Difference In Graft Patency Research Articles

Effectiveness of the Vascular Quality Initiative Chronic Limb-Threatening Ischemia Mortality Prediction Model in Patents with Distal Bypass

The purpose of this study is to evaluate the effectiveness of mortality prediction using the Vascular Quality Initiative (VQI) chronic limb-threatening ischemia (CLTI) model in patients with distal bypass. Patients who underwent distal bypass for CLTI from 2009 to 2020 at a single center were retrospectively reviewed. Distal bypass was defined as any bypass with a distal anastomosis to the posterior tibial, anterior tibial, dorsalis pedis, plantar, or peroneal artery. Baseline characteristics, operative details, hospital outcomes, and medium-term outcomes were compared among patients with a low-, medium-, and high-risk of mortality based on a VQI CLTI calculation. The primary endpoints were survival and limb salvage. A total of 287 distal bypasses were performed in 230 patients (153 males; median age, 74years; diabetes mellitus, 70%; end-stage renal disease [ESRD] with hemodialysis, 38%). These patients were stratified into 153 (66%) low-, 35 (15%) medium-, and 42 (18%) high-risk cases based on the VQI CLTI model. There were two hospital deaths (1%) within 30days. During a mean follow-up period of 33±29months, 105 patients died and 26 limbs (9%) required major amputation. The 2-year survival rate of 81% in the low-risk group was significantly higher than those of 41% in the medium-risk group and 46% in the high-risk group (both P<0.001). The 2-year survival rates did not differ significantly between the medium- and high-risk groups (P=0.81). The 2-year limb salvage rate of 93% in the low-risk group was significantly higher than those of 81% in the medium-risk (P=0.023) and those of 87% in the high-risk (P=0.039) groups. There were no significant differences in graft patency and wound healing among the three groups. These results suggest that distal bypass is optimal treatment for patients with a low VQI-predicted risk of mortality. However, the lower limb salvage and higher mortality rates at 2years suggest that the decision-making for VQI medium- and high-risk patients may be carefully considered.

Zoledronate alters natural progression of tissue-engineered vascular grafts.

Macrophages are a critical driver of neovessel formation in tissue-engineered vascular grafts (TEVGs), but also contribute to graft stenosis, a leading clinical trial complication. Macrophage depletion via liposomal delivery of clodronate, a first-generation bisphosphonate, mitigates stenosis, but simultaneously leads to a complete lack of tissue development in TEVGs. This result and the associated difficulty of utilizing liposomal delivery means that clodronate may not be an ideal means of preventing graft stenosis. Newer generation bisphosphonates, such as zoledronate, may have differential effects on graft development with more facile drug delivery. We sought to examine the effect of zoledronate on TEVG neotissue formation and its potential application for mitigating TEVG stenosis. Thus, mice implanted with TEVGs received zoledronate or no treatment and were monitored by serial ultrasound for graft dilation and stenosis. After two weeks, TEVGs were explanted for histological examination. The overall graft area and remaining graft material (polyglycolic-acid) were higher in the zoledronate treatment group. These effects were associated with a corresponding decrease in macrophage infiltration. In addition, zoledronate affected the deposition of collagen in TEVGs, specifically, total and mature collagen. These differences may be, in part, explained by a depletion of leukocytes within the bone marrow that subsequently led to a decrease in the number of tissue-infiltrating macrophages. TEVGs from zoledronate-treated mice demonstrated a significantly greater degree of smooth muscle cell presence. There was no statistical difference in graft patency between treatment and control groups. While zoledronate led to a decrease in the number of macrophages in the TEVGs, the severity of stenosis appears to have increased significantly. Zoledronate treatment demonstrates that the process of smooth muscle cell-mediated neointimal hyperplasia may occur separately from a macrophage-mediated mechanism.

Medical adjuvant treatment to increase patency of arteriovenous fistulae and grafts.

