What is the treatment for blocked coronary arteries (CABG) when two arteries are occluded?

Treatment for Two Blocked Coronary Arteries

For patients with two-vessel (double-vessel) coronary artery disease, either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) may be appropriate, with the choice depending on specific anatomical features, particularly involvement of the proximal left anterior descending artery and presence of left ventricular dysfunction. 1

Decision Algorithm for Two-Vessel Disease

When CABG is Preferred:

• Two-vessel disease WITH proximal left anterior descending (LAD) involvement: CABG demonstrates superior long-term survival compared to stenting, with an adjusted hazard ratio of 0.76 for death (meaning 24% lower mortality risk with CABG). 2
• Presence of left ventricular dysfunction (reduced ejection fraction): CABG is the recommended procedure in this setting. 1
• Diabetes mellitus: CABG generally provides better outcomes in diabetic patients with multivessel disease. 1

When PCI May Be Appropriate:

• Two-vessel disease WITHOUT proximal LAD involvement: PCI with drug-eluting stents is a reasonable option, though CABG still shows survival advantage. 1, 2
• Single culprit lesion identified in acute coronary syndrome: Immediate PCI of the culprit lesion with staged reassessment for the second vessel is an acceptable strategy. 1
• Significant comorbidities that contraindicate surgery: PCI becomes the preferred option when surgical risk is prohibitive. 1

Important Clinical Considerations

Anatomical Features That Guide Decision:

• Location of disease: Proximal LAD involvement strongly favors CABG over PCI. 1, 2
• Lesion complexity: Complex lesions with poor distal run-off may not be suitable for either revascularization approach. 1
• Left main involvement: If present, this shifts the recommendation strongly toward CABG. 1

Long-Term Outcomes:

• Repeat revascularization rates: Patients receiving stents have dramatically higher rates of requiring additional procedures within three years (27.3% for repeat PCI and 7.8% for subsequent CABG) compared to initial CABG patients (4.6% for PCI and 0.3% for CABG). 2
• Survival advantage: CABG demonstrates superior risk-adjusted survival rates across all anatomical subgroups of multivessel disease compared to stenting. 2

Post-Revascularization Medical Management

After PCI with Stenting:

• Dual antiplatelet therapy (DAPT): Aspirin plus a P2Y12 inhibitor (ticagrelor or prasugrel preferred over clopidogrel in acute coronary syndrome) for 12 months minimum. 1, 3
• Clopidogrel loading: 300-600 mg loading dose during the procedure. 1

Before Planned CABG:

• Stop clopidogrel: Discontinue approximately 5 days before surgery to reduce bleeding risk, unless surgery is urgent. 1
• Continue aspirin: Maintain aspirin therapy perioperatively. 1
• Beta-blockers: Should be administered for at least 24 hours before CABG and reinstituted as soon as possible after surgery. 1

Common Pitfalls to Avoid

• Premature PCI in stable patients: In non-urgent situations, consultation with cardiac surgery is essential before proceeding with PCI in two-vessel disease, as CABG may offer superior long-term outcomes. 1
• Incomplete revascularization: Treating only the "culprit" lesion without addressing the second significant stenosis may lead to recurrent symptoms and events. 1
• Inadequate antiplatelet therapy duration: Stopping DAPT prematurely after stenting significantly increases stent thrombosis risk. 1