Artery Bypass Grafting Research Articles

R054: Radial Artery Graft for Bypass of the Maxillary to Proximal Middle Cerebral Artery

R054: Radial Artery Graft for Bypass of the Maxillary to Proximal Middle Cerebral Artery

Alterations of myocardial presynaptic sympathetic innervation in patients with multi-vessel coronary artery disease but without history of myocardial infarction

In patients with myocardial infarction, left ventricular sympathetic denervation exceeds the size of the scar tissue. However, little is known about the regional innervation in patients with coronary artery disease (CAD) but no myocardial infarction. Using positron emission tomography (PET) with N-ammonia and C-hydroxyephedrine (HED), resting perfusion and presynaptic sympathetic innervation were studied in eight patients (seven males, one female; 58+/-9 years) with multi-vessel CAD and no history of myocardial infarction. Using polar map analysis of the PET data, the results were regionally compared with normal databases. The mean HED retention was 8.0%+/-2.0% x min(-1). Myocardial resting perfusion was normal in 23 of 24 vascular territories. Despite normal resting perfusion, significantly reduced HED retention, indicating dysinnervation, was found in 14 of 23 (61%) vascular territories (six of eight patients). Of the dysinnervated territories, 11 (79%) showed angiographically severe stenosis (>or=90% of native vessel/coronary artery bypass graft), eight (57%) showed ischaemia (myocardial perfusion scintigraphy/stress-electrocardiogram) and 12 (86%) had been revascularized. Of the nine segments with normal innervation, two (22%) revealed severe stenosis, two (22%) showed ischaemia and seven (78%) had been revascularized. It can be concluded that, in patients with advanced CAD and normal left ventricular function, dysinnervation can occur in the absence of myocardial infarction. This is consistent with the hypothesis that sympathetic neurones are more susceptible than myocytes to ischaemic damage.

High thoracic epidural anesthesia as the sole anesthetic for redo off-pump coronary artery bypass surgery

CASE REPORT An obese, 69-year-old woman suffering from hypertension, diabetes, and chronic obstructive pulmonary disease with seasonal wheezing presented to the hospital with progressive worsening of breathlessness and chest pain on exertion. She weighed 72 kg, her height was150 cm, and her body mass index was 32. She was not a smoker and did not give a history suggestive of sleep apnea. She was admitted to the hospital with unstable angina (grade III, the Canadian Cardiovascular Society grading of angina of effort) and was started on medical therapy for the control of angina. The patient gave a history of seasonal bronchospasm and was being treated with nebulization with salbutamol and ipratropium. Her vital signs on admission were as follows: heart rate 90 beats/min, blood pressure 180/ 100 mmHg, respiratory rate 22/min, and transcutaneous oxygen saturation 95% on room air The pulmonary function tests showed moderate, reversible airflow obstruction with no restriction. Her forced vital capacity, forced expiratory volume in one second, forced expiratory volume and forced vital capacity ratio were 1.1 L, 0.72 L, and 63.9%, respectively, which increased 15% after 2 puffs of salbutamol inhalation. Her other medications consisted of amlodipine, 5 mg once daily; aspirin, 100 mg once daily; human insulin, thrice daily according to her blood sugar; and ranitidine, 150 mg thrice daily. The laboratory tests showed a hematocrit of 33%, white cell count of 9,000 CU/MM, and platelet count of 250,000 CU/MM. Blood urea nitrogen was 20 mg/dL and serum creatinine 1.0 mg/dL. The arterial blood gases were unremarkable except for PCO2 of 42 mmHg. The chest radiograph showed prominent bronchovesicular markings. The patient had undergone coronary artery bypass grafting 7 years ago, wherein the left internal mammary artery (LIMA) and radial artery were used to make a “T” anastomosis and grafts to the left anterior descending artery (LAD), ramus

Follow-up Study of Coronary Artery Bypass Grafting in Patients with Kawasaki Disease

