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Late recurrent angina pectoris after coronary artery bypass graft surgery

Sary Aranki, MD
Rakesh M Suri, MD, DPhil
John A Bittl, MD
Section Editors
Donald Cutlip, MD
Stephan Windecker, MD
Deputy Editor
Gordon M Saperia, MD, FACC


Coronary artery bypass graft surgery (CABG) is performed in patients with stable angina and acute coronary syndromes to prolong life or to treat angina refractory to medical or percutaneous revascularization therapies.  

Angina may return after apparently successful CABG. The cause varies with the time when symptoms are first noted after surgery:

Recurrent angina during the early postoperative period is usually due to a technical problem with a graft or with early graft closure. This is indication for prompt coronary angiography with percutaneous coronary intervention (PCI), if feasible.

Recurrent angina after the first few months, called late recurrent angina, can occur with the development of stenosis in a bypass graft (either saphenous vein or arterial) or with progression of atherosclerosis in non-bypassed vessels.

This topic will review the management of patients with late recurrent angina after CABG. Early ischemia due to graft occlusion, the technical aspects of percutaneous coronary intervention to treat saphenous vein graft stenosis, and determinants of long-term outcome after CABG are discussed separately. (See "Early noncardiac complications of coronary artery bypass graft surgery" and "Coronary artery bypass graft surgery: Prevention and management of vein graft stenosis" and "Coronary artery bypass graft surgery: Causes and rates of graft failure".)


