Midterm angiographic assessment of coronary artery bypass grafting without cardiopulmonary bypass

doi:10.1016/S0003-4975(00)01567-8

The Annals of Thoracic Surgery

Volume 70, Issue 3, September 2000, Pages 844-849

https://doi.org/10.1016/S0003-4975(00)01567-8 Get rights and content

Abstract

Background. Coronary bypass surgery that provides good long-term graft patency can be performed on the beating heart as a viable alternative to conventional coronary artery bypass grafting (CABG).

Methods. From September 1993 to December 1996, 696 patients underwent CABG on the beating heart at the Koşuyolu Heart and Research Hospital in Istanbul. Among them, 70 patients were chosen randomly for angiographic assessment of off-pump coronary artery bypass grafting.

Results. The interval from operation to angiography varied from 24 to 61 months (mean, 36.1 ± 10.9 months). The patency rate of left internal mammary–left anterior descending artery anastomoses was 95.59% (patency achieved in 65 of 68 patients) and of vein grafts was 47.06% (patency achieved in 16 of 34 patients) (p < 0.0001). The patency rates of grafts anastomosed to the left anterior descending artery were significantly higher than the rates of the grafts anastomosed to the other coronary arteries (95.71% versus 45.45%, p < 0.0001). Multivariate analysis showed that graft type (p < 0.0001) and hyperlipidemia (p = 0.023) were significant predictors for graft occlusion. Left ventricular function improved significantly after CABG (p = 0.04). Reintervention (using percutaneous transluminal cardiac angioplasty) and reoperation rates were 0.97% and 1.4%, respectively.

Conclusions. Off-pump coronary artery bypass grafting appears to produce midterm and long-term patency rates that are comparable to those of conventional techniques; that is especially true in cases of arterial conduits and of conduits anastomosed to the left anterior descending artery.

Section snippets

Material and methods

In the period from September 1993 to October 1999, a total of 2,063 patients underwent operations on the beating heart at Koşuyolu Heart and Research Hospital. Of 696 patients operated upon by only two surgeons (C.Y. and Ö.I.) between September 1993 and December 1996, 70 were chosen randomly for the midterm and long-term angiographic assessment of off-pump procedures. Of those, 63 patients (90%) were male and 7 (10%) were female; their mean age was 53.21 ± 9.82 years (range, 36 to 76 years).

Results

The mean interval from operation to angiography was 36.11 plus or minus 10.88 months (range, 24 to 61 months).

Comment

Myocardial revascularization has become the standard therapy for ischemic coronary artery disease in patients who do not benefit from medical therapy, percutaneous transluminal coronary angioplasty, or other noninvasive cardiac interventions. Revascularization’s efficacy in relieving angina and prolonging life is well proved in certain subgroups of patients, and it can be performed with acceptable mortality and morbidity rates. On the other hand, although the adverse effects of cardiopulmonary

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Cited by (67)