Background: The purpose of this study was to assess the long-term clinical outcome of coronary artery bypass grafting in pediatric patients with Kawasaki disease. Methods: Six patients (mean age, 9.3±1.6 years) underwent coronary artery bypass graft ing be tween September 1985 and December 1992. The number of bypass grafts placed was 1-2/patient(mean of 1.3±0.5). The left internal mammary artery (IMA) was used as a bypass graft in 3 patients, bilateral IMA in 1 and saphenous vein in 3. All pa t ients underw e nt postoperative evaluations after one month, and between 5 and 10 years.Results: Follow-up ranged between 9 and 16 years (mean,12.6±2.7 years). Stress myocardial scintigraphy identified two patients with transient ischemia, one o f w hom died suddenly a ft er 16 postoperative years. Coronary angiography demonstrated that the grafts of 5 patients were patent at both the short- and long-term follow-ups. However, in one patient, the IMA that was grafted to the diagonal artery was occ l ude d one month after su rgery. Five survivors are in good health without clinical angina. Conclusions: We consider that coronary revascularization using bilateral IMA grafts may provide a more favorable prognosis in patients with severe Kawasaki coronary artery disease. Stre ss myocardial scintigraphy and echocardiography can be used effectively to follow such patients.

The Erlanger chest pain evaluation protocol: A one-year experience with serial 12-lead ECG monitoring, two-hour delta serum marker measurements, and selective nuclear stress testing to identify and exclude acute coronary syndromes

Study objective: We determine the overall use of a 6-step accelerated chest pain protocol to identify and exclude acute coronary syndrome (ACS) and to confirm previous findings of the use of serial 12-lead ECG monitoring (SECG) in conjunction with 2-hour delta serum marker measurements to identify and exclude acute myocardial infarction (AMI). Methods: A prospective observational study was conducted over a 1-year period from January 1, 1999, through December 31, 1999, in 2,074 consecutive patients with chest pain who underwent our accelerated evaluation protocol, which includes 2-hour delta serum marker determinations in conjunction with automated SECG for the early identification and exclusion of AMI and selective nuclear stress testing for identification and exclusion of ACS. In patients not undergoing emergency reperfusion therapy, physician judgment was used to determine patient disposition at the completion of the 2-hour evaluation period: admit for ACS, discharge or admit for non-ACS condition, or immediate emergency department nuclear stress scan for possible ACS. A positive protocol was defined as a positive result in 1 or more of the 6 incremental steps in our chest pain evaluation protocol: (1) initial ECG diagnostic of acute injury or reciprocal injury; (2) baseline creatine kinase (CK)-MB level of 10 ng/mL or greater and index of 5% or greater or cardiac troponin I level of 2 ng/mL or greater; (3) new/evolving injury or new/evolving ischemia on SECG; (4) increase in CK-MB level of +1.5 ng/mL or greater or cardiac troponin I level of +0.2 ng/mL or greater in 2 hours; (5) clinical diagnosis of ACS despite a negative 2-hour evaluation; and (6) reversible perfusion defect on stress scan compared with on resting scan. All patients were followed up for 30-day ACS, which was defined as myocardial infarction (MI), percutaneous coronary intervention/coronary artery bypass grafting, coronary arteriography revealing stenosis of major coronary artery of 70% or greater not amenable to percutaneous coronary intervention/coronary artery bypass grafting, life-threatening complication, or cardiac death within 30 days of ED presentation. Results: Discharge diagnosis in the 2,074 study patients consisted of 179 (8.6%) patients with AMI, 26 (1.3%) patients with recent AMI (decreasing curve of CK-MB), and 327 (15.8%) patients with 30-day ACS. At 2 hours, sensitivity and specificity for MI (AMI or recent AMI) of SECG plus delta serum marker measurements was 93.2% and 93.9%, respectively (positive likelihood ratio 15.3; negative likelihood ratio 0.07). At the completion of the full ED evaluation protocol (positive result in ≥1 of the 6 incremental steps), sensitivity and specificity for 30-day ACS was 99.1% and 87.4%, respectively (positive likelihood ratio 7.9; negative likelihood ratio 0.01). Conclusion: An accelerated chest pain evaluation strategy consisting of SECG, 2-hour delta serum marker measurements, and selective nuclear stress testing in conjunction with physician judgment identifies and excludes MI and 30-day ACS during the initial evaluation of patients with chest pain. [Ann Emerg Med. 2002;40:584-594.]

