CABG RE-DOs : THE PROBLEM OF CABG ON THE YOUNG

I was thinking very hard as to what to blog. There seem to be no new clinical trials or medical studies that are clinically useful, this last weekend. So I thought that I will share my work for tomorrow. Tomorrow, I have to do two difficult angioplasties. The first will be a 60+ yrs male with diabetes and who have CABG done when he was about 40yrs. I started to take care of him about ten years ago when his CABG began to fail and he began to develop positive stress ECG and now unstable angina. For the last 10 years, he already had at least 5 angioplasties. Of course, he refuse to undergo a re-CABG because of the risk. I am very concern that I may not be able to do much tomorrow. He also has renal failure probably from diabetes. The second male is also in the sixties and he had CAD treated by me over the last 10 years. He has had three angioplasties. If I have to do it again tomorrow, it will be the fourth in 10 years. Lets see what I will find tomorrow and see what I can do.
The point I am trying to discuss is whether, we should do CABG in young 40 year olds or shall we do angioplaties, until it is no longer feasible to do. Doing CABG in the young has the problem of CABG graft attrition. The LIMA graft may be good, but the SVG grafts invariably fail after about 10 years. We can plasty them, but with CABG, there is also a 30-40% risk of re-stenosis, especally in diabetics. With the new DES, that number drops to 15-20% ( still significant ). I remember abot 20 years ago, I send a rich male to UK for a repeat CABG by arguably the best cardiac surgeon in UK. He nearly died. Those were his exact words to me. The grafts blocked again, and he refused a third CABG, and I ghad to do repeat angioplasties to keep him going. He is still around, but the arteries and SVGs are all bad.
Early CABG with re-dos are both very expensive and also very risky. Early angioplasties with CABG only when angioplasties are no longer feasible, is an expensive strategy but much less risky.
If I should have significant, symptomatic CAD, I will opt for angioplasties, until they are no longer technically feasible. Then I may opt for CABG. Having seen many such patients. I think that is the best strategy, and I am aware of the guidelines.