Ten-year experience with off-pump coronary artery bypass grafting: Lessons learned from early postoperative angiography
2010, Journal of Thoracic and Cardiovascular Surgery
We performed early postoperative angiography to assess anastomosis accuracy and patency after off-pump coronary artery bypass grafting.
One thousand three hundred forty-five patients who underwent off-pump coronary artery bypass grafting between January 1998 and December 2007 were studied. Grafts for distal anastomoses were left internal thoracic artery (n = 1281), right internal thoracic artery (n = 679), right gastroepiploic artery (n = 836), radial artery (n = 14), and saphenous vein (n = 188). Groups underwent off-pump coronary artery bypass grafting without (group I, n = 234) or with (group II, n = 1111) intraoperative graft flowmetry. Early postoperative (≤7 days) angiography was performed in 1278 cases (95.0%) at 1.6 ± 1.2 postoperative days.
Operative mortality was 1.6%. Average number of distal anastomoses was 3.0 ± 1.0. Postoperative angiography showed early patencies of 98.9% for arterial grafts and 88.2% for venous grafts (P < .001). In group II, intraoperative flowmetry-guided revision was performed in 2.2% of distal anastomoses. Patency of arterial grafts was significantly higher in group II than group I (97.2% vs 99.1%, P < .001); however, patency of venous grafts was not significantly different (86.0% vs 92.2%, P = .099). Early reoperation for graft revision according to angiographic findings was performed in 35 patients.
Early patency of venous grafts was significantly lower than that of arterial grafts. Intraoperative flowmetry and revision of abnormal grafts improved early graft patency, and reoperation according to early angiographic findings may further improve graft patency.
Coronary vein graft disease: Pathogenesis and prevention
2009, Canadian Journal of Cardiology
Not long after coronary artery bypass grafting surgery was described, several reports presented follow-up angiographic data on large cohorts of patients, demonstrating that approximately one-half of saphenous vein grafts fail within 10 to 15 years of surgery and that graft failure is associated with worse clinical outcomes. Three processes are responsible for vein graft failure. Thrombosis, intimal hyperplasia and accelerated atherosclerosis contribute to graft failure in the acute, subacute and late postoperative periods, respectively. Studies have shown that perioperative antiplatelet therapy can reduce early thrombosis and graft failure. As in native coronaries, intensive lipid lowering can attenuate the process of atherosclerosis in vein grafts. Intimal hyperplasia in the vein graft is thought to be an adaptation of the vein to higher pressures in the arterial circulation. This process is further promoted by the loss of inhibition from the endothelial layer, which is injured during surgery. A new ‘no-touch’ technique for harvesting grafts may be effective in preventing disruption to the endothelial layer, and subsequent intimal hyperplasia and graft loss. Off-pump surgery and endoscopic vein harvesting, which are known to reduce surgical morbidity, have been shown to be no worse than on-pump surgery and open vein harvesting, respectively, in terms of vein graft patency. Various gene therapies can prevent intimal hyperplasia in animal models, but human data obtained so far have been disappointing. Placing an external stent around a vein graft may reduce tangential wall stress and subsequent intimal hyperplasia.
Peu après la description du pontage aortocoronarien, plusieurs rapports ont porté sur les données angiographiques de suivi de vastes cohortes de patients, démontrant qu’environ la moitié des greffons veineux saphènes échouent dans les dix à 15 ans suivant l’opération et que l’échec des greffons s’associe à des issues cliniques encore plus négatives. Trois processus sont responsables de l’échec des greffons veineux. La thrombose, l’hyperplasie intimale et l’athérosclérose accélérée contribuent à l’échec du greffon pendant les périodes postopératoires aiguë, subaiguë et tardive, respectivement. Les études démontrent qu’une thérapie antiplaquettaire périopératoire peut réduire le risque de thrombose précoce et d’échec du greffon. Tout comme dans les artères coronaires originales, une diminution lipidique intensive peut atténuer le processus d’athérosclérose dans les greffons veineux. On pense que l’hyperplasie intimale dans le greffon veineux est une adaptation de la veine à de plus fortes pressions de la circulation artérielle. Ce processus est favorisé par la perte d’inhibition de la couche endothéliale, blessé pendant l’opération. Une nouvelle méthode sans contact de prélèvement du greffon pourrait être efficace pour prévenir la perturbation de la couche endothéliale, l’hyperplasie intimale qui s’ensuit et la perte du greffon. Il est démontré que le pontage à cœur battant et le prélèvement veineux par endoscopie, dont l’effet sur la réduction de la morbidité chirurgicale est connu, ne sont pas plus néfastes que le pontage avec circulation extracorporelle et le prélèvement veineux ouvert, respectivement, pour ce qui est de la perméabilité du greffon veineux. Plusieurs thérapies géniques peuvent prévenir l’hyperplasie intimale dans les modèles animaux, mais les données humaines obtenues jusqu’à présent sont décevantes. L’installation d’une endoprothèse externe autour d’un greffon veineux peut réduire la contrainte tangentielle exercée sur la paroi et l’hyperplasie intimale qui s’ensuit.
