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CLINICAL STUDY

Outcomes of repeat revascularization in diabetic patients with prior coronary surgery

Jason H. Cole, MD^*, Ellis L. Jones, MD, FACC, Joseph M. Craver, MD, FACC, Robert A. Guyton, MD, FACC, Douglas C. Morris, MD, FACC^*, John S. Douglas, Jr, MD, FACC^*, Ziyad Ghazzal, MD, FACC^* and William S. Weintraub, MD, FACC^*,*

^* Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
Department of Surgery, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA

Manuscript received June 25, 2002; revised manuscript received August 6, 2002, accepted August 26, 2002.

^* Reprint requests and correspondence: Dr. William S. Weintraub, Emory Center for Outcomes Research, 1256 Briarcliff Road, Suite 1-North, Atlanta, Georgia, USA 30306.
wweintr{at}emory.edu

OBJECTIVES: This study evaluated both short- and long-term outcomes of diabetic patients who underwent repeat coronary artery bypass graft surgery (CABG) or percutaneous coronary intervention (PCI) after initial CABG.

BACKGROUND: Although diabetic patients who have multivessel coronary disease and require initial revascularization may benefit from CABG as compared with PCI, the uncertainty concerning the choice of revascularization may be greater for diabetic patients who have had previous CABG.

METHODS: Data were obtained over 15 years for diabetic patients undergoing PCI procedures or repeat CABG after previous coronary surgery. Baseline characteristics were compared between groups, and in-hospital, 5-year, and 10-year mortality rates were calculated. Multivariate correlates of in-hospital and long-term mortality were determined.

RESULTS: Both PCI (n = 1,123) and CABG (n = 598) patients were similar in age, gender, years of diabetes, and insulin dependence, but they varied in presence of hypertension, prior myocardial infarction, angina severity, heart failure, ejection fraction, and left main disease. In-hospital mortality was greater for CABG, but differences in long-term mortality were not significant (10 year mortality, 68% PCI vs. 74% CABG, p = 0.14). Multivariate correlates of long-term mortality were older age, hypertension, low ejection fraction, and an interaction between heart failure and choice of PCI. The PCI itself did not correlate with mortality.

CONCLUSIONS: The increased initial risk of redo CABG in diabetic patients and the comparable high long-term mortality regardless of type of intervention suggest that, except for patients with severe heart failure, PCI be strongly considered in all patients for whom there is a percutaneous alternative.

Abbreviations and Acronyms   BARI   Bypass Angioplasty Revascularization Investigation   CABG   coronary artery bypass graft surgery   CABRI   Coronary Angioplasty versus Bypass Revascularization Investigation   CHF   congestive heart failure   CI   confidence interval   HR   hazard ratio   IMA   internal mammary artery   LAD   left anterior descending artery   LCX   left circumflex artery   MI   myocardial infarction   OR   odds ratio   PCI   percutaneous coronary intervention   SVG   saphenous vein graft

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