People with end-stage renal disease (ESRD) often require either the formation ofan arteriovenousfistula (AVF) or an interposition prostheticarteriovenousgraft (AVG) for haemodialysis. These access sites should ideally have a long life and a low rate of complications (e.g. thrombosis, infection, stenosis, aneurysm formation and distal limb ischaemia). Although some of the complications may be unavoidable, any adjuvant technique or medical treatment aimed at decreasing complications would be welcome. This is the fourth update of the review first published in 2003. To assess the effects of adjuvant drug treatment in people with ESRD on haemodialysis via autologous AVFs or prosthetic interposition AVGs. The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases and ClinicalTrials.gov trials register to 6 August 2020. Randomised controlled trials of active drug versus placebo in people with ESRD undergoing haemodialysis via an AVF or prosthetic interposition AVG. For this update, two review authors (IM, MFAK) independently selected trials for inclusion, extracted data, assessed risk of bias and assessed the certainty of the evidence according to GRADE. We resolved disagreements by discussion or consultation with another review author (ADS). The primary outcome was the long-term fistula or graft patency rate. Secondary outcomes included duration of hospital stay; complications such as infection, aneurysm formation, stenosis and distal limb ischaemia; and number of related surgical or radiological interventions. For this update, one additional study was suitable for inclusion, making a total of 13trials with 2080 participants. Overall the certainty of the evidence was low or moderate due to short follow-up periods, heterogeneity between trials, small sample sizes, and risk of bias due to incomplete reporting. Medical adjuvant treatments used in the included trials were aspirin, ticlopidine, dipyridamole, dipyridamole plus aspirin, warfarin, fish oil, clopidogrel, sulphinpyrazone and glyceryl trinitrate (GTN) patch. All included studies reported on graft patency by measuring graft thrombosis. There was insufficient evidence to determine if there was a difference in graft patency in studies comparing aspirin versus placebo (odds ratio (OR) 0.40, 95% confidence interval (CI) 0.07 to 2.25; 3 studies, 175 participants; low-certainty evidence). The meta-analysis for graft patency comparing ticlopidine versus placebo favoured ticlopidine (OR 0.45, 95% CI 0.25 to 0.82; 3 studies, 339 participants; moderate-certainty evidence). There was insufficient evidence to determine if there was a difference in graft patency in studies comparing fish oil versus placebo (OR 0.24, 95% CI 0.03 to 1.95; 2 studies, 220 participants; low-certainty evidence); and studies comparing clopidogrel and placebo (OR 0.40, 95% CI 0.13 to 1.19; 2 studies, 959 participants; moderate-certainty evidence). Similarly, there was insufficient evidence to determine if there was a difference in graft patency comparing the effect of dipyridamole versus placebo (OR 0.46, 95% CI 0.11 to 1.94; 1 study, 42 participants, moderate-certainty evidence) and dipyridamole plus aspirin versus placebo (OR 0.64, CI 0.16 to 2.56; 1 study, 41 participants; moderate-certainty evidence); comparing low-intensity warfarin with placebo (OR 1.76, 95% CI 0.78 to 3.99; 1 study, 107 participants; low-certainty evidence); comparing sulphinpyrazone versus placebo (OR 0.43, 95% CI 0.03 to 5.98; 1 study, 16 participants; low-certainty evidence) and comparing GTN patch and placebo (OR 1.26, 95% CI 0.63 to 2.54; 1 study, 167 participants; moderate-certainty evidence). The single trial evaluating warfarin was terminated early because of major bleeding events in the warfarin group. Only two studies published data on the secondary outcome of related interventions (surgical or radiological); there was insufficient evidence to determine if there was a difference in related interventions between placebo and treatment groups. None of the included studies reported on the duration of hospital stay. Most studies reported complications ranging from mortality to nausea. However, data on complications were limited and reporting varied between studies. The meta-analyses of three studies for ticlopidine (an antiplatelet treatment), which all used the same dose of treatment but with a short follow-up of only one month, suggest ticlopidine may have a beneficial effect as an adjuvant treatment to increase the patency of AVFs and AVGs in the short term. There was insufficient evidence to determine if there was a difference in graft patency between placebo and other treatments such as aspirin, fish oil, clopidogrel, dipyridamole, dipyridamole plus aspirin, warfarin,sulphinpyrazone and GTN patch. The certainty of the evidence was low to moderate due to short follow-up periods, the small number of studies for each comparison, small sample sizes, heterogeneity between trials and risk of bias due to incomplete reporting. Therefore, it appears reasonable to suggest further prospective studies be undertaken to assess the use of these antiplatelet drugs in renal patients with an AVF or AVG.