Influence of Diabetes Mellitus on Long-Term Survival in Systematic Off-Pump Coronary Artery Bypass Surgery
2008, Annals of Thoracic Surgery
Citation Excerpt :
Despite active perioperative blood glucose control in diabetic patients during the perioperative period, postoperative infections were still more frequent in the diabetic population. The predisposition of diabetic patients to infective complications after cardiac surgery has been often suggested [16, 36–40]. Angiopathy, neuropathy, and hyperglycemia associated with DM are identified as the main reasons for predisposition to infections [41].
Diabetic patients generally present a more diffuse and calcified coronary artery disease than nondiabetic patients that can affect long-term outcome especially if an off-pump coronary artery bybass graft (OPCABG) technique is used. The aim of this study was to compare long-term results of OPCABG surgery for diabetic and nondiabetic patients.
This is a retrospective analysis of prospectively gathered data over a 10-year period of 1,000 consecutive and systematic OPCABG patients operated on between September 1996 and April 2004. Average follow-up period was 66 ± 28 months and was 97% complete. Overall survival as well as occurrence of major adverse cardiac events in diabetic and nondiabetic patients were specifically studied.
In all, 278 diabetic patients and 722 nondiabetic patients were treated. There was no difference in 30-day mortality between the two groups (p = 0.70). Diabetic patients had more postoperative acute renal insufficiency (p = 0.01) and infections (sepsis; p = 0.002), and deep sternal infections (p = 0.04) Ten-year survival (p = 0.006) and survival free of major adverse cardiac events (p = 0.02) was decreased in the diabetic group. Age (hazard ratio [HR] = 1.06), peripheral vascular disease (HR = 1.72), carotid disease (HR = 1.53), congestive heart failure (HR = 1.51), incomplete revascularization (HR = 2.37), chronic renal insufficiency (HR = 1.93), left ventricular ejection fraction (HR = 0.13), and a lesser use of multiple internal thoracic artery grafts (HR = 0.67), but not diabetes mellitus (p = 0.13) were significant determinants of long-term mortality. Similarly, peripheral vascular disease (HR = 1.92), chronic renal insufficiency (HR = 2.36), emergent operation (HR = 1.71), chronic obstructive pulmonary disease (HR = 1.76), previous percutaneous coronary intervention (HR = 1.66), left ventricular ejection fraction (HR = 0.26), ischemic mitral regurgitation (HR = 1.83), and a lesser use of multiple internal thoracic artery grafts (HR = 0.72) were determinants of decreased survival free of major adverse cardiac events but not diabetes (p = 0.2). Breaking down the major adverse cardiac events, diabetes was found an independent predictive factor of recurrent myocardial infarction (HR = 1.85) and a borderline cause of readmission for congestive heart failure (p = 0.06). Need for new revascularization was comparable for both population (p = 0.37).
In our series of OPCABG surgery patients, diabetic patients had a comparative operative mortality and perioperative myocardial infarction rate as nondiabetic patients. However, they had an increased prevalence of postoperative acute renal insufficiency and infections. They also had a worse outcome than nondiabetic patients, but that was mainly due to a higher prevalence of preoperative comorbidities and a lesser use of multiple internal thoracic artery grafts. However, diabetes itself was a potential risk factor for long-term occurrence of myocardial infarction and congestive heart failure.
Midterm angiographic follow-up after off-pump coronary artery bypass: Serial comparison using early, 1-year, and 5-year postoperative angiograms
2008, Journal of Thoracic and Cardiovascular Surgery
Citation Excerpt :
Those differences were mainly attributable to the lower saphenous vein or radial artery graft patency rates. A significantly lowered patency for saphenous vein grafts than for ITA grafts was suggested to result from the type of graft, presence of hyperlipidemia, the exposure and quality of stabilization, and increased procoagulant activity in OPCAB patients.7,9,10 Another meta-analysis5 that included two more randomized trials11,12 found a statistically insignificant benefit of conventional CABG over OPCAB for arterial graft patency and a statistically significant 28% increase in venous graft occlusion with OPCAB relative to conventional CABG.
We analyzed the angiographic changes of the anastomotic sites at three time points for 5 years after off-pump coronary artery bypass surgery.
Of the 402 patients who underwent off-pump coronary artery bypass surgery between January 1998 and December 2001, 240 patients who received the early, 1-year, and 5-year follow-up coronary angiograms regardless of the patient's anginal symptoms were studied. Morphologic changes of grafts were traced by the FitzGibbon grading system.
