Cardiovascular · Topic 6 of 48

Coronary Revascularization: PCI & CABG

Cardiovascular · coronary revascularization

Coronary Revascularization: PCI & CABG

The Heart Team picks the procedure: CABG for left main or diabetic multivessel disease, PCI for simpler anatomy — then protect the stent with DAPT.

Key numbers

DAPT 12 months after ACS stent12 months (ACS)

Hold P2Y12 inhibitors before elective CABG5 / 3–5 / 7 days

01 · The ruleLeft main: CABG improves survival

Significant left main disease is a surgical indication — CABG improves survival over medical therapy; PCI is a reasonable alternative only with low-to-medium anatomic complexity equally suited to either approach.

02 · The ruleDiabetes + 3-vessel disease: CABG

Patients with diabetes and 3-vessel disease (or multivessel disease involving the LAD) should have CABG; PCI is considered only for poor surgical candidates.

03 · GiveDAPT 12 months after ACS stent

After PCI give aspirin plus a P2Y12 inhibitor: 12 months by default after ACS; 6–12 months after elective PCI, or 1–3 months then P2Y12 monotherapy when bleeding risk is high.

Management

Orders

Hold P2Y12 inhibitors before elective CABGBefore elective CABG, stop clopidogrel 5 days, ticagrelor 3–5 days and prasugrel at least 7 days ahead; do not start prasugrel when urgent CABG is likely.

Radial access is preferred for PCIUse radial rather than femoral access for PCI: fewer bleeding and vascular complications, faster ambulation, and lower mortality in acute coronary syndromes.

LIMA to LAD; radial artery secondCABG typically grafts the left internal mammary artery to the LAD; a radial artery is preferred over saphenous vein for the second most important target because of better patency and survival.

On anticoagulation: stop aspirin at 1–4 weeksPatients who need an oral anticoagulant stop aspirin 1–4 weeks after PCI and continue a DOAC (preferred over warfarin) plus a P2Y12 inhibitor, preferably clopidogrel, for up to 12 months.

Red flags & don'ts

Avoid harm

Stopping DAPT early risks stent thrombosis avoidPremature discontinuation of DAPT (nonadherence or surgery) is a major cause of stent thrombosis, which presents as acute MI; if a P2Y12 inhibitor must be interrupted, restart it as soon as hemostasis allows.

Post-CABG atrial fibrillation peaks days 2–4 complicationAtrial fibrillation follows CABG in 30–55% of patients, most often on postoperative days 2–4; beta-blockers and amiodarone reduce its incidence.

Check the access site after catheterization complicationAfter catheterization check the access site: an enlarging mass needs ultrasound for pseudoaneurysm, a bruit suggests an AV fistula; most resolve with compression, and radial access makes all of these rarer.

Prevent contrast AKI: hydrate, limit contrast complicationPCI carries a high contrast-nephropathy risk: identify at-risk patients (CKD, urgent cases), hydrate before the procedure and set a maximum contrast volume.

Post-bypass bleeding: reverse heparin with protamine complicationBleeding after cardiopulmonary bypass comes from hemodilution, heparin, pump-induced platelet dysfunction, DIC and hypothermia; heparin is reversed with protamine at the end of bypass.

The rules

Know these

Heart Team chooses PCI or CABG must knowWhen the best strategy is unclear, a multidisciplinary Heart Team chooses PCI or CABG with the patient, weighing anatomic complexity, the STS surgical-risk score and the patient's goals.

ACS multivessel: complete revascularization, except shockIn STEMI or NSTE-ACS with multivessel disease, complete revascularization is recommended (nonculprit PCI at the index procedure or staged); in cardiogenic shock treat only the culprit artery.

CABG survival benefit: 3-vessel disease, low EFCABG improves survival for left main disease and 3-vessel disease with poor LV function; for 1-vessel disease outside the left main or proximal LAD, medical therapy, PCI and CABG give similar outcomes.

PCI or CABG?

Commonly confused

Best fit	1–2-vessel disease with favorable anatomy
30-day stroke	Lower (about 0.4%)
Repeat revascularization	More often needed
Recovery	Radial access; fast ambulation
Antiplatelet issue	DAPT protects the stent

More detail

Reference

Show 7 reference facts

With drug-eluting stents, acute and subacute (within 30 days) stent thrombosis occurs in under 0.5–1.3%, late thrombosis about 0.1% per year, and restenosis needing revascularization about 0.5–1% per year.

Cardiopulmonary bypass can cause stroke (1–2% in low-risk patients) and neurocognitive changes in about 25–30%, more often in older adults.

A median sternotomy takes 4–6 weeks to heal; wound infection can progress to mediastinitis or sternal osteomyelitis.

Fractional flow reserve clarifies whether an equivocal stenosis is hemodynamically significant; without it, a luminal diameter reduction over 70% is assumed significant.

Unfractionated heparin is the usual anticoagulant during PCI (enoxaparin and bivalirudin are alternatives); use bivalirudin or argatroban with heparin-induced thrombocytopenia.

In-hospital mortality is 0.5–1.9% after PCI and under 1–3% after CABG in otherwise healthy patients at experienced centers; the STS risk calculator estimates operative risk.

Intracoronary imaging (IVUS or OCT) is recommended to guide PCI of complex lesions.

Pearl

A stent needs DAPT; bypass surgery needs it stopped — clopidogrel 5 days, ticagrelor 3–5, prasugrel 7.

Sources · ACC — 2021 ACC/AHA/SCAI Coronary Revascularization Guideline: Key Perspectives (Lawton JS et al., J Am Coll Cardiol 2022;79:e21–e129) · Merck Manual Professional — Overview of Revascularization for Acute Coronary Syndromes · Merck Manual Professional — Stable Angina (revascularization) · Merck Manual Professional — Percutaneous Coronary Interventions (PCI) · Merck Manual Professional — Coronary Artery Bypass Grafting (CABG) · Clopidogrel tablets prescribing information — DailyMed · Ticagrelor tablets prescribing information — DailyMed · Prasugrel tablets prescribing information — DailyMed · Merck Manual Professional — Cardiac Catheterization · Rao SV et al. 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes (summary of key recommendations, Medical Dialogues, March 2025) · Society for the Advancement of Patient Blood Management — Management of antiplatelet agents (platelet recovery: clopidogrel 5–7 d, ticagrelor 3–5 d, prasugrel 7–10 d) · Starter sheet built from the verified AGACNP fact map (facts reviewed 2026-10-15).