Critical Analysis of the Preoperative and Operative Predictors of Aortocoronary Bypass Patency (original) (raw)
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Arterial grafts for coronary surgery: Vasospasm and patency rate
The Journal of Thoracic and Cardiovascular Surgery, 2003
I nterest in the use of arterial grafts in coronary artery bypass grafting (CABG) has increased significantly for the following reasons: (1) The number of patients receiving arterial grafts has risen sharply in most major cardiac surgery centers around the world; (2) the number of arterial grafts received per patient has increased; (3) more diverse arteries are used as grafts than previously; (4) more is understood about the biologic characteristics of arterial grafts; (5) clinical protocols for the use of arterial grafts are more advanced; and (6) midterm results with alternative arterial grafts are encouraging in a large number of patients. It is widely accepted that the left internal thoracic artery (ITA) is the artery of choice for an arterial graft. Opinions differ, however, as to the second choice for an arterial graft, which frequently depends on the personal preference of the surgeon. The right ITA, the radial artery (RA), and the right gastroepiploic artery (GEA) are the candidates for second choice for arterial grafts for CABG. In general, which artery is chosen depends on the surgeon's views about the quality of the graft, that is, its length and diameter, whether the artery can be used as a pedicle graft, the technical difficulties, the incidence of vasospasm, and the possible superior longterm patency. Usually, pedicle grafts are considered to be superior to free grafts because the anatomic structure of the pedicle artery is thought to be more intact (the nerve and the blood supply to the vaso vasorum are better preserved in the pedicle graft). On the other hand, for arterial grafts such as the GEA, the pattern of direct flow from the ascending aorta in the free graft is better than that from the abdominal aorta (in the in situ pedicle graft). Therefore, although the ITA is better used as a pedicle graft than as a free graft, the GEA, when used as a free graft, has some advantages with regard to the flow pattern. Because the most important advantage for arterial grafts compared with vein grafts is their superior long-term patency, any alteration of the technique used for all kinds of arterial grafts should also take long-term patency into account. The long-term patency of arterial grafts is related to many factors: 1. Biologic characteristics of the arