Multiple Arterial Grafts Research Articles

Multiple arterial grafts and survival.

Limitations in the long-term patency of saphenous veins for bypass grafts have encouraged interest in the use of arterial conduits. The positive effect of an internal thoracic artery graft on survival has been accepted for more than a decade, but it has proven difficult to show additional benefit from additional arterial conduits; this is probably due to multiple factors, including inappropriate choice of target vessels, short follow-up, and inadequate numbers of patients. Recently, however, the positive effect of a second arterial graft was confirmed. It will probably be difficult to show a survival benefit from a third or fourth arterial graft, but we believe that complete arterial revascularization will result in improved long-term freedom from reintervention. Interest in arterial conduits for coronary artery bypass was primarily limited to the left internal thoracic artery until the mid-1980s, when enthusiasm for the use of bilateral internal thoracic arteries grew. More recently, the gastroepiploic artery, the inferior epigastric artery, and especially the radial artery have all found advocates. However, the original conduit--and the standard against which all others are compared--is the greater saphenous vein.

Off or on bypass: what is the safety threshold?

Background. To identify the technical profile of the patients operated on without cardiopulmonary bypass (CPB) and the benefit of the procedure. Methods. From May 21, 1997, to December 31, 1998, 785 patients had coronary artery bypass grafting through a median sternotomy (group A: 472 without CPB; group B: 290 with CPB; group C: 23 converted). Technical aspects, mortality rate, cerebrovascular accident (CVA) incidence (crude and risk-adjusted), and incidence of major complications were recorded. Results. Patients without CPB had mainly one to three grafts and one- or two-vessel disease. Multiple arterial grafting was not a limit, whereas sequential grafting was. Group A had lower complications rates, shorter intensive care unit and postoperative in hospital stays, and lower transfusion rates. Mortality rates and CVA incidence (crude and risk-adjusted) were similar in both groups and in each subgroup considered. In group A, a lower complications rate was present in some patients (aged greater than 70 years, female, with unstable angina). Group C showed higher mortality and complications rates. Failure of revascularization showed no difference between groups. Conclusions. Primary endpoints are not affected by the surgical strategy, whereas some of the secondary endpoints are. However, patients in group A experienced fewer complications. Both techniques can give satisfying results and must be applied according to the surgeon’s preference.

Arterial revascularization. 18-year experience with coronary artery bypass grafting in familial hypercholesterolemia.

Familial hypercholesterolemia is characterized by a high plasma level of cholesterol and is frequently associated with rapidly progressing coronary heart disease. The internal thoracic artery is recognized as the conduit of choice for coronary artery bypass grafting. This study was performed to determine whether multiple arterial grafting was associated or not with additional benefits for patients with familial hypercholesterolemia. Between June 1980 and March 1998, 95 patients with familial hypercholesterolemia. underwent a total of 103 coronary artery bypass procedures with one hospital death. The patients were divided into 3 groups according to the type of bypass graft. Group 1 included 31 patients with only saphenous vein grafts; Group 2,48 patients with one arterial graft and supplemental vein grafts; and Group 3, 24 patients with multiple arterial grafts. The overall actuarial survival rate was 90.9% at 10 years and 81.8% at 18 years. The overall actuarial freedom from recurrent angina was 68.9% at 10 years and 55.8% at 16 years. The actuarial survival rate in group 2 was higher than that in Group 1 (p < 0.05). There was no difference in the actuarial survival or in the freedom from cardiac events between Group 2 and Group 3. Single arterial grafting improved the long-term survival in patients with familial hypercholesterolemia. However, no additional benefit from multiple arterial grafting was identified.

First cardiological or cardiosurgical reintervention for ischemic heart disease after primary coronary artery bypass grafting.

