CABG and PCI Before Surgery or Transplant

First question

Independent indication?ACS, significant left main, refractory angina or selected prognostic indication.

Solely to lower surgical risk?Routine intervention for stable non-left-main CAD has not improved principal randomized outcomes.

Which evidence applies?

population before extrapolation

Setting	What the evidence supports
Elective vascular surgery	CARP: no survival/postoperative-MI benefit. Longer delay.
Kidney transplant	ISCHEMIA-CKD/listed subgroup: no routine invasive-strategy benefit for stable moderate/severe ischemia. Immediate transplant evidence limited.
Liver transplant	Observational comparisons. Joint coronary-risk, treatment-feasibility and transplant-timing decision.

Count the full pathway

benefit must survive the delay

Original decision sequence. Coronary benefit must be weighed against procedural harm, recovery, bleeding and lost surgical or transplant opportunity.

Playing

Selection trap Post-transplant survivors cannot establish benefit for everyone evaluated.
Recommendation Treatment indication, candidacy impact and readiness reassessment owner.

Stable CAD before elective vascular surgery: CARP found no routine revascularization benefit.

Trial at a glance

defined, selected population

Who / treatment

Enrollment 510/5,859 screened (9%), 98% men. Stable CAD, elective AAA/lower-extremity vascular surgery.
Intervention 59% PCI, 41% CABG among revascularized. No randomized CABG–PCI comparison. Procedure choice was not the randomized question.

Excluded / limits

Exclusions Left-main ≥50%, EF <20%, severe AS, urgent/emergency surgery.
Applicability Earlier stent/medical era. Not transplant, ACS or urgent limb salvage. Confidence intervals retain uncertainty.

Results

revascularization vs no revascularization

Endpoint	Revascularization versus no revascularization
Mortality at median 2.7 years	22% versus 23%, relative risk 0.98, 95% CI 0.70-1.37, P=0.92
MI within 30 days after vascular surgery	12% versus 14%, P=0.37
Median randomization-to-vascular-surgery interval	54 versus 18 days, P<0.001

Apply the 2024 AHA/ACC guideline

indication beyond the operation

ACS Treat, then defer elective surgery.
Significant left main ≥50% Revascularization reasonable when hemodynamically significant.
Stable non-left-main Do not intervene routinely solely to lower perioperative events.
Before another test Specify how anatomy would reveal an independent indication or change the operation.

ISCHEMIA-CKD: medical therapy is the foundation for comparable stable advanced-CKD disease.

Strategy trial

777 patients

Entry + comparison

Entry eGFR <30 mL/min/1.73 m² or dialysis, stable moderate/severe ischemia.
Comparison Initial invasive strategy + medical care versus medical care with angiography for clinical failure. Rescue intervention allowed. Conservative care was active medical treatment.

Important exclusions

Disease Refractory angina, recent ACS, EF <35%, NYHA III/IV HF/recent HF admission, known or strongly suspected significant unprotected left-main disease.
Imaging / surgery Routine CCTA to exclude unknown left main discouraged for kidney risk. Planned major surgery requiring DAPT interruption excluded.

Outcomes and treatment exposure

invasive vs conservative

Outcome or treatment exposure	Invasive versus conservative strategy
Estimated 3-year death or nonfatal MI	36.4% versus 36.7%, adjusted HR 1.01, 95% CI 0.79-1.29
Stroke	HR 3.76, 95% CI 1.52-9.32
Death or initiation of dialysis	HR 1.48, 95% CI 1.04-2.11. This safety analysis concerned participants not receiving dialysis at baseline
Cumulative revascularization at 3 years	50.2% versus 19.6%

What changes practice?

no automatic invasive mandate

Ischemic burden alone No demonstrated routine invasive-strategy benefit.
Still assess anatomy If it creates an independent indication or changes candidacy. Weigh renal injury, bleeding and delay.
Do not extrapolate Not CABG versus PCI, immediate transplant surgery, ACS, refractory symptoms, severe LV dysfunction or significant left-main treatment.

Modern stable-CKD strategy evidence outweighs a small historical transplant trial for comparable patients.

ISCHEMIA-CKD listed subgroup

post hoc · 194 candidates

Death/nonfatal MI

27/94 vs 30/100

Invasive vs conservative.