Rapid increase in hybrid surgery for the treatment of peripheral artery disease in the Vascular Quality Initiative database

ObjectiveAdvances in technology have increased the use of endovascular therapy for lower extremity revascularization (LER), but the impact on hybrid surgery has not been studied. This study aims to (1) investigate the contemporary national trends in frequency of hybrid LER and (2) compare the outcomes of open bypass (BYP) and hybrid surgery for isolated femoropopliteal revascularization. MethodsUsing the national Vascular Quality Initiative database from 2010 to 2017, all patients receiving bypass or hybrid LER for PAD were identified. A trend of all hybrid LER compared with open LER was obtained. Next, only patients who underwent hybrid or open isolated femoropopliteal LER were identified. Patients treated with hybrid surgery underwent femoral endarterectomy and antegrade endovascular intervention of the femoropopliteal vessels (HYB), whereas patients treated with BYP underwent femoral endarterectomy and femoropopliteal bypass. These two groups of patients were matched based on age, gender, race, indication, ambulatory status, emergency status, diabetes, hypertension, coronary artery disease, chronic obstructive pulmonary disease, and hemodialysis. Patient characteristics and the perioperative and 1-year outcomes of the two groups were compared. ResultsThe overall rate of hybrid LER procedures increased from 6.1% in 2010 to 32% in 2017 (P = .03). Hybrid LER was significantly more commonly used in patients with claudication (47%) and BYP surgery was used in patients with tissue loss (38.5%; P = .019). There were 456 HYB and 2665 BYP for isolated femoropopliteal revascularization. After propensity matching, the cohort comprised 425 patients in each group. HYB was associated with lower rate of myocardial infarction (1.9% vs 5.7%; P = .005) and renal complications (2.1% vs 6.7%; P = .003), length of stay (4.7 vs 6.1 days; P = .001), and higher rate of discharge to home (90.8% vs 81.4%; P < .001) compared with BYP. There was no significant difference in 30-day mortality (HYB 1.5% vs BYP, 2.5%; P = .44). The 1-year outcomes comparison suggested that patients in the BYP group had a higher likelihood of improvement in ambulatory status compared with patients in HYB group (16.7% vs 7.7%; P = .044). However, Kaplan-Meier analysis showed no difference in overall survival (P = .13) or amputation-free survival (P = .057) between the two groups. There was no statistical difference in graft patency, limb loss, or secondary interventions. ConclusionsHybrid LER for PAD has been increasingly used and accounts for up to one-third of open LER in the Vascular Quality Initiative. Hybrid femoropopliteal revascularization improves perioperative outcomes compared with femoropopliteal bypass. However, the 1-year outcomes between the two procedures are comparable, suggesting that hybrid femoropopliteal revascularization should be favored in high-risk patients because of its perioperative advantages.

The Influence of Preoperative Anemia on Clinical Outcomes After Infrainguinal Bypass Surgery

Anaemia is associated with a greater mortality and complications in cardiovascular surgery. Within chronic limb-threatening ischaemia (CLTI) the effect of anaemia is becoming apparent. This study aimed to further understand the influence of anaemia in patients undergoing surgical revascularisation for lower-limb ischaemia. A retrospective review of all patients undergoing infra-inguinal surgical revascularisation between 2016 and 2018 at a tertiary centre was performed. Anaemia was defined as a haemoglobin (Hb) of less than 120g/L. Primary outcome was overall survival by Kaplan-Meier analysis. Secondary outcomes included, length of hospital stay, blood-transfusion requirements, wound infection, myocardial infarction, limb-loss and all-cause mortality. Cox-proportional hazard analysis and receiver operator characteristics (ROC) were performed. 124 patients were followed up for a mean of 23(8) months. 45 patients were anaemic. There were comparable baseline demographics, comorbidity and severity of symptoms. Overall survival was significantly worse (Log rank p<0.01) in the anaemic group as was the duration of stay; 27(23) days vs. 14(16) days (P=0.001). Anaemic patients received more blood transfusions; 19 (42%) compared to 13 (16.5%) (p=0.001) and had more cardiac complications (11.1% vs 3.8%) (P=0.02). Surgical Site infection rates were also higher (20% vs. 6.3% P=0.036). There was no difference in graft patency or subsequent ipsilateral major lower extremity amputation. 30-day mortality was comparable between the anaemic versus the non-anaemic; 3 (6.7%) vs. 1 (1.3%) (P=0.132). At 1-year there was a greater mortality in the anaemic group of 8 (18%) vs. 4 (5%) in the non-anaemic group (P=0.037) which persisted into the long-term. Anaemia was independently associated with mortality; Hazard Ratio 4.0 (1.14-12.1). A 'cut-off' Hb of 112g/L was identified by ROC analysis. Pre-operative anaemia in infra-inguinal bypass surgery has a significant association with mortality and morbidity. Pre-operative anaemia should prompt the vascular team to consider these patients as higher risk and consider optimisation of haemoglobin.