To study the first reintervention for ischemic heart disease anytime after coronary artery bypass grafting (CABG) and the variables that drive its need or bias its occurrence. Reintervention is defined as an isolated or combined repeat surgical or cardiological procedure for ischemic heart disease. A consecutive series of 9600 CABG patients (1971-1992) were followed for up to 20 years (99.9% complete). A multivariable time-related analysis was performed. The 1-, 10- and 15-year freedom from reintervention was 99, 89 and 72% respectively. A three-phase hazard function was identified. Patient variables influencing early freedom included anginal instability, completeness of revascularization and institutional variables. Late freedom was influenced importantly by demographic variables, cardiac and non-cardiac comorbidity and extensive arterial grafting. The 1-month and 10-year survival after reintervention was 95 and 73%. The 1- and 10-year freedom from angina after reintervention was 74 and 32%. Reinterventions for ischemic heart disease by interventional cardiology or surgery are rather infrequent in the first decade after CABG but nearly half the patients surviving their second decade undergo one. The increased reintervention rate, apparent after 1985 did not go parallel with improved late post-CABG survival. Older age and the presence of multiple arterial grafts seem to reduce but also to bias the event. The very good survival, only when return of angina is present, suggests a more restrictive differential therapy approach, certainly in the presence of a well functioning arterial graft to the antero-septal region and where the co-morbidity might induce a high reinterventional survival cost.

F2.5 Multiple arterial coronary artery grafting without cardiopulmonary bypass

F2.5 Multiple arterial coronary artery grafting without cardiopulmonary bypass

Asymptomatic carotid stenosis in patients undergoing major cardiac surgery: can percutaneous carotid angioplasty be an alternative?

As the mortality associated with coronary artery bypass grafts has fallen, morbidity has become an increasing problem. The improvement of transluminal carotid angioplasty is enlarged to patients with asymptomatic severe carotid stenosis (> 85%) requiring coronary surgery. Between January 1993 and January 1995, 10 patients underwent percutaneous carotid angioplasty prior to cardiac surgery (17.4 days). Mean age was 71 +/- 4.3 years. Four patients showed a contralateral occlusion of the internal carotid artery. Transluminal carotid angioplasty was carried out with a triple coaxial catheter system. Six angioplasties required a Strecker stent. Mean follow-up was 11.4 months. No mortality was observed. Only one patient showed a transient hemianopsia. All patients underwent angiography at four months. Two patients required a new procedure of carotid angioplasty completed with a Strecker stent in one case and by dilatation of a stent in another patient. The results of transluminal carotid angioplasty, in this short series, are encouraging in this group of high-risk morbidity and mortality (elderly patients, bilateral carotid lesions, multiple coronary arterial grafts).

The Current Status of Myocardial Revascularization: Changing Trends and Risk Factor Analysis

From November 1989 to December 1994, we performed 2264 bypass procedures. Data were collected prospectively. The population was divided into three subgroups: group 1 = single internal mammary artery (IMA) +/- veins (n = 1584); group 2 = veins only (n = 503); and group 3 = two or more arterial conduits +/- veins (n = 177). Patients who received only saphenous vein conduits (group 2) were significantly older (66.7 +/- 8.9 years) than either group 1 (60.3 +/- 8.3 years) or group 3 (51.6 +/- 9.2 years). Furthermore, this cohort group had the highest percentage of females (28.6%), urgent cases (43.5%), preoperative myocardial infarction (MI) (18.5%), and redo surgery (5.4%). In contrast, patients who received two or more arterial conduits were 94.9% male, and had the lowest incidence of urgent cases (18.1%) and redo surgery (0.5%). Mortality was 1.4% in group 1 and 3.2% in group 2; there were no deaths in group 3. Furthermore, group 2 patients had the highest incidence of perioperative MI (6.6%), low output syndrome (22.1%), intra-aortic balloon pump (IABP) assist (6.2%), and stroke (2.7%). By multivariate logistic regression analysis (odds ratio in parentheses), redo surgery (7.92), preoperative IABP (5.53), poor LV function (4.01), renal impairment (3.94), and advanced age (2.12) were all predictors of operative mortality. When mortality and morbidity (death, infarction, low output syndrome, IABP assist) were combined, regression analysis revealed that in addition to the above variables, female gender and cold cardioplegia were also independent predictors of combined mortality and morbidity. Resource utilization was determined for the three patient groups. There was concern that the increased technical demands of multiple arterial grafting along with longer periods of aortic occlusion and pump times may lead to increased complications and prolonged hospital stay. However, we found that group 3 had the lowest ventilation time, intensive care unit stay, and hospital stay. The results no doubt were influenced by case selection. Whether or not this approach to revascularization will increase long-term survival and freedom from reoperation will require further study.