Adjusted effect

HR 0.91

95% CI 0.54–1.54.

Transplanted

Treatment-by-list-status interaction P=0.68.

Limit Small post hoc subgroup, wide interval and substantial crossover. Absence of significance does not establish equivalence. Immediate transplant-operation benefit remains imprecise.

Manske 1992

historical comparator

Population + result

Population 26 insulin-dependent diabetic patients with atypical or no chest pain, chronic renal failure, substantial CAD during transplant assessment.
Unstable angina, MI or cardiac death 10/13 medical vs 2/13 revascularization, median 8.4 months.

Why not a modern rule?

Medical care Calcium-channel blocker + aspirin, not contemporary prevention.
Inference Small sample, limited precision/generalizability. No predicted transplant benefit assignable from either trial.

Decision before PCI

indication + offer access

Assess Symptoms, LV function, anatomy, feasible medical care, independent indication, procedural risk and time away from readiness.
Donor pathway Living donation allows scheduling. Deceased-donor offers require an explicit antiplatelet/readiness plan.

No randomized liver-transplant trial establishes benefit from routine prophylactic PCI.

Recipient cohort versus evaluation cohort

denominator changes the question

Umadat 2025: post-LT outcomes

Population 111 asymptomatic recipients with significant angiographic CAD. 66 PCI, 45 medical. CABG excluded.
MACE 52% vs 60% at median 32 months, P=0.40.
Unadjusted HR 1.16, 95% CI 0.68–1.96.
Composite Death, MI, stroke/TIA, new systolic dysfunction or post-LT coronary intervention.
Limit Small single-center cohort selected by reaching transplantation. No demonstrated lower MACE, no equivalence conclusion.

Ginard 2025: evaluation harms

Population 912 evaluated → 202 angiography → 18 PCI.
Complications 8/202 overall, 4/18 after PCI.
Death One acute-on-chronic liver-failure death after DAPT-related bleeding.
Limit Captures pretransplant harm. Small PCI sample, disease-based treatment selection.
One-month DAPT Used in many PCI patients. Does not establish universal transplant timing.

AASLD/AST 2026 decision

individual benefit and feasibility

Current guidance Significant asymptomatic CAD: multidisciplinary revascularization assessment before/around LT. Replaces older broad consideration for all significant CAD.
Balance Lesion significance, hepatic reserve, portal bleeding, kidneys, DAPT tolerance, delayed listing and declined organs.
Endpoint caution Umadat MACE is broader than CARP/ISCHEMIA-CKD endpoints.

Selected recipient survival demonstrates feasibility, not a causal revascularization benefit.

Wray 2025

historical cohort, long follow-up

Cohort

604 recipients

Pre-LT angiography, 7 centers, transplantation 1998–2010.

CAD / follow-up

145 obstructive CAD

Mean follow-up 7.3 years.

Comparison with recipients without obstructive CAD	Adjusted mortality association
Any obstructive CAD	HR 1.39, 95% CI 1.06-1.82
Severe CAD, >70% stenosis	HR 1.63, 95% CI 1.19-2.22
Pretransplant revascularization	HR 1.62, 95% CI 1.18-2.23

Read the comparison correctly

against recipients without obstructive CAD

What HR 1.62 cannot show

Causal harm Revascularized patients differ from recipients without CAD.
Risk eliminated Successful treatment does not remove long-term coronary risk.

Cohort checks

Start point Evaluation, listing or transplantation?
Comparator Similar anatomy/symptoms? Treatment selected for worse disease?
Missing interval Deaths, bleeding, delisting and missed organs before LT?
Era Current stents, medical care and selection?

Residual risk

complete the whole assessment

Beyond coronaries HF, RV/vascular disease, frailty and transplant hemodynamic stress.
Outcome horizon Post-LT survival is one part of evaluation-to-transplant survival.

Contemporary selected cirrhosis cohort

Jenkins · cardiac surgery with cardiopulmonary bypass

30-day mortality

4.1%

220 patients, median MELD 10.

90-day mortality

12.6%

Operated 2014–2022. Recovery deaths matter.

By class at 30 days A: 2.8% (n=143). B: 6.8% (n=73). Only 4 class C patients.
Selection Confirmed cirrhosis. Prior/concomitant LT and off-pump operations excluded. Declined patients absent.

Historical severity gradient

Jacob · 19 studies · 638 patients

Child-Pugh class	Deaths / patients	Pooled mortality, 95% CI
A	38/420	9.0% (6.6-12.2%)
B	72/193	37.3% (30.8-44.3%)
C	13/25	52.0% (33.5-70.0%)

Endpoint Pooled short-term mortality <30 days, variable component follow-up. Mixed CABG/valve studies through early 2014.
Limit Heterogeneous historical data, class C n=25. Not a contemporary risk calculator or an individual CABG estimate. Keep the operation and follow-up horizon attached to each rate.

Death and decompensation

Suman · 44 cardiac-surgery patients with CPB · 1992–2002

Child-Pugh class, n	Mortality	Hepatic decompensation
A, 31	1/31 (3.2%)	3/31 (9.7%)
B, 12	5/12 (41.7%)	8/12 (66.7%)
C, 1	1/1	1/1

By 3 months 7/44 deaths, 12/44 hepatic decompensations. These are not 30-day rates.
Class C One patient cannot estimate class-specific risk. Contemporary selected outcomes do not erase advanced-disease risk.

Mortality alone misses hepatic decompensation, renal injury, ventilation and lost transplant opportunity.

Broader liver disease, not cirrhosis alone

Pétursson · 285 patients · 2010–2020

Group, n	Death by 30 days / in hospital	≥1 complication
Child-Pugh A, 219	5.9%	37.9%
Early B, MELD <12.7, 34	5.9%	38.2%
Advanced B, MELD ≥12.7, 32	18.8%	59.4%

Advanced B Renal failure 21.9%, prolonged ventilation 46.9%.
Selection No class C. Early B younger, frequent endocarditis/tricuspid surgery. Conventional MELD 12.7 derived within this dataset.
Inference No universal “safe MELD” for CABG.

Other outcome estimates

keep endpoints distinct

2025 cirrhosis meta-analysis

Inpatient mortality 11% (95% CI 9–14%).
Renal failure 30% (21–39%), not an estimate of new dialysis. Check component definitions.

Individual assessment

Hepatic Child-Pugh points, dated MELD/version, ascites/encephalopathy, portal bleeding.
Operative Kidney reserve, nutrition/frailty, urgency and complexity. Cardiac-surgery/hepatology adjudication.
Versions MELD, MELD-Na and MELD 3.0 cutoffs are not interchangeable. Record the score version used by the study and calculator.

Calibration in 220 operated patients

Jenkins: mean prediction vs observation

Model or observed outcome	30-day mortality	90-day mortality
Mayo model, mean predicted	20.9%	29.6%
VOCAL-Penn, mean predicted	9.0%	14.0%
Observed	4.1%	12.6%

Limits Nine 30-day deaths. Mean estimates are not individual corrections or evidence of safety for patients declined surgery.
Report Calculator, endpoint and limitations.

CABG decision

IndicationCoronary benefit must be established.

FeasibilityHepatic reserve and transplant rescue require separate assessment.

CABG-specific absolute risk

Siraw · US inpatient data · 2016–2020

Cirrhosis

8.6%

In-hospital mortality.

Noncirrhotic liver disease

5.9%

In-hospital mortality.

No chronic liver disease

2.8%

In-hospital mortality.

Population 7,945 chronic-liver-disease patients matched to 7,945 without. Cirrhosis n=6,687.
Adjusted association Mortality OR 4.21 (95% CI 3.61–4.94). No granular Child-Pugh/MELD severity.

Avoiding bypass ≠ established safety

Gopaldas · 1998–2009

Observed association

Population 6,448 cirrhotic patients among about 3 million CABG admissions.
On-pump Excess mortality/morbidity across severity categories.
Off-pump Association concentrated in severe disease, defined administratively. No causal off-pump benefit or advanced-cirrhosis safety claim. Operative selection can explain part of the association.

Clinical boundary

Technical Suitability and completeness still matter.
AHA 2022 Isolated CABG described as contraindicated at MELD >13 or Child-Pugh B/C.
Adjudication Experienced team, especially with decompensation. New mixed-operation cohorts do not validate CABG across class B.

Simultaneous cardiac surgery + LT

selected-center feasibility

2026 report 46 selected patients, CABG/valve mix. Actuarial survival 74.2% at 1 year, 50% at 5 years.
Limits Single center, nonrandomized, not CABG-specific. No staged-care superiority or broadly validated internal score.
Plan Medical care, PCI, staged CABG, selected combined surgery or prohibitive risk. Transplant impact and reassessment owner.

Choose treatment after establishing an indication

coronary guideline conditions

CABG when surgically suitable

Left main Recommended for significant disease.
LV dysfunction Recommended: multivessel CAD, severe LV dysfunction and amenable anatomy.
Diabetes Preferred: multivessel disease involving LAD, in a suitable surgical candidate.

PCI consideration

Left main Selected anatomy permitting equivalent revascularization.
Surgery unsuitable PCI remains an option when revascularization is indicated.
Heart Team Symptoms, anatomy, LV function, completeness, harm, DAPT, preference and life expectancy.

Labeled CABG illustration showing an internal mammary artery conduit and a saphenous vein graft connecting to native coronary arteries beyond plaque. — **Conduit, inflow and target.** Illustrative anatomy, not a prescribed graft plan. Assess distal targets and conduit suitability.
Blausen 0151 CABG 02.png by BruceBlaus / Blausen Medical Communications. Source · CC BY 3.0. Unmodified.

Evidence: match population and comparator

no cross-trial CABG–PCI inference

Trial / population	Outcome	Clinical lesson
FREEDOM · 1,900 Diabetes, multivessel CAD	5-year death/MI/stroke: 26.6% PCI vs 18.7% CABG. Stroke: 2.4% vs 5.2%.	CABG benefit, stroke tradeoff. Earlier DES era.
STICHES · 1,212 EF ≤35%, CABG-amenable CAD	Median 9.8 years: death 58.9% CABG vs 66.1% medical. HR 0.84 (95% CI 0.73–0.97).	Selected ischemic CM: long-term CABG benefit, with recovery/time-to-benefit costs.
REVIVED-BCIS2 · 700 EF ≤35%, extensive CAD, viability	Median 41 months: death/HF admission 37.2% PCI vs 38.0% medical. HR 0.99 (95% CI 0.78–1.27).	No demonstrated endpoint benefit. Viability alone does not establish prognostic PCI benefit.

Transplant boundary

benefit must fit the patient

Limits Different questions and populations. No immediate liver/kidney-transplant protection estimate or randomized STICHES–REVIVED comparison.

Dialysis CABG–PCI evidence is observational, with conflicting survival signals.

Compare early harm and later outcomes

treatment selection remains

USRDS · Chang 2012

Population 21,981 dialysis patients, multivessel CABG versus PCI, 1997–2009.
Death CABG HR 0.87 (95% CI 0.84–0.90).
Death/MI HR 0.88 (95% CI 0.86–0.91).
Limit Administrative data, older PCI era, selection/residual confounding.

Taiwan · Pan 2024

Population 1,840 propensity-matched dialysis patients, 2009–2015, CABG versus DES PCI.
In-hospital death 12.5% vs 3.3%.
Overall mortality HR 1.19 (95% CI 1.05–1.35), favoring PCI, median 2.8 years.
Tradeoff More repeat revascularization, ACS and rehospitalization after PCI. Observational population/practice differences.

What these cohorts cannot establish

no prophylactic-transplant comparison

Confounding Anatomy, frailty, urgency and surgical selection persist despite adjustment. Transplant candidates may have different competing risk.
Question Neither tested routine intervention versus medical care before transplantation.

Individual comparison

when revascularization is indicated

Coronary Anatomy/completeness, diabetes, LV function, conduits, CABG recovery, PCI complexity and DAPT.
Transplant Nephrology constraints, expected survival with/without transplant and time away from readiness.
Counsel No randomized dialysis-specific CABG superiority established by these cohorts. Shorter PCI recovery alone does not settle treatment.

Two decisions

DAPT durationAbbreviated therapy retains a defined antithrombotic regimen.

Permission to operateDepends on interruption, bleeding, thrombosis and urgency.