Relation of percutaneous coronary intervention of complex lesions to clinical outcomes (from the NHLBI Dynamic Registry)

Advances in percutaneous coronary intervention (PCI) have reduced complications but expanded indications. We used the National Heart, Lung, and Blood Insitute Dynamic Registry to determine clinical outcomes up to 1 year after PCI in 2,839 patients with at least 1 treated complex lesion (defined as a lesion showing evidence of thrombus, calcification, bifurcation or ostial location, or chronic occlusion) and 1,790 patients with only simple lesions treated. Complex lesion interventions were associated (p <0.05) with more sustained major dissections, distal embolization, side branch occlusion, and persistent flow reduction. Patients with treated complex lesions had a lower procedural success rate (93.8% vs 97.3%, p <0.001) and increased in-hospital rates (p <0.001) of death (2.0% vs 0.6%), death/myocardial infarction [MI] (5.2% vs 2.4%), or death/MI/coronary artery bypass graft [CABG] surgery (6.5% vs 2.9%). After adjustment for potential confounders, patients treated for multiple complex lesions were more likely to experience the in-hospital combined end points of death/MI (odds ratio 3.22, 95% confidence interval 2.10 to 4.92), or death/MI/CABG (odds ratio 2.55, 95% confidence interval 1.71 to 3.80). At 1 year, patients with treated complex lesions were more likely (p <0.001) to die (6.2% vs 3.7%), suffer death/MI (11.7% vs 7.5%), or death/MI/CABG/repeat PCI (27.2% vs 23.4%). Patients treated for multiple complex lesions were approximately 50% more likely to die or to have major adverse events than with patients only treated for simple lesions. An increased in-hospital adverse clinical event rate was independently noted for thrombotic, bifurcation, and calcified lesions, and bifurcation lesions had worse long-term event rates.

Correlates of coronary blood flow before and after percutaneous coronary intervention and their relationship to angiographic and clinical outcomes in the RESTORE trial

Background and Objectives Slower blood flow in the setting of acute myocardial infarction (MI) has been related to adverse outcomes, but the relationship of coronary blood flow after percutaneous transluminal coronary angioplasty (PTCA) in the setting of acute coronary syndromes to adverse outcomes and restenosis has not been well described. We sought to evaluate the correlates of pre- and post-PTCA coronary blood flow to shed light on potential modifiable determinants. Methods The RESTORE trial (Randomized Efficacy Study of Tirofiban for Outcomes and REstenosis) was a randomized, double-blind, placebo-controlled trial of tirofiban in patients undergoing balloon angioplasty or directional atherectomy within 72 hours of occurrence of either unstable angina pectoris or acute MI. Coronary blood flow was assessed with the corrected TIMI frame count (CTFC), and clinical outcomes were assessed at 30 days. Results In addition to tighter and longer minimum lumen diameters (MLDs), the multivariate correlates of slower flow before PTCA also included the presence of thrombus, collaterals, left coronary artery lesion location, acute MI, and >8F catheter size. As well as the above variables, type C and D dissection grades were related to slower post-PTCA CTFC. Death, or the composite of death/MI/coronary artery bypass graft at 30 days, was more frequent among patients with slower post-PTCA CTFCs and those with post-PTCA thrombus. In a multivariate model correcting for reference segment diameter and MLD, the post-PTCA CTFC was an independent predictor of late lumen loss and the follow-up MLD at 6 months. As a single index that integrates functional and anatomical aspects of the post-PTCA results, the ratio of CTFC/MLD was associated with death/MI by 30 days. Conclusions In addition to MLD, variables such as the presence of thrombus, left coronary artery lesion location, and dissection grade also are associated with slower coronary blood flow after PTCA. In turn, post-PTCA CTFCs were an independent predictor of late lumen loss and follow-up MLDs. Furthermore, patients who die or who sustain other adverse cardiac events have slower coronary blood flow and greater thrombus burden after PTCA. (Am Heart J 2002;144:130-5.)

