Arterial graft patency in coronary artery bypass grafting: what do we really know?

doi:10.1016/S0003-4975(98)00815-7

The Annals of Thoracic Surgery

Volume 66, Issue 3, September 1998, Pages 1055-1059

Presented at “Facts and Myths of Minimally Invasive Cardiac Surgery: Current Trends in Thoracic Surgery IV,” New Orleans, LA, Jan 24, 1998.

https://doi.org/10.1016/S0003-4975(98)00815-7 Get rights and content

Abstract

Background. With increasing use of beating heart techniques for bypass of the left anterior descending coronary artery with the left internal mammary artery (LIMA), appropriate concerns have been raised of whether graft patency by these techniques compares favorably with conventional, arrested heart techniques.

Methods. All published articles that examine outcome efficacy of the LIMA graft to the left anterior descending coronary artery were reviewed. Because angiography has been considered the “gold standard,” only those studies that included angiographic follow-up were analyzed.

Results. From 1972 through 1998, there have been 37 peer-reviewed publications that examined outcomes of LIMA grafting in conventional coronary bypass grafting, of which 27 contained angiographic follow-up data. The completeness of angiographic follow-up was variable, but early graft patency (≤1 month) in studied patients ranged between 94% and 99%. Late graft patency (up to 15 years) ranged from 51% to 98%. Five recent series of minimally invasive direct coronary artery bypass grafting that contained LIMA graft patency data show early graft patency rates between 91% and 99%.

Conclusions. Meaningful comparison of LIMA graft patency between arrested heart, conventional coronary artery bypass grafting, and minimally invasive direct coronary artery bypass grafting is difficult; however, early graft patency by both techniques can confidently be stated as being 90% or greater.

Section snippets

Material and methods

A literature review was undertaken to determine the published results regarding the efficacy of the use of the LIMA for revascularization of the LAD. All articles from the first published article by Green in 1972 to the most recently published series of MIDCABG in 1998 were analyzed 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40. Determination of the end points used to demonstrate benefit was made for

Conventional coronary artery bypass grafting

From 1972 through 1998, there have been a total of 37 peer-reviewed publications that address the efficacy of the LIMA for revascularization of the LAD. These include two editorials, which themselves contain no results 4, 5. The remaining 35 publications present the results of LIMA grafting from 18 institutions. Institutions with multiple publications include St. Luke’s-Roosevelt (6), Cleveland Clinic (5), St. Louis University (4), and Ottawa (3), with two publications each from the groups in

Comment

Although an extensive body of literature exists addressing the issue of LIMA graft patency, the ability to answer the question of whether MIDCABG graft patency is comparable with that of conventional coronary artery bypass grafting is difficult to assess because the series are not comparable. Table 1 and Table 5, which illustrate early graft patency results, are most comparable. However, the conventional coronary artery bypass grafting series can be variously criticized for not including

References (42)

A.M Calafiore et al.
Midterm results after minimally invasive coronary surgery (LAST operation)
J Thorac Cardiovasc Surg
(1998)
A.C Cameron et al.
Internal thoracic artery grafts20-year clinical follow-up
J Am Coll Cardiol
(1995)
G.E Green et al.
Five-year follow-up of microsurgical multiple internal thoracic artery grafts
Ann Thorac Surg
(1994)
J.W Jones et al.
The internal mammary bypass grafta superior second coronary artery
J Thorac Cardiovasc Surg
(1978)
J.W Jones et al.
Clinical comparison with saphenous vein and internal mammary artery as a coronary graft
J Thorac Cardiovasc Surg
(1980)
J.R Kramer et al.
Late follow-up of 781 patients undergoing percutaneous transluminal coronary angioplasty of coronary artery bypass grafting for an isolated obstruction in the left anterior descending coronary artery
Am Heart J
(1989)
G.E Green
Internal mammary artery-to-coronary artery anastomosisthree-year experience with 165 patients
Ann Thorac Surg
(1972)
B.W Lytle et al.
Long-term (5 to 12 years) serial studies of internal mammary artery and saphenous vein coronary bypass grafts
J Thorac Cardiovasc Surg
(1985)
M.J Boylan et al.
Surgical treatment of isolated left anterior descending coronary stenosis
J Thorac Cardiovasc Surg
(1994)
H.B Barner et al.
Late patency of the internal mammary artery as a coronary bypass conduit
Ann Thorac Surg
(1982)

D.H Tyras et al.

Bypass grafts to the left anterior descending coronary arterysaphenous vein versus internal mammary artery

J Thorac Cardiovasc Surg

(1980)

A.C Fiore et al.