LEA3. Open Distal Revascularization in Chronic Kidney Disease: Is It Worthwhile?

The incidence of chronic kidney disease (CKD) has reached pandemic proportions across the world. Occlusive arterial disease causing critical limb ischemia and sepsis in the CKD patient is a huge clinical challenge often culminating in major amputation or mortality. Successful revascularization of these patients is challenging with added limitations due to impaired renal function, difficulties in contrast-enhanced imaging, heavily calcified arteries, and overall comorbid status. All patients with Fontaine stage IV critical limb ischemia with tibial occlusive disease for whom angioplasty was either contraindicated or unsuccessful were considered. All those with overwhelming sepsis that warranted primary amputation were excluded. A prospective single-center case-control study was done to evaluate the outcome of surgical revascularization in those with CKD (group 1, estimated glomerular filtration rate [eGFR] of 15-90 mL/min/1.73 m2), those with end-stage renal failure (ESRF; group 2, eGFR <15 mL/min/1.73 m2), and those with preserved renal function (group 3, eGFR >90 mL/min/1.73 m2). The mean ages of the three groups were 54, 58, and 51 years, respectively. The study period was December 2014 to December 2017; the 6-month patient survival, graft patency, limb salvage rates were compared. All had autogenous vein grafts with standardized surgical technique. There were 149 consecutive surgical revascularizations performed (group 1, 62; group 2, 28; group 3, 59). There was one perioperative death (group 1) on day 2. The respective rates of 6-month patient survival were 92%, 89%, and 93% (P > .05). The corresponding graft patency rates of group 1 and group 3 were 89% and 96% (P > .05), whereas limb salvage rates were 91% and 96% (P > .05). However, group 2 showed a significant decline in both graft patency (76%) and limb salvage (71%). Four patients (two in group 1, two in group 2) had below-knee amputations with a functioning graft because of advancing sepsis. There was no significant difference in graft patency or limb salvage in comparing those who had previously failed endovascular intervention with those who had primary surgical revascularization. The presence of advanced CKD including ESRF should not be considered a limiting factor in limb revascularization. Whereas meticulous planning and care are needed to safeguard and to preserve remaining renal functions as well as to optimize outcomes in those with ESRF, the resulting limb salvage results have been excellent.

Endoscopic versus open radial artery harvesting: A meta-analysis of randomized controlled and propensity matched studies.

We sought to investigate the impact of radial artery harvesting techniques on clinical outcomes using a meta-analytic approach limited to randomized controlled trials and propensity-matched studies for clinical outcomes, in which graft patency was analyzed. A systematic literature review was conducted using PubMed and MEDLINE to identify publications containing comparisons between endoscopic radial artery harvesting (ERAH) and open harvesting (ORAH). Only randomized controlled trials and propensity-matched series were included. Data were extracted and analyzed with RevMan. The primary endpoint was wound complication rate, while secondary endpoints were patency rate, early mortality, and long-term cardiac mortality. Six studies comprising 743 patients were included in the meta-analysis. Of them 324 (43.6%) underwent ERAH and 419 (56.4%) ORAH. ERAH was associated with a lower incidence of wound complications (odds ratio: 0.33, confidence interval 0.14-0.77; p = 0.01). There were no differences in graft patency, and early and long-term cardiac mortality between the two techniques. ERAH reduces wound complications and does not affect graft patency, or short- and long-term mortality compared to ORAH.