Endovascular Repair of Multiple Peripheral Aneurysms via a Dual Approach Involving a Venous Graft Conduit

Introduction stent across the other sheath, thereby facilitating haemostasis on removal. The profunda femoris origin was The authors report the management of a difficult occluded with Gianturco embolisation coils (Cook U.K. Ltd.) following a satisfactory trial balloon occlusion. surgical problem involving the repair of multiple peripheral aneurysms in a patient with a pre-existing The CFA puncture site was used to sequentially deploy three Wallgraft endoprostheses (nominal size 9 mm synthetic aortic graft in whom autologous long saphenous vein was unavailable. This was carried out long, Boston Scientific Ltd.) within the SFA and venous graft, to exclude the aneurysmal SFA from the cirby an endovascular route through dual access sites, involving uniquely a venous graft conduit. culation. The distal vein graft puncture site was then used to deploy a further Wallgraft (9 mm×70 mm) within the aneurysmal external iliac and CFA. Balloon remodelling at the Wallgraft junctions reduced any Technical Report minor endoleaks. There were no immediate complications and the patient’s feet remained well perfused A 72-year-old man with a history of a coronary artery throughout the procedure. Follow-up arterial duplex bypass graft had previously undergone several surultrasound scans at 3 days, 2 months and 3 months gical procedures for aneurysmal disease including an demonstrated graft patency with aneurysmal exaortic reconstruction with a Dacron aorto-bi-iliac graft, clusion. The patient was discharged home 3 days a right-sided superficial femoral artery (SFA) to belowfollowing the procedure. The cost of four Wallgrafts knee popliteal long saphenous vein bypass graft, and was £3800. a left-sided SFA to peroneal long saphenous vein bypass graft. Since these procedures, however, he presented with multiple aneurysms (1.6–3.6 cm diaDiscussion meter) extending from the left external iliac to the femorodistal graft (Figure 1). The option of extensive surgical repair via a groin The patient underwent endovascular repair of the approach entailing a high risk of morbidity was unaneurysms under local anaesthetic (Figure 2). An antedesirable in this patient. Factors including in-situ syngrade left common femoral artery (CFA) puncture and thetic graft infection and perioperative haemorrhage retrograde distal saphenous vein graft puncture were were also major concerns. Furthermore, the reperformed and accessed with 10 French sheaths. Dual constructed aortic segment and the unavailability of sites were accessed to enable each to deploy a covered both long saphenous veins would clearly complicate a surgical challenge. The use of endovascular covered stents to repair ∗ Please address all correspondence to: R. D. Sayers, Consultant peripheral aneurysms is a relatively new modality. Vascular Surgeon, Department of Surgery, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, U.K. Reports have been limited to only small numbers

Seleção da artéria radial para utilização como enxerto aortocoronário: correlação cirúrgica x avaliação pré-operatória com ecocolor Doppler e fotopletismografia digital