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Literature review current through: Sep 2016. | This topic last updated: Oct 5, 2015.
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  1. Peduzzi P, Kamina A, Detre K. Twenty-two-year follow-up in the VA Cooperative Study of Coronary Artery Bypass Surgery for Stable Angina. Am J Cardiol 1998; 81:1393.
  2. Weintraub WS, Jones EL, Craver JM, Guyton RA. Frequency of repeat coronary bypass or coronary angioplasty after coronary artery bypass surgery using saphenous venous grafts. Am J Cardiol 1994; 73:103.
  3. Kappetein AP, Feldman TE, Mack MJ, et al. Comparison of coronary bypass surgery with drug-eluting stenting for the treatment of left main and/or three-vessel disease: 3-year follow-up of the SYNTAX trial. Eur Heart J 2011; 32:2125.
  4. Cameron AA, Green GE, Brogno DA, Thornton J. Internal thoracic artery grafts: 20-year clinical follow-up. J Am Coll Cardiol 1995; 25:188.
  5. Loop FD, Lytle BW, Cosgrove DM, et al. Influence of the internal-mammary-artery graft on 10-year survival and other cardiac events. N Engl J Med 1986; 314:1.
  6. Muneretto C, Negri A, Manfredi J, et al. Safety and usefulness of composite grafts for total arterial myocardial revascularization: a prospective randomized evaluation. J Thorac Cardiovasc Surg 2003; 125:826.
  7. Chen L, Théroux P, Lespérance J, et al. Angiographic features of vein grafts versus ungrafted coronary arteries in patients with unstable angina and previous bypass surgery. J Am Coll Cardiol 1996; 28:1493.
  8. Fitzgibbon GM, Kafka HP, Leach AJ, et al. Coronary bypass graft fate and patient outcome: angiographic follow-up of 5,065 grafts related to survival and reoperation in 1,388 patients during 25 years. J Am Coll Cardiol 1996; 28:616.
  9. Alderman EL, Kip KE, Whitlow PL, et al. Native coronary disease progression exceeds failed revascularization as cause of angina after five years in the Bypass Angioplasty Revascularization Investigation (BARI). J Am Coll Cardiol 2004; 44:766.
  10. Motwani JG, Topol EJ. Aortocoronary saphenous vein graft disease: pathogenesis, predisposition, and prevention. Circulation 1998; 97:916.
  11. DeBakey ME, Glaeser DH. Patterns of atherosclerosis: effect of risk factors on recurrence and survival-analysis of 11,890 cases with more than 25-year follow-up. Am J Cardiol 2000; 85:1045.
  12. Voors AA, van Brussel BL, Kelder JC, Plokker HW. Usefulness of hypertriglyceridemia in predicting myocardial infarction late after coronary artery bypass operation. Am J Cardiol 1997; 79:1350.
  13. Solymoss BC, Nadeau P, Millette D, Campeau L. Late thrombosis of saphenous vein coronary bypass grafts related to risk factors. Circulation 1988; 78:I140.
  14. Subramanian S, Sabik JF 3rd, Houghtaling PL, et al. Decision-making for patients with patent left internal thoracic artery grafts to left anterior descending. Ann Thorac Surg 2009; 87:1392.
  15. Labinaz M, Kilaru R, Pieper K, et al. Outcomes of patients with acute coronary syndromes and prior coronary artery bypass grafting: results from the platelet glycoprotein IIb/IIIa in unstable angina: receptor suppression using integrilin therapy (PURSUIT) trial. Circulation 2002; 105:322.
  16. Stephan WJ, O'Keefe JH Jr, Piehler JM, et al. Coronary angioplasty versus repeat coronary artery bypass grafting for patients with previous bypass surgery. J Am Coll Cardiol 1996; 28:1140.
  17. Cole JH, Jones EL, Craver JM, et al. Outcomes of repeat revascularization in diabetic patients with prior coronary surgery. J Am Coll Cardiol 2002; 40:1968.
  18. Morrison DA, Sethi G, Sacks J, et al. Percutaneous coronary intervention versus coronary artery bypass graft surgery for patients with medically refractory myocardial ischemia and risk factors for adverse outcomes with bypass: a multicenter, randomized trial. Investigators of the Department of Veterans Affairs Cooperative Study #385, the Angina With Extremely Serious Operative Mortality Evaluation (AWESOME). J Am Coll Cardiol 2001; 38:143.
  19. Morrison DA, Sethi G, Sacks J, et al. Percutaneous coronary intervention versus repeat bypass surgery for patients with medically refractory myocardial ischemia: AWESOME randomized trial and registry experience with post-CABG patients. J Am Coll Cardiol 2002; 40:1951.
  20. Brener SJ, Lytle BW, Casserly IP, et al. Predictors of revascularization method and long-term outcome of percutaneous coronary intervention or repeat coronary bypass surgery in patients with multivessel coronary disease and previous coronary bypass surgery. Eur Heart J 2006; 27:413.
  21. Yau TM, Borger MA, Weisel RD, Ivanov J. The changing pattern of reoperative coronary surgery: trends in 1230 consecutive reoperations. J Thorac Cardiovasc Surg 2000; 120:156.
  22. Yap CH, Sposato L, Akowuah E, et al. Contemporary results show repeat coronary artery bypass grafting remains a risk factor for operative mortality. Ann Thorac Surg 2009; 87:1386.
  23. Christenson JT, Schmuziger M, Simonet F. Reoperative coronary artery bypass procedures: risk factors for early mortality and late survival. Eur J Cardiothorac Surg 1997; 11:129.
  24. Hoffmann R, Hamm C, Nienaber CA, et al. Implantation of sirolimus-eluting stents in saphenous vein grafts is associated with high clinical follow-up event rates compared with treatment of native vessels. Coron Artery Dis 2007; 18:559.
  25. Baim DS, Wahr D, George B, et al. Randomized trial of a distal embolic protection device during percutaneous intervention of saphenous vein aorto-coronary bypass grafts. Circulation 2002; 105:1285.
  26. Coolong A, Baim DS, Kuntz RE, et al. Saphenous vein graft stenting and major adverse cardiac events: a predictive model derived from a pooled analysis of 3958 patients. Circulation 2008; 117:790.
  27. Stone GW, Rogers C, Hermiller J, et al. Randomized comparison of distal protection with a filter-based catheter and a balloon occlusion and aspiration system during percutaneous intervention of diseased saphenous vein aorto-coronary bypass grafts. Circulation 2003; 108:548.
  28. Gruberg L, Dangas G, Mehran R, et al. Percutaneous revascularization of the internal mammary artery graft: short- and long-term outcomes. J Am Coll Cardiol 2000; 35:944.
  29. Hosono M, Ueda M, Suehiro S, et al. Neointimal formation at the sites of anastomosis of the internal thoracic artery grafts after coronary artery bypass grafting in human subjects: an immunohistochemical analysis. J Thorac Cardiovasc Surg 2000; 120:319.
  30. Shimshak TM, Giorgi LV, Johnson WL, et al. Application of percutaneous transluminal coronary angioplasty to the internal mammary artery graft. J Am Coll Cardiol 1988; 12:1205.
  31. Dimas AP, Arora RR, Whitlow PL, et al. Percutaneous transluminal angioplasty involving internal mammary artery grafts. Am Heart J 1991; 122:423.
  32. Najm HK, Leddy D, Hendry PJ, et al. Postoperative symptomatic internal thoracic artery stenosis and successful treatment with PTCA. Ann Thorac Surg 1995; 59:323.
  33. Blankenship JC, Moussa ID, Chambers CC, et al. Staging of multivessel percutaneous coronary interventions: an expert consensus statement from the Society for Cardiovascular Angiography and Interventions. Catheter Cardiovasc Interv 2012; 79:1138.
  34. Al-Lamee R, Ielasi A, Latib A, et al. Clinical and angiographic outcomes after percutaneous recanalization of chronic total saphenous vein graft occlusion using modern techniques. Am J Cardiol 2010; 106:1721.
  35. de Feyter PJ, Serruys P, van den Brand M, et al. Percutaneous transluminal angioplasty of a totally occluded venous bypass graft: a challenge that should be resisted. Am J Cardiol 1989; 64:88.
  36. Levine GN, Bates ER, Blankenship JC, et al. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation 2011; 124:2574.
  37. Hillis LD, Smith PK, Anderson JL, et al. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons. J Am Coll Cardiol 2011; 58:e123.