performing CABG while the patient is receiving dual antiplatelet therapy (DAPT) required after PCI, thereby substantially reducing perioperative bleeding complications 1
Timing Windows for Staged Procedures
Standard timing: The procedures are separated by hours to 2 days, with completion during the same hospitalization 1
Alternative approach: Simultaneous procedures can be performed in a hybrid operating suite during one operative setting, though most hospitals lack this capability 1
Antiplatelet Management Considerations
The timing must account for antiplatelet therapy requirements:
- Clopidogrel/ticagrelor: Should be discontinued at least 5 days before elective CABG to limit blood transfusions 1, 2
- Prasugrel: Requires at least 7 days discontinuation before surgery 1, 2
- Urgent cases: A minimum 24-hour discontinuation of clopidogrel/ticagrelor may be acceptable to reduce major bleeding, though this carries increased risk 1, 2
Graft Verification Protocol
Critical step: Because minimally invasive CABG may have lower graft patency rates compared to median sternotomy, angiographic imaging of all grafts performed through minimally invasive approaches is prudent to confirm patency before proceeding with PCI 1
Evidence Supporting PCI-First vs CABG-First
While one retrospective study of 80 patients found no significant differences in outcomes between CABG-first (n=12) and PCI-first (n=68) approaches, with similar rates of major adverse cardiac and cerebrovascular events (8.3% vs 7.4%, p>0.999) 3, the guideline recommendations strongly favor CABG-first based on the physiologic rationale of bleeding risk and graft verification 1. The research evidence is limited to small retrospective series and lacks randomized controlled trial data 1.
Common Pitfalls to Avoid
- Performing PCI first: This necessitates CABG while on DAPT, dramatically increasing bleeding complications and transfusion requirements 1
- Inadequate antiplatelet washout: Proceeding with CABG less than 5 days after stopping clopidogrel/ticagrelor (or 7 days for prasugrel) in elective cases increases bleeding risk 1, 2
- Skipping graft verification: Failing to angiographically confirm LIMA-LAD patency before PCI may result in incomplete revascularization if the surgical graft is occluded 1