OBJETIVO: Com o crescente uso da artéria radial como enxerto aortocoronário, torna-se necessário reavaliar os critérios utilizados para a seleção desse vaso no pré-operatório da cirurgia de revascularização miocárdica. O objetivo deste estudo foi correlacionar a avaliação da viabilidade do vaso pelo cirurgião cardíaco no per-operatório com o estudo de seleção da artéria radial pelos métodos não invasivos, como o ecocolor Doppler e a fotopletismografia digital. CASUÍSTICA E MÉTODOS: Foram estudadas, entre julho de 1998 e maio de 2000, 78 artérias radiais e 78 artérias ulnares de 39 pacientes selecionados para cirurgia de revascularização miocárdica. O estudo foi realizado bilateralmente, utilizando aparelhos de ultra-sonografia ATL-HDI 5000 e Acuson-Sequóia 512, e o aparelho de fotopletismografia Parks Vascular Mini-Lab Model 1052-C. A artéria radial foi considerada passível de ser utilizada como enxerto aortocoronário, quando preenchia os seguintes critérios: ausência de ateromatose ou oclusão da artéria radial e ulnar ipsilateral, diâmetro interno da artéria radial maior ou igual a 2,5mm, avaliados pelo ecocolor Doppler, e presença de onda de pulso em dois ou mais dígitos durante a compressão radial, avaliada pela fotopletismografia. RESULTADOS: Dentre as 78 artérias radiais estudadas, 64 (82%) foram consideradas apropriadas para utilização como enxerto aortocoronário e 12 (18,7%) não apropriadas. Dos 39 pacientes selecionados, 24 (61,5%) foram submetidos à cirurgia de revascularização miocárdica com utilização da artéria radial e a correlação entre a viabilidade da artéria radial avaliada pelo cirurgião durante o per-operatório com a avaliação pré-operatória pelo ecocolor Doppler e pela fotopletismografia para seleção da artéria radial foi de 100%. A contra-indicação da retirada de 12 (18,7%) artérias radiais levou à alteração do planejamento cirúrgico de dois pacientes, devido ao comprometimento bilateral. Em 3 pacientes que, por diferentes motivos, não foram submetidos ao estudo pelo Ecocolor Doppler e pela fotopletismografia, a avaliação clínica da perviedade da artéria radial utilizando a manobra de Allen não foi suficiente para afastar a presença de calcificação da parede arterial encontrada no ato operatório, impossibilitando o uso dessa artéria como enxerto. CONCLUSÃO: Os autores concluem que a seleção da artéria radial para utilização como ponte aortocoronária, avaliada por testes não invasivos, como o ECD e a fotopletismografia, é eficaz, pois a associação desses métodos apresenta excelente correlação com os achados per-operatórios e permite a nós, cirurgiões cardiovasculares, além da segurança, um melhor planejamento cirúrgico para cada paciente.

Is there a gender bias in outcome after combined carotid endarterectomy/coronary artery bypass grafting?

Is there a gender bias in outcome after combined carotid endarterectomy/coronary artery bypass grafting?

Selective dual nuclear scanning in low-risk patients with chest pain to reliably identify and exclude acute coronary syndromes

Study Objective: We sought to determine the use in routine clinical practice of selective dual nuclear cardiac scanning (rest and stress) in low-risk patients with chest pain for identifying and excluding acute coronary syndromes (ACSs) during the initial emergency department evaluation. Methods: A prospective observational study was conducted over 13 months in 1,775 low-risk patients with chest pain who had intermediate- and high-risk ACSs ruled out by means of our 2-hour protocol, which consists of automated serial 12-lead ECG monitoring in conjunction with baseline and 2-hour creatine kinase (CK) MB and troponin I (cTnI) measurements. At the completion of the 2-hour evaluation period, low-risk patients were stratified by means of physician judgment into 1 of 2 categories: category III, possible ACS; and category IV, probable non-ACS chest pain. Level III patients underwent immediate dual nuclear scanning (rest thallium and stress sestamibi scanning), and level IV patients were discharged directly from the ED unless another serious non-ACS medical condition was thought to exist. Rest and stress scans were interpreted by a board-certified radiologist contemporaneous with patient evaluation. All patients were followed up for 30-day ACS, which was defined as acute myocardial infarction, percutaneous transluminal coronary angioplasty/coronary artery bypass grafting, coronary arteriography revealing stenosis of the major coronary artery of 70% or greater not amenable to percutaneous transluminal coronary angioplasty/coronary artery bypass grafting, life-threatening complication, or cardiac death within 30 days of ED presentation. Results: A total of 2,206 ED patients with chest pain were evaluated for ACS during the study period. Four hundred thirty-one patients were excluded for having 1 or more of the following findings: initial ECG diagnostic of injury; baseline CK-MB level, cTnI level, or both diagnostic of acute myocardial infarction; 2-hour ΔCK-MB level of +1.5 ng/mL or greater; 2-hour ΔcTnI level of +0.2 ng/mL or greater; injury or new or evolving ischemia on serial 12-lead ECG monitoring; or clinical diagnosis of ACS. Of the 1,775 study patients, 805 (45.4%) underwent immediate dual nuclear scanning. A positive stress nuclear scan result was more sensitive (97.3% versus 71.2%, P <.0001) and specific (87.7% versus 72.6%, P <.0001) for 30-day ACS than a positive resting nuclear scan result. The protocol of selective dual nuclear scanning (ie, patients who did not undergo dual nuclear scanning were counted as having a negative test result) had a sensitivity and specificity for 30-day ACS of 93.4% and 94.7%, respectively (positive likelihood ratio 17.6; negative likelihood ratio 0.07). Conclusion: Stress nuclear scanning is more sensitive and specific than resting nuclear scanning for identification of ACS in low-risk patients with chest pain. A strategy of using selective dual nuclear scanning once high- and intermediate-risk ACS has been ruled out with our 2-hour evaluation both reliably identifies and reliably excludes 30-day ACS. [Fesmire FM, Hughes AD, Stout PK, Wojcik JF, Wharton DR. Selective dual nuclear scanning in low-risk patients with chest pain to reliably identify and exclude acute coronary syndromes. Ann Emerg Med. September 2001;38:207-215.]