2024 AHA/ACC surgical timing

planned noncardiac surgery

PCI context	Timing anchor
Balloon angioplasty without stenting	Delay elective surgery ≥14 days
DES for ACS	Ideally delay elective surgery ≥12 months
DES for chronic coronary disease	A delay ≥6 months is reasonable for elective surgery
Time-sensitive surgery after DES	May be considered ≥3 months when the harm of delay exceeds cardiac risk
BMS or DES within 30 days	Elective surgery requiring antiplatelet interruption is potentially harmful

DES rows Assume interruption of ≥1 antiplatelet agent.
Early time-sensitive surgery Continue DAPT within 30 days of BMS or <3 months of DES unless bleeding outweighs thrombosis protection.
Aspirin Continue low dose after PCI when feasible.

MASTER DAPT

4,579 high-bleeding-risk patients

What was tested

Entry Event-free first month after a specific contemporary DES.
Net events Per-protocol death/MI/stroke/major bleeding: 7.5% abbreviated vs 7.7% standard, noninferior.
Bleeding Intention-to-treat major/clinically relevant nonmajor bleeding: 6.5% vs 9.4%.

What was not tested

Transplant Routine liver/kidney transplantation at one month with all antiplatelets stopped. Short DAPT is not zero antiplatelet therapy.
Stent protection Heparin does not replace antiplatelet protection.

Organ-offer plan before PCI

interventional + transplant + anesthesia

Decide Accept on current therapy, allow interruption or wait? Include harm of delay and individual urgency.
Handoff Actual last doses, restart ownership and anesthesia restrictions.

No randomized trial establishes a universal CABG-to-transplant waiting interval.

Recovery determines readiness

clinical domains, not a validated score

Cardiac + systemic

Cardiac Indication/grafts, perioperative MI/stroke, rhythm, residual ischemia, ventricular function/congestion.
Systemic Lung/kidney recovery, anemia, infection, wound/sternum, activity, nutrition and rehabilitation.

Treatment + timing

Antithrombotics Aspirin, P2Y12 indication, OAC and anesthesia/bleeding plan. CABG does not erase constraints, especially after ACS.
Cost of delay Malignancy, limb threat, organ failure and operative urgency.

Mallick timing association

US readmissions data · 2016–2020

Source population

1,335,175

Elective cardiac operations. CABG, valve and combined.

Subsequent surgery

20,253

Patients undergoing subsequent noncardiac surgery.

Around 100 days Modeled inflection. Later surgery: major adverse events adjusted OR 0.69 (95% CI 0.62–0.76).
In-hospital death Adjusted OR 0.66 (95% CI 0.46–0.96).
Limits Administrative/observational, not CABG-only or transplant-specific. Composite includes cardiac, neurologic, respiratory, renal and other serious complications.
Inference No proof every patient benefits from waiting 100 days. An observational inflection is not a mandatory waiting period.

Conclude with conditions

operation or organ offer

Planned surgery Earliest reasonable reassessment, residual disease and recovery.
Transplant Offer availability and remaining activation/acceptance conditions.
Cardiac operation Valve/CABG optimization, ICU handoff and recovery.

Resolve the decision

clinical state → indication → feasibility

StabilityACS, unstable symptoms, HF/arrhythmia first. Actual activity and limitations.

Coronary significanceDated anatomy/physiology, left main, LV function and prior treatment.

Independent indicationSymptom or prognostic benefit, with expected time to benefit.

FeasibilityMedical care, PCI, CABG or selected combined options. Renal/hepatic reserve and patient priorities.

Consultation fields

fill with verified evidence

Treatment decision

Context [ ] Operation/organ, stability, dated anatomy/ischemia and LV function.
Treatment [ ] Independent indication or none solely to lower operative risk. Feasible medical care, limitations and chosen option.
Benefit/harm [ ] Applicable population/limits, time to benefit, kidneys/liver, bleeding, recovery/DAPT and transplant/surgical delay.

Liver + operative plan

Cirrhosis [ ] Child-Pugh points, dated MELD/version, decompensation, 30-/90-day mortality and hepatic complications, with source/limits.
Readiness [ ] Proceed / optimize / team pending / prohibitive. Conditions, reassessment owner/date and the evidence needed to change the decision.
Offer/operation [ ] Dates, antiplatelets, interruption/restart and harm of waiting.

Complete the wider assessment

linked workups

Companions Perioperative assessment and organ-specific transplant workups.