Efficacy of Revascularization for Critical Limb Ischemia in Patients with End-stage Renal Disease

To evaluate the outcomes of surgical revascularization for critical limb ischemia in patients with end-stage renal disease (ESRD). From 2004 to 2010, 184 patients with 213 critically ischaemic limbs caused by arteriosclerosis were admitted to The University of Tokyo Hospital. The outcomes of primarily surgical revascularization-based treatments were retrospectively compared in patients with ESRD (ESRD group: 79 patients, 101 limbs) and without ESRD (non-ESRD group: 105 patients, 112 limbs) during the same period. Arterial reconstruction was performed on 56 limbs in 46 patients in the ESRD group and 78 limbs in 73 patients in the non-ESRD group (55% vs. 70%; p = .03). Major amputation was performed in 6 of 48 limbs with patent grafts in the ESRD group because of uncontrolled infection or progression of necrosis. The limb salvage rate after arterial reconstruction was significantly lower in the ESRD group than in the non-ESRD group (p = .0019). The postoperative survival rate was lower in the ESRD group than in the non-ESRD group, although this difference was not significant (p = .052). Associated cardiovascular disease and systemic infection were the most frequent causes of death in the ESRD group. There was no significant difference in graft patency between the two groups after distal bypass surgery; however, the limb salvage rate was significantly lower in the ESRD group than in the non-ESRD group (p = .03). Critical limb ischemia associated with ESRD has a poor prognosis. Infection control is particularly important for achievement of good treatment outcomes.

Endoscopic Radial Artery Harvesting Does not Compromise Graft Patency for Coronary Artery Bypass Graft: A Meta Analysis of 2782 Patients

Endoscopic radial artery harvesting is a favourable harvesting technique which provides excellent cosmetic result and low incidence of incision related complications, however the impact of this technique on graft quality is less well-explained. We sought to evaluate the impact of harvesting technique on graft patency and relevant clinical outcomes in patients undergoing coronary artery bypass graft (CABG). A systematic literature search was conducted to identify publications containing comparisons between different sampling skills in CABG, data was extracted and analysed with Revman, Downs and Black score was applied to evaluate the methodological quality of included studies. Ten studies containing 2782 patients were undertaken, the quality was generally acceptable. Pooled analysis results indicate endoscopic radial artery harvesting was associated with a lower incidence of wound infection and a similar incidence of haematoma formation compared with open harvesting. The difference in graft patency and all-cause mortality was insignificant between two cohorts. Endoscopic radial artery harvesting is a safe technique and provides equivalent graft patency as compared with open harvesting, further investigation is required to confirm the aforementioned conclusion and evaluate the impact of harvesting technique on hand sensory and motor function.

The effect of graft configuration on 30-day failure of infrapopliteal bypasses

Despite advances in endovascular techniques, infrapopliteal bypasses are still required for limb salvage. Short-term graft patency is an important outcome parameter reflecting technical considerations and acute graft thrombosis. Both are important prerequisites for long-term patency. In this analysis, we compared the 30-day patency of all conduit configurations for infrapopliteal bypasses. All primary infrapopliteal bypasses from the American College of Surgeons-National Surgical Quality Improvement Program database between 2005 and 2010 were divided into six groups: (1) great saphenous vein (GSV); (2) prosthetic conduit (prosthetic); (3) prosthetic conduit with a distal anastomotic venous adjunct (ADJ), such as a cuff or patch (prosthetic + ADJ); (4) composite graft of prosthetic and a vein segment (composite); (5) spliced autogenous vein (spliced vein); and (6) arm vein. Thirty-day graft failure, patient demographics, and operative details were compared among groups. A multivariate model was used for statistical analysis. A total of 5375 infrapopliteal bypasses were analyzed by conduit: GSV, 3983 (75%); prosthetic, 898 (17%); spliced vein, 160 (3%); prosthetic + ADJ, 112 (2%); arm vein, 93 (2%); and composite, 91 (2%). The difference among groups in demographics and comorbidities was not statistically significant. Perioperative mortality rates were similar among different conduits. After adjusting for sex, age, weight, race, and previous cardiac surgery, the bypass conduit had a significant independent association with 30-day graft patency (P = .006). The GSV failure rate was 7.5%. Composite had a significantly higher 30-day failure rate (15.4%, P = .006). There was no significant difference in 30-day failure rate of spliced vein (5.6%, P = .37) or arm vein (4.3%, P = .24) conduits compared with GSV. Prosthetic had significantly higher 30-day failure rate than GSV (10.5%, P = .004). The addition of adjuvant venous tissue at the distal anastomosis of prosthetic bypasses did not significantly improve their 30-day patency (failure rate of 9.8% for prosthetic + ADJ and 10.5% for prosthetic). There was no significant difference in graft patency between alternative venous conduits (arm vein/spliced vein) and prosthetic + ADJ. Venous conduits (GSV, spliced vein, arm vein) deliver the best 30-day patency for infrapopliteal bypasses, and GSV remains the most commonly used graft. Prosthetic grafts had a higher 30-day failure rate. Composite grafts should be abandoned because their early patency is not better than pure prosthetic conduits. The addition of a distal venous adjunct did not seem to improve acute prosthetic graft patency, which may reflect lack of effect on thrombogenicity rather than the myointimal hyperplastic response that effects long-term failure of infrapopliteal bypass.