Combination of Goldman risk and initial cardiac troponin I for emergency department chest pain patient risk stratification.

Accurate identification of low-risk emergency department (ED) chest pain patients who may be safe for discharge has not been well defined. Goldman criteria have reliably risk-stratified patients but have not identified any subset safe for ED release. Cardiac troponin I (cTnI) values have also been shown to risk-stratify patients but have not identified a subset safe for ED release. To test the hypothesis that ED chest pain patients with a Goldman risk of < or =4% and a single negative cTnI (< or =0.3 ng/mL) at the time of ED presentation would be safe for discharge [<1% risk for death, acute myocardial infarction (AMI), revascularization]. A prospective cohort study was performed in which consecutive ED chest pain patients were enrolled from July 1999 to November 2000. Data collected included patient demographics, medical and cardiac history, electrocardiogram, and creatine kinase-MB and cTnI. Goldman risk stratification score was calculated while patients were still in the ED. Hospital course was followed daily. Telephone follow-up occurred at 30 days. The main outcome was death, AMI, or revascularization (percutaneous transluminal coronary angioplasty/stents/coronary artery bypass grafting) within 30 days. Of 2,322 patients evaluated, 998 had both a Goldman risk < or =4% and a cTnI < or =0.3 ng/mL. During the initial hospitalization, 37 patients met the composite endpoint (3.7%): 6 deaths (0.7%), 17 AMIs (1.7%), 18 revascularizations (1.8%). Between the time of hospital discharge and 30-day follow-up, 15 patients met the composite endpoint: 4 deaths (0.4%), 6 AMIs (0.6%), and 5 revascularizations (0.5%). Overall, 49 patients met the composite endpoint (4.9%; 95% CI = 3.6% to 6.2%): 10 deaths (1.0%; 95% CI = 0.4% to 1.6%); 23 AMIs (2.3%; 95% CI = 1.4% to 3.2%), and 23 revascularizations (2.3%; 95% CI = 1.4% to 3.2%) within 30 days of presentation. The combination of two risk stratification modalities for ED chest pain patients (Goldman risk < or =4% and cTnI < or =0.3 ng/mL) did not identify a subgroup of chest pain patients at <1% risk for death, AMI, or revascularization within 30 days.

Efficacy and durability of autogenous saphenous vein conduits for lower extremity arterial reconstructions in preadolescent children

Objective: Limb length discrepancies (LLDs) in growing children may accompany extremity arterial occlusions. Revascularization with vein grafts has been questioned because of degenerative graft changes observed at other sites. This study was undertaken to define vein graft durability and efficacy in lower extremity revascularizations in preadolescent children. Study Design: Fourteen children (10 boys, 4 girls) with a mean age of 7.3 years (range, 2-11 years) who underwent 16 lower extremity revascularizations with greater saphenous vein grafts were subjected to follow-up with graft ultrasonography, ankle/brachial indices (ABIs) with and without exercise, and limb length determinations. A mean of 5.7 years elapsed between the onset of ischemia and operation. Arterial occlusions resulted from cardiac catheterizations (11), arteritis (1), dialysis cannulation (1), and penetrating trauma (1). Indications for operation included LLD (6), claudication (4), both LLD and claudication (3), markedly diminished ABIs with a potential for LLD (2), and a traumatic transection with hemorrhage (1). The reconstructions with 15 reversed and one in situ vein grafts included iliofemoral (11), femorofemoral (1), aortofemoral (1), femoropopliteal (1), popliteal-popliteal (1), and popliteal-posterior tibial (1) arterial bypass grafts. Results: Among patent grafts available for follow-up, 36% (5 of 14) remained unchanged, 50% (7 of 14) developed nonaneurysmal dilatation, and 14% (2 of 14) exhibited nonprogressive aneurysmal expansion. One graft became occluded, and one graft was lost to follow-up. Collectively, the grafts manifest an 11.2% expansion at an average of 10.7 years postoperatively. ABIs increased from 0.75 preoperatively to 0.97, at an average of 11.0 years postoperatively. LLDs were reduced from 1.66 to 1.24 cm, at an average of 11.4 years postoperatively. Conclusion: Vein graft reconstructions of lower extremity arteries in preadolescent children are durable. They provide an efficacious means of restoring normal blood flow, and in 70% of children their preexisting LLDs were reduced. (J Vasc Surg 2001;34:34-40.)

Saphenous Vein Harvesting for Coronary Artery Bypass Grafting. Retrospective Analysis of Possible Causes of Major Wound Complications in Patients with Peripheral Arterial Disease

to retrospectively evaluate the possible reasons for major wound complications at the saphenous vein harvesting site in patients with peripheral arterial disease (PAD). retrospective study. fifteen consecutive patients admitted to the vascular department for impaired healing at the saphenous vein harvesting site after successful coronary bypass artery grafting (CABG) (Group A) were evaluated for medical, perioperative, laboratory and pathological factors and outcome. Findings were compared with those in 15 matched controls followed in the outpatient clinic after CABG (Group B). absence of pedal pulses in the affected leg was noted in 13 patients in group A and 3 patients in group B. Ankle brachial index ranged from 0.4--0.7 in group A and 1.7--1.1 in group B; corresponding ankle pressures were 40--100 mmHg (mean 60 mmHg) and 80--160 mmHg (mean 110 mmHg). All patients in group A had PAD, whereas none did in group B, and all patients in group A required intervention to save the leg. Wound healing was noted in 11 group A patients; four patients underwent below-knee amputation. saphenous vein harvesting from limbs with severe PAD can lead to significant morbidity, including limb loss. In patients lacking a palpable pedal pulse, we recommend harvesting only the proximal saphenous vein.

9. Adenosine-rest 201Tl-SPECT follow-up of transmyocardial revascularization (TMR) in patients with TMR or TMR/coronary artery bypass graft

9. Adenosine-rest 201Tl-SPECT follow-up of transmyocardial revascularization (TMR) in patients with TMR or TMR/coronary artery bypass graft

Extra-anatomic bypass graft for management of axillary artery occlusion in pitchers

Objective: Our goal was to evaluate the long-term results of vein bypass grafts for axillary artery occlusion, specifically those placed extra-anatomically to prevent arterial injury in pitchers. Methods: With the greater saphenous veins used as the selected conduit, arterial bypass grafts were routed anterior to the pectoralis minor muscle in four baseball pitchers who had occlusion of the axillary artery. We performed a follow-up in excess of 10 years with evaluations of the bypass grafts by ultrasonic duplex scan and magnetic resonance angiography. Results: All four pitchers treated in this manner returned to the game and played for several seasons without a recurrence of the arterial injury. Long-term evaluation of the bypass grafts did not reveal any structural or functional disorder. Conclusions: Axillary artery occlusion in an athlete can be effectively treated with a vein bypass graft placed extra-anatomically, anterior to the pectoralis minor muscle. The greater saphenous vein should be considered the conduit of choice. (J Vasc Surg 2001;33:797-801.)