Myocardial Revascularization with Multiple Arterial Grafts

From October 1991 10 July 1994, 439 patients underwent elective or urgent coronary artery bypass grafting utilizing 2 or more arterial conduits. Age ranged from 28 to 79 years (mean, 62.3 years). Most of the patients had 3-vessel disease (301); the remaining had 2-vessel (120) or 1-vessel (18) disease. A stenosis of the left main trunk greater than or equal to 50% was present in 73 patients; in 16 cases it was a redo operation. The left ventricular ejection fraction ranged from 0.19 to 0.84 (mean, 0.53). We utilized 1110 arterial conduits (430 left internal mammary arteries, 259 right internal mammary arteries, 136 right gastroepiploic arteries, 120 inferior epigastric arteries, 165 radial arteries) together with 113 saphenous veins (2.63 arterial anastomoses per patient, ranging from 2 to 6). In 347 patients (79%) we performed a complete arterial myocardial revascularization with an average of 2.80 anastomoses per patient. Two arterial conduits were used in 245 patients, 3 in 163, 4 in 30, and 5 in 1 patient. The myocardial protection was achieved by means of intermittent antegrade warm blood cardioplegia. The mean cross-clamping time was 47.3 ± 16 minutes (range, 16 to 142 minutes). Five patients (1.1%) died in the postoperative period, none were in the operating theater. The causes of death were cardiac (2), sepsis (1), pneumonia (1) and pancreatic necrosis (1). In 7 patients (1.6%) a perioperative myocardial necrosis occurred without any hemodynamic sequelae. Out of 430 patients alive, 419 (97.4%) are asymptomatic. At the postoperative angiographic control all the arterial grafts explored showed complete patency; the midterm angiography (mean, 14 months) revealed a cumulative patency of 96% (range, 100% for the left internal thoracic artery to 94.1% for the radial artery). We conclude that on the basis of the early results the technique herein described is effective and reproducible, even if long-term follow-up is needed to confirm these data.

Multiarterial coronary artery bypass grafting with special reference to small vessel disease and results in women

From 1985 to 1991 a total of 220 patients underwent coronary artery bypass grafting (CABG) with at least two native pedicled artery grafts. Bilateral internal mammary artery (IMA) grafting was performed in 201 patients, IMA combined with gastro-epiploic artery (GEA) grafting in five, and double IMA plus GEA grafting in 14; in addition 156 patients received 1-3 vein grafts. The primary indication for elective multi-arterial CABG was coronary arteries of small calibre (small vessel disease) in 77 patients, repeat CABG in 17 (without small vessel disease), varicose/stripped saphenous veins in 57 (without small vessel disease), while the remaining 69 were routine cases; the distribution differed between women (42, 0, 47, and 11%, respectively) and men (33, 10, 19, and 38%, respectively; P < 0.0001). The women also were older (62 +/- 7 vs 56 +/- 9 years; P < 0.001), and had higher prevalences of systemic hypertension, diabetes mellitus, and hypercholesterolaemia. The number of artery grafts and total number of grafts were, however, similar for women and men. Early mortality (< or = 30 days) was 5.6% in women and 2.4% in men (ns). Early mortalities in relation to primary indications were: 7.8% for small vessel disease, 5.9% for repeat CABG, and 0% for both varicose/stripped saphenous veins and routine cases (P < 0.05). Logistic regression analysis identified small vessel disease, insufficient grafting, age of > = 60 years, a history of smoking, a family history of ischaemic heart disease, and female gender as independent risk factors for early mortality.(ABSTRACT TRUNCATED AT 250 WORDS)

