Coronary Artery Bypass Graft Degenerative Disease.

The choice of conduit is the most important factor influencing long-term patency of coronary artery bypass grafts (CABGs); arterial grafts are far superior to saphenous vein bypass grafts (SVGs) in this regard. Aspirin therapy should be started early in the perioperative period and continued indefinitely. Warfarin (Coumadin; Dupont, Wilmington, DE) and other platelet inhibitors offer no added value to aspirin, but may be used with benefit in aspirin-intolerant patients. Every effort should be made to reduce low-density lipoprotein cholesterol (LDL-C) to a value well below 100 mg/dL. In most instances, this will require the use of an 3-hydroxy-3-methyglutaryl coenzyme A (HMG CoA) reductase inhibitor. Avoidance of cigarette smoking is imperative. Achieving a normal blood pressure, ideal body weight, and a regular exercise program are helpful. Those patients who have important obstruction in a SVG or arterial graft and who are symptomatic, or who have important myocardial ischemia with orjwithout symptoms should be treated with a procedure to improve perfusion to the myocardium supplied by the occluded bypass graft. Successful percutaneous transluminal coronary angioplasty (PTCA) and stenting of the obstructed graft usually will lead to improved myocardial perfusion, although in other clinical circumstances repeat CABG surgery will be required. On occasion, reperfusion of the myocardium can be achieved by PTCA of the native coronary artery with or without stenting while the degenerated graft is abandoned. When planning therapy for myocardial ischemia, the higher rate of PTCA related restenosis and the increased risks from repeat CABG must be carefully considered.