Overall graft patency rates (FitzGibbon grade A+B) at early, 1-year, and 5-year angiography were 98.6%, 91.9%, and 88.3%, respectively. Graft patency rates in the left anterior descending artery, left circumflex artery, and right coronary artery territories were similar at early angiograms (P = .162). However, graft patency rate in the left anterior descending artery territory was higher than that in the left circumflex artery and right coronary artery territories at both the 1-year (P < .001) and 5-year (P < .001) angiograms. Of the 31 FitzGibbon grade B arterial grafts (internal thoracic artery and right gastroepiploic artery) at early angiography, 10 became occluded and 19 became grade A at 5-year angiography. In the saphenous vein grafts, grade B lesions gradually increased during the 5 postoperative years (2.6% vs 6.5% vs 13.3%).
Midterm angiographic follow-up demonstrated acceptable patency rates of grafts after off-pump coronary artery bypass surgery. Approximately half of the FitzGibbon grade B arterial grafts in the early angiograms became grade A at 5 years after surgery, but the proportion of grade B saphenous vein grafts gradually increased over the 5 postoperative years.
Early and Midterm Results of Off-Pump Coronary Artery Bypass Grafting
2007, Annals of Thoracic Surgery
Citation Excerpt :
We believe that the same early graft patency rate can be obtained in patients treated with OPCAB as compared with those undergoing conventional CABG. Some investigators have demonstrated a reduced patency rate for SVG in patients undergoing OPCAB [19]. Hypercoagulability may exist after OPCAB, and prophylactic postoperative anticoagulation therapy may be indicated for these patients [20].
Early outcomes of off-pump coronary artery bypass grafting have been documented by numerous studies. However, there have been few reports concerning midterm outcomes after off-pump coronary artery bypass grafting.
We retrospectively reviewed the records of 602 consecutive patients (24.8% female) who underwent isolated off-pump coronary artery bypass grafting between April 2001 and July 2004. Mean age was 66.7 ± 9.3 years. Mean Canadian Cardiovascular Society score was 2.5 ± 0.9. Early postoperative angiograms were evaluated during the same period of hospitalization. Midterm outcomes, including overall patient survival, freedom from cardiac death, and freedom from the combined endpoint of cardiac events, were evaluated.
The average number of distal anastomoses per patient was 3.6 ± 1.4. The average operation time was 286.1 ± 72.1 minutes. Long segmental reconstruction of the left anterior descending coronary artery was performed in 218 patients (36.2%). Total arterial grafting was performed in 466 patients (77.4%). Thirty-day mortality was 0.5%. Overall patency rate for all grafts and anastomoses was 97.5% and 97.6%, respectively. Mean follow-up time was 2.9 ± 1.0 years. Cumulative patient survival at 5 years was 87.9% ± 2.4%. Freedom from cardiac death was 97.7% ± 0.6% at 5 years. Freedom from the combined endpoint of cardiac events was 83.8% ± 2.3% at 5 years.
Early and midterm outcomes after off-pump coronary artery bypass grafting have acceptable mortality and cardiac events rates, with favorable early graft patency rates.
Meta-analysis of randomized trials comparing off-pump with on-pump coronary artery bypass graft patency
2005, Annals of Thoracic Surgery
Off-pump coronary artery bypass graft surgery (OPCAB) is increasingly becoming a widely used technique and challenges conventional on-pump coronary artery bypass grafting as the standard surgical therapy for coronary artery disease. Little information, however, is available concerning postoperative performance of bypass grafts done with this new technique. The aim of this study is to assess differences in graft patency between OPCAB and coronary artery bypass grafting by meta-analysis of data published in randomized trials.
A literature search for the period beginning January 1990 until December 2004 supplemented with manual bibliographic review was performed for all peer-reviewed English-language publications. A systematic overview (meta-analysis) of randomized trials was conducted to assess differences between OPCAB and coronary artery bypass grafting in graft occlusion rates.
Literature search yielded five comparable randomized studies, for a total of 872 and 998 grafts performed during OPCAB and coronary artery bypass grafting procedures, respectively. Meta-analysis of these studies showed an increased risk of graft occlusion in the OPCAB group of patients, both when all the studies were analyzed together (odds ratio, 1.51; 95% confidence intervals, 1.15 to 1.99; p = 0.003), and when low-quality (odds ratio, 1.46; 95% confidence intervals, 1.05 to 2.03; p = 0.02) and high-quality (odds ratio, 1.65; 95% confidence intervals, 0.99 to 2.75; p = 0.05) studies were analyzed separately.
Cumulative analysis of the few prospective randomized studies currently available in the literature documents a reduction in postoperative patency of coronary artery bypass grafts performed during OPCAB procedures. The risk of reduced graft patency needs to be considered when choosing OPCAB as tailored strategy for selected patients.

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Original article: cardiovascularMidterm angiographic assessment of coronary artery bypass grafting without cardiopulmonary bypass

Abstract

Section snippets

Material and methods

Results

Comment

J Thorac Cardiovasc Surg

J Am Coll Cardiol

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Chest

Ann Thorac Surg

J Thorac Cardiovasc Surg

Original article: cardiovascular
Midterm angiographic assessment of coronary artery bypass grafting without cardiopulmonary bypass