RR2. The Influence of Gender on Functional Outcomes of Lower Extremity Bypass

The purpose of this study was to evaluate the impact of gender on late functional outcomes of lower extremity bypass (LEB). We reviewed 3,301 patients (1,060; 32% females) undergoing LEB in the Vascular Surgery Group of New England from January 2003 to June 2010 to assess procedural outcomes, independent living, and ambulatory status according to preoperative baseline. Logistic regression models adjusted for differences between genders and potential confounders (age, race, smoking, indication, preoperative ambulation, statin use, conduit, and length of follow up). Ambulation and living status were analyzed by life table analysis. On univariate analysis woman had less CAD (35% vs. 40 %, P <.001), smoking (75% vs. 89%, P = .002), and autogenous conduits (63% vs. 71%, P <.001). Women had higher rates of reoperation for thrombosis (4% vs. 2%; OR 2.09, P <.001) or infection (2% vs. 1%; OR 2.36, P = .02) without differences in graft patency (94% vs. 95%; P = .25) or mortality (2.1% vs. 2.1%; P = .84) at discharge. Multivariate analysis showed fewer women were discharged home (63% vs. 73%; OR 0.72, P <.001) and ambulating at discharge (90% vs. 93%; OR 0.65, P = .009) regardless of preoperative ambulation. At long-term follow-up fewer women lived independently (HR 1.46, P = .06) and significantly fewer were ambulatory (HR 1.65, P = .004) (Fig). Women have similar procedural-related complications but slightly inferior early and late functional outcomes after LEB. These findings may help define physician and patient expectations in women before revascularization.

39 A randomised controlled trial comparing conventional coronary artery bypass graft surgery with a composite arterial graft technique

Background Composite (Y/T) coronary artery bypass graft surgery (CABG) confers full arterial revascularisation, and “hands off” aorta compared to conventional bypass graft surgery. However, the composite surgical configuration could lead to preferential blood flow down one arm than the other (left internal mammary artery LIMA or radial artery RA) with its potential impact on graft patency. Aim To investigate the impact of bypass graft configuration on short-term grafts patency and cardiac related quality of life. Methods and Results This is a single centre randomised, controlled trial Between March 2006 and July 2007, 322 patients undergoing isolated bypass graft surgery at our institution were screened and 89 (27%) met the inclusion criteria and were randomised. Patients were allocated to conventional (conv n=46) or composite (comp n=43). The two primary end points were graft patency defined as (Thrombolysis In Myocardial Infarction) TIMI III flow in distal anastomosis at angiography 12–24 months after surgery, and cardiac-related health status assesses by Seattle angina questionnaire (SAQ). Baseline characteristics were similar between the two groups apart from diabetes where there were more diabetic patients in the composite arm than the conventional one (15(35%) vs 5(11%) p Conclusions In our randomised trial, composite bypass graft surgery was associated with higher graft failure rate at 12–24 months after surgery compared to conventional type. This difference may be due to the composite conduit configuration. Further blood flow characteristics study in this configuration can help understand such an important finding and its implication on our clinical practice. Despite the difference in graft patency there were no differences in physical limitation, angina stability, angina frequency, or quality of life between the two groups.