Triple sequential grafts using the internal mammary artery

Between December 1984 and December 1988, coronary artery bypass operations, involving the use of 119 sequential internal mammary artery grafts with three or more anastomoses per conduit, were performed in 116 patients. Patients included 14 women and 102 men, with a mean age of 60 years. They received a total of 629 anastomoses; 373 anastomoses were used in multiple sequential arterial bypass grafts; 116 sequential left and three right internal mammary artery jump grafts were performed. There were 27 patients with bilateral internal mammary artery grafts, but only 17 had completely arterial revascularizations. Perioperative infarction occurred in 3.4 % of the patients; 1.7% of infarctions were related to sequential internal mammary artery grafts. There were no hospital deaths. Control angiography was performed within a month of the operation in 72 patients (with 371 anastomoses, of which 229 were in sequential arterial bypass grafts). The overall patency rate was 94.6 %, and for the internal mammary artery sequential graft with three or more anastomoses it was 96.1%. The mean follow-up period was 13 months; 110 patients were in New York Heart Association class I; there was one non-cardiac-related death, and three patients (2.6%) had a late myocardial infarction. One was related to the area revascularized by the sequential internal mammary artery graft. Multiple sequential internal mammary artery bypass grafts in coronary artery disease are feasible, with a high short-term patency and a low perioperative morbidity and mortality. (J T horac C ardiovasc S urg 1992;104:60–5)

Clinical Results of Endarterectomy of the Right and Left Anterior Descending Coronary Arteries

Abstract In this study, we examined the clinical outcome of coronary endarterectomy. From 1990 to 1998, 4839 patients underwent surgical revascularization. Coronary artery bypass graft surgery (CABG) was performed alone on 4516 patients, was combined with right coronary artery endarterectomy (RCA‐E) in 242 patients, and was combined with left anterior descending coronary artery endarterectomy (LAD‐E) in 81 patients. An analysis of preoperative variables revealed a higher proportion of males (90.79'0 vs 80.2%, p &lt; 0.001), of patients with low ejection fraction (&lt; 35%; 4.69'0 vs 1.796, p &lt; 0.001), and of three‐vessel disease (47.9% vs 3696, p &lt; 0.001) in the RCA‐E versus the CABG patients. There was a higher proportion of unstable angina (51.9% vs 40.3%, p = 0.04) in the LAD‐E patients. The 30‐day mortality rate for CABG was 2% versus 2.5% for RCA‐E and 3.7% for LAD‐E (p = NS). Perioperative myocardial infarction (MI) rate for CABG was 3.49/0 versus 7.00/0 for RCA‐E (p &lt; 0.001) and 4.996 for LAD‐E patients (p = NS). Postoperative low cardiac output syndrome was recorded in 11.596 of CABG, 18.6% of RCA‐E (p = 0.01), and 11.1% of LAD‐E (p = NS) patients. Predictors of postoperative bad outcome (death, MI, low cardiac output, cere‐brovascular accident) were preoperative intra‐aortic balloon pump, repeat operation, ejection fraction of &lt; 350/, renal insufficiency, female gender, RCA‐E, and age over 70. Protective factors included the use of internal mammary artery, multiple arterial grafts, and warm cardioplegia. Actuarial analysis at 6, 12, and 24 months showed late mortality rates of 0.8%, 1.3%, and 2.19'0 for CABG; 1.2%, 3.7%, and 3.7% for RCA‐E; and 2.9%, 2.996, and 2.9% for LAD‐E, respectively. Late MI occurrence was 0.4%. 0.49/0, and 0.7% for CABG; 1.5%, 1.5%. and 2.7% for RCA‐E; and 0% for LAD‐E, respectively. Multivariate analysis found renal insufficiency, ejection fraction of &lt; 3556, repeat operation, female gender, New York Heart Association functional class IV, and diabetes to be predictors for late adverse events (recurrence of angina, MI, and cardiac death), and RCA‐E was found to be a predictor of late MI. We conclude that the use of coronary endarterectomy to achieve complete revascularization in patients with diffuse distal coronary artery disease is a reasonable option, associated with a minimal addition in complication rates.