Results of internal thoracic artery grafting over 15 yearssingle versus double grafts

Ann Thorac Surg

(1990)

G.M Fitzgibbon et al.

Coronary bypass graft fatelong-term angiographic study

J Am Coll Cardiol

(1991)

G.M FitzGibbon et al.

Coronary bypass graft fate and patient outcomeangiographic follow-up of 5,065 grafts related to survival and reoperation in 1,388 patients during 25 years

J Am Coll Cardiol

(1996)

T Ivert et al.

Angiographic studies of internal mammary artery grafts 11 years after coronary artery bypass grafting

J Thorac Cardiovasc Surg

(1988)

I.S Gill et al.

Minimally invasive coronary artery bypassa series with early qualitative angiographic follow-up

Ann Thorac Surg

(1997)

E.B Kay et al.

Internal mammary artery bypass graftlong-term patency rate and follow-up

Ann Thorac Surg

(1974)

R.H Zeff et al.

Internal mammary artery versus saphenous vein graft to the left anterior descending coronary arteryprospective randomized study with 10-year follow-up

Ann Thorac Surg

(1988)

A.J Tector et al.

Experience with internal mammary artery grafts in 298 patients

Ann Thorac Surg

(1976)

R.N Singh et al.

Long-term fate of the internal mammary artery and saphenous vein grafts

J Thorac Cardiovasc Surg

(1983)

C.B Huddleston et al.

Internal mammary artery graftstechnical factors influencing patency

Ann Thorac Surg

(1986)

Cited by (101)