Graft patency after off-pump versus on-pump coronary artery surgery in high-risk patients

Objective. To compare angiographic graft patency in high-risk patients randomly allocated to off-pump vs. on-pump coronary artery bypass grafting (CABG). Design. From a randomised, single-centre clinical trial including patients undergoing isolated first-time coronary bypass surgery a subgroup of patients were scheduled to 1-year coronary angiographic follow-up. Patients had 3-vessel disease and a EuroSCORE ≥5. We evaluated graft patency using a patency index (percentage of patent grafts out of the total number of grafts in each patient). Results. One-year angiography was performed in 34 patients undergoing off-pump surgery and 35 patients undergoing on-pump surgery. The mean number of distal anastomoses was 3.38±0.65 in the off-pump group versus 3.46±0.61 in the on-pump group (NS). The number of patients without graft failure was 22 in the off-pump group and 24 in the on-pump group (NS). The overall patency index was 85% in the off-pump group versus 87% in the on-pump group with a mean difference of –2.1%, 95% confidence interval –12.9 to 8.7 (NS). Conclusions. In patients with 3-vessel disease and a high-risk profile we found no statistically significant difference in graft patency between off-pump and on-pump CABG at 1-year coronary angiographic follow-up.Trial registration: ClinicalTrials.gov identifier: NCT00120991.

Clopidogrel and Aspirin Versus Clopidogrel Alone on Graft Patency After Coronary Artery Bypass Grafting

Clopidogrel and aspirin are the most popular antiplatelet agents for anticoagulation management after coronary artery bypass grafting (CABG) in clinical practice, but there is neither a standard antiplatelet therapy for patients undergoing CABG, nor an exact conclusion about its effects on graft patency until now. One-hundred and ninety-seven selected patients undergoing CABG were assigned to two groups according to antiplatelet drug: the clopidogrel group of 102 patients who received clopidogrel (75 mg) daily; and the combination group of 95 patients who received clopidogrel (75 mg) plus aspirin (100 mg) daily. Multislice computed tomography angiography was performed to evaluate graft patency at 1 month and 12 months after CABG. There were no significant differences between the two groups in preoperational data. At 1 month and 12 months after CABG graft patency rates of clopidogrel group were, respectively, 99.0% and 96.9% for the left internal mammary artery (LIMA) and 98.1% and 93.5% for the saphenous vein grafts; those of the combination group were, respectively, 98.9% and 97.8% for LIMA, and 98.2% and 96.3% for saphenous vein grafts. There were no significant differences in graft patency between the two groups (p > 0.05). Either clopidogrel plus aspirin or clopidogrel alone maintain high graft patency in the early postoperative phase after CABG. The observed trend toward higher patency rates in patients treated with clopidogrel plus aspirin compared to those in the clopidogrel group did not reach statistical significance.

Rationale, design and methodology for a Prospective Randomized Study of graft patency in Off-pump and On-pump MultI-Vessel coronary artery bypasS Surgery (PROMISS) using multidetector computed tomography

BackgroundOff-pump coronary artery bypass grafting has been accused of possibly compromising graft patency. Sixteen slice computed tomography has shown good diagnostic accuracy in the assessment of coronary bypass graft patency when compared with conventional coronary artery angiography and is less invasive. The study hypothesis is that coronary artery bypass grafting (CABG) performed without cardiopulmonary bypass (Off-Pump) has equivalent early graft patency as if performed with cardiopulmonary bypass (On-Pump) and may have reduced complication rate.Methods/DesignThe Prospective Randomized Comparison of Off-Pump and On-Pump MultI-vessel Coronary Artery BypasS Surgery (PROMISS) is a controlled, single blinded, single centre clinical trial, comparing early graft patency using 16-slice computed tomography in patients with multi-vessel coronary artery disease operated either without or with extracorporeal circulation. Inclusion criteria are multivessel disease with an indication for first time, isolated, non emergent coronary artery bypass grafting with a minimum of three distal anastomoses. Secondary end points are peri-operative mortality, combined morbidity, length of stay, neuro-cognitive testing at 6 weeks and adverse events, stress test and quality of life at 6 months and one year. The sample size of one hundred and fifty patients was calculated in order to enable the detection of a 5% difference in graft patency, with 80% power, considering a minimum of 3 distal anastomoses per patient. Enrolment started in April 2005 and ended July 2007 with study closure in July 2008.ConclusionThe PROMISS trial aims to shed new light on the effect of Off-Pump as compared to On-Pump coronary artery bypass surgery on graft patency, assessed by multidetector computed tomography, in unselected patients with multivessel coronary artery disease.Trial RegistrationCurrent Controlled Trials ISRCTN58800729