Prognosis of patients with a recurrent acute myocardial infarction before and in the reperfusion era—A national study

Background Patients with recurrent acute myocardial infarction (AMI) are at increased risk for morbidity and mortality. We compared the outcome of patients with recurrent AMI hospitalized in coronary care units in the prereperfusion and reperfusion eras. Methods The study population comprised 2 large-scale cohorts with recurrent AMI: (1) 1415 (24%) of 5839 consecutive patients with AMI hospitalized in 1981 to 1983 (Secondary Prevention Reinfarction Israeli Nifedipine Trial [SPRINT] Registry) and (2) 1093 (25%) of 4317 patients with AMI from three national surveys performed in 1992 to 1996. Results Patients in the 1990s had significantly lower rates of heart failure and cardiogenic shock. The 7-day mortality declined from 18% in 1981-1983 to 10% in 1992-1996 (adjusted odds ratio [OR] 0.57 [0.44-0.75]), the 30-day mortality rate from 26% to 16% (OR 0.56 [0.44-0.71]), and the 1-year mortality rate from 39% to 26% (adjusted hazard ratio [HR] 0.64 [0.54-0.75]), respectively. In the 1992-1996 cohort, the adjusted risk of 7-day, 30-day, and 1-year mortality for patients with recurrent AMI treated with thrombolysis in comparison to patients without thrombolysis was OR 1.69 (1.07-2.65), 1.51 (1.03-2.23), and HR 1.18 (0.90-1.55), respectively. The mortality rate among patients treated with early percutaneous transluminal coronary angioplasty/coronary artery bypass grafting was 3% versus 12% at 7 days (OR 0.36 [0.16-0.73]), 7% versus 18% at 30 days (OR 0.45 [0.25-0.77]), and 16% versus 29% at 1 year (HR 0.64 [0.46-0.96]), in comparison to patients without revascularization. Conclusion The prognosis of patients with recurrent AMI improved significantly during the reperfusion era. Although thrombolysis may have a limited therapeutic effect among patients with recurrent AMI, an interventional approach seems more appropriate when indicated. A randomized trial of thrombolysis versus early revascularization is needed in patients with recurrent AMI. (Am Heart J 2001;141:478-84.)

Return to work after myocardial infarction/coronary artery bypass grafting: patients’ and physicians’ initial viewpoints and outcome 12 months later

Nonmedical factors play an important role in determining whether patients resume their work after myocardial infarction or CABG. The main questions dealt with in this study are: What is the respective basis of physicians’ and patients’ judgements as far as vocational disabilities are concerned, and what are the decisive factors that facilitate a prediction as to who will return to work and who will not? 132 male patients participating in a cardiac rehabilitation program served as subjects. The age group was limited to patients between 40 and 59 yr of age. The work situation 12 months following rehabilitation is known for 119 subjects; 74 had resumed their occupations. Results of regression analyses show that patients’ and physicians’ views on disabilities and re-employment are based on different factors. The physicians derive their estimates mainly from medical variables (cardiac status and comorbidity), whereas the patients’ views are based on the overall health status, their former job status, job satisfaction, and negative incentives for the return to work. Three variables were found that allow a prediction to be made as to re-employment in 85% of all cases: (1) age, (2) patients’ feelings about the extent to which they are disabled by their cardiac problem, and (3) the physicians’ views on the extent to which the patient is vocationally disabled by his overall medical situation. Medical variables (e.g. cardiac status) had little relevance to re-employment. The results are discussed with regard to the consequences for cardiac rehabilitation.

1.21 Predictive Value of Myocardial SPECT for Long-term Outcome after Coronary Artery Bypass Grafting Artery Bypass Grafting

1.21 Predictive Value of Myocardial SPECT for Long-term Outcome after Coronary Artery Bypass Grafting Artery Bypass Grafting

Follow-up experience with coronary hybrid-revascularisation.

Minimally invasive direct coronary artery bypass (MIDCAB) grafting is an accepted therapeutical option especially in multimorbid, elderly and reoperative patients with single vessel disease. To expand the benefits of M