Nanofiber-coated, tacrolimus-eluting sutures inhibit post-operative neointimal hyperplasia in rats
2023, Journal of Controlled Release
Post-operative complications of vascular anastomosis procedures remain a significant clinical challenge and health burden globally. Each year, millions of anastomosis procedures connect arteries and/or veins in vascular bypass, vascular access, organ transplant, and reconstructive surgeries, generally via suturing. Dysfunction of these anastomoses, primarily due to neointimal hyperplasia and the resulting narrowing of the vessel lumen, results in failure rates of up to 50% and billions of dollars in costs to the healthcare system. Non-absorbable sutures are the gold standard for vessel anastomosis; however, damage from the surgical procedure and closure itself causes an inflammatory cascade that leads to neointimal hyperplasia at the anastomosis site. Here, we demonstrate the development of a novel, scalable manufacturing system for fabrication of high strength sutures with nanofiber-based coatings composed of generally regarded as safe (GRAS) polymers and either sirolimus, tacrolimus, everolimus, or pimecrolimus. These sutures provided sufficient tensile strength for maintenance of the vascular anastomosis and sustained drug delivery at the site of the anastomosis. Tacrolimus-eluting sutures provided a significant reduction in neointimal hyperplasia in rats over a period of 14 days with similar vessel endothelialization in comparison to conventional nylon sutures. In contrast, systemically delivered tacrolimus caused significant weight loss and mortality due to toxicity. Thus, drug-eluting sutures provide a promising platform to improve the outcomes of vascular interventions without modifying the clinical workflow and without the risks associated with systemic drug delivery.
The research and preparation of a bi-layer biodegradable external sheath with directional drug release profiles for vein graft
2013, Applied Surface Science
External sheath has been suggested for autologous vein grafts to inhibit neointimal hyperplasia and prevent anastomosis stricture. In this study, we prepared a bi-layer biodegradable paclitaxel-loaded sheaths with a synthetic copolymer poly(ethylene carbonate-ɛ-caprolactone) at room temperature. The bi-layer drug release profiles of the Paclitaxel-loaded (PTX-loaded) sheath significantly slow down the paclitaxel (PTX) release rates and result in a directional drug release way. Moreover, the nanofibrous layer of PTX-loaded poly(EC-CL) sheaths reduced the cytotoxicity and provided a better support for fibroblast adhesion and proliferation than the PTX-loaded layer of the sheaths. Thus, this study demonstrates that the bi-layer PTX-loaded poly(EC-CL) sheath with directional drug release profiles have a promising application for vein graft to against neointimal hyperplasia and anastomotic stricture.
Beating Heart Totally Endoscopic Coronary Artery Bypass
2010, Annals of Thoracic Surgery
Graft patency and clinical freedom from graft failure remains a subject of investigation in beating-heart totally endoscopic coronary artery bypass.
A total of 214 patients underwent successful beating-heart totally endoscopic coronary artery bypass from July 2004 to June 2007. Single-, double-, and triple-vessel beating-heart totally endoscopic coronary artery bypass was performed in 139, 68, and 7 patients, respectively. Fifty patients underwent planned hybrid revascularization. Eighty percent of patients (172 of 214) underwent computed tomography angiography or conventional angiography within 3 months from the time of surgery. On computed tomography angiography, the analysis included gross patency, stenosis within the graft, and contrast in the grafted coronary artery. A FitzGibbon score was used to analyze graft patency and anastomosis in patients undergoing conventional angiography. Clinical follow-up was done in all patients for any major adverse cardiac event in relation to the revascularized coronary arteries.
There was no myocardial infarction, operative mortality, or conversion to cardiopulmonary bypass. All patients who had computed tomography angiography were found to have grossly patent graft without stenosis and demonstrated opacification of the grafted coronary artery. Fifty-seven grafts were studied in 39 patients by conventional angiography postoperatively during hybrid revascularization. At the time of study, all grafts except one had FitzGibbon grade A anastomosis and Thrombolysis In Myocardial Infarction grade 3 flow. Three patients (1.4%) required reintervention at 2, 3, and 13 months after initial beating-heart totally endoscopic coronary artery bypass.
The clinical freedom from graft failure noted in 98.6% patients appears to be excellent. Further angiographic and clinical follow-up is required to determine the long-term results.
Enabling Technology for Minimally Invasive Coronary Artery Bypass Grafting
2009, Seminars in Thoracic and Cardiovascular Surgery
Over the past 8 years, new techniques and perhaps more significantly new technology have expanded the possibilities for minimally invasive coronary artery bypass grafting. In this section, we review 3 important and potentially enabling technologies: (1) robotics, (2) anastomotic connectors, and (3) the expanding role of imaging in the context of combined operating room/catheterization laboratories (hybrid suites).
A new strategy for prevention of anastomotic stricture using tacrolimus-eluting biodegradable nanofiber
2009, Journal of Thoracic and Cardiovascular Surgery
We developed a novel sustained drug-eluting device using tacrolimus-eluting biodegradable nanofiber to prevent anastomotic stricture and evaluated the effects in a rat abdominal aortic anastomosis model.
In vitro and in vivo tacrolimus release tests for tacrolimus-eluting biodegradable nanofiber were performed to confirm its sustained release. To verify the prevention of anastomotic stricture, tacrolimus-eluting biodegradable nanofiber was placed around the end-to-end anastomosis of abdominal aorta in rats. Five rats were allocated to the following 5 groups: (1) control without tacrolimus-eluting biodegradable nanofiber, (2) 5 mg of nanofiber only (0 wt% of tacrolimus), (3) 5 mg of tacrolimus-eluting biodegradable nanofiber containing 0.04 wt% of tacrolimus, (4) 5 mg of tacrolimus-eluting biodegradable nanofiber containing 0.1 wt% of tacrolimus, and (5) 5 mg of tacrolimus-eluting biodegradable nanofiber containing 1.0 wt% of tacrolimus. Morphometric and histologic analyses including immunohistochemistry were performed in each of the groups 2 weeks after the operation.
The tacrolimus-eluting biodegradable nanofiber gradually released tacrolimus for at least 1 month in vitro and in vivo. The ratio of intimal area was significantly reduced in the 1.0 wt% tacrolimus-eluting biodegradable nanofiber group compared with the other groups (0.26, 0.24, 0.25, 0.21, and 0.08 in control, 0 wt%, 0.04 wt%, 0.1 wt%, and 1.0 wt%, respectively, P < .05). The cells, which constitute intimal hyperplasia, were positive for smooth muscle actin and SMemb, and factor VIII revealed that endothelial cells covered the surface of the aortic lumen even in the 1.0 wt% tacrolimus-eluting biodegradable nanofiber group in immunohistochemistry.
Tacrolimus-eluting biodegradable nanofiber reduced neointimal hyperplasia and preserved endothelialization. This device may be useful in the prevention of anastomotic stricture.
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
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.

View all citing articles on Scopus

View full text

Minimally Invasive Cardiac Surgery SupplementsArterial graft patency in coronary artery bypass grafting: what do we really know?

Abstract

Section snippets

Material and methods

Conventional coronary artery bypass grafting

Comment

J Thorac Cardiovasc Surg

J Am Coll Cardiol

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Am Heart J

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Am Coll Cardiol

J Am Coll Cardiol

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Minimally Invasive Cardiac Surgery Supplements
Arterial graft patency in coronary artery bypass grafting: what do we really know?