The Value of Vein Graft Surveillance in Bypasses Performed with Small-Diameter Vein Grafts

We assessed the impact of preoperative diameter of the venous conduit on reintervention rate and outcome following infrainguinal vein graft bypass. Consecutive infrainguinal vein bypasses between January 2001 and December 2006 were reviewed. All patients underwent preoperative measurement of vein graft diameter (VGD). Grafts were classified into those with VGD <3.5 mm and those with VGD > or =3.5 mm. All patients were enrolled in a duplex surveillance program. The association between VGD and reintervention rate was assessed. Graft patency and amputation rates were compared. There were 377 bypasses followed up for a median of 23 months (range 8-67). VGD was <3.5 mm in 139 grafts (36.9%) and > or =3.5 mm in 238 grafts (63.1%). A higher proportion of smaller vein grafts (32.3%) required reintervention to maintain graft patency compared with larger conduits (20.2%) (chi(2) = 7.7, p < 0.001). VGD (odds ratio [OR] = 2.87, 95% confidence interval [CI] 1.63-3.81; p < 0.001), smoking (OR = 1.83, 95% CI 1.39-3.20; p = 0.02), and type of bypass (OR = 1.86, 95% CI 1.49-2.47; p = 0.02) were variables associated with higher reintervention rate. There was no difference in graft patency (p = 0.13) or amputation rates (p = 0.35) between the two groups. Use of smaller vein grafts was associated with a higher reintervention rate. Provided that these grafts are surveyed and where necessary repaired, the use of smaller vein grafts is successful and expands the availability of autogenous conduit for infrainguinal arterial reconstruction.

Significance of the Early Postoperative Duplex Result in Infrainguinal Vein Bypass Surveillance

Duplex surveillance of infrainguinal vein grafts may not be efficient. Consecutive patients who had received infrainguinal vein grafts were enrolled in a duplex surveillance program. A first scan at 6 weeks after surgery categorized grafts into four groups: (a) low risk grafts, (b) mild flow disturbance, (c) intermediate stenosis and (d) critical stenosis. Disease progression was assessed over time. Of 364 grafts followed-up for a median of 23 months, 236 (65%) had no flow abnormality at 6-weeks, and had a 40-month cumulative patency rate of 82%. The remaining 128 (35%) grafts had a flow disturbance. Of 29 critical stenoses, 15 were repaired, 11 occluded and three did not change. Of 57 intermediate lesions, 32 progressed to critical, nine occluded, two were repaired and 14 did not change or improved. Of 42 mild lesions, 16 progressed to a higher grade, four occluded and 22 did not change or improved. There was no significant difference in graft patency between grafts with repaired stenoses and those without stenoses, but grafts with untreated critical stenoses were associated with lower patency (p<0.001). A duplex scan 6 weeks after operation can predict those patients who require continuing duplex surveillance.

Off-pump coronary artery bypass sacrifices graft patency: Meta-analysis of randomized trials

Off-pump coronary artery bypass sacrifices graft patency: Meta-analysis of randomized trials

Pro: Aprotinin Has a Good Efficacy and Safety Profile Relative to Other Alternatives for Prevention of Bleeding in Cardiac Surgery

Pro: Aprotinin Has a Good Efficacy and Safety Profile Relative to Other Alternatives for Prevention of Bleeding in Cardiac Surgery

Meta-Analysis of Randomized Trials Comparing Off-Pump With On-Pump Coronary Artery Bypass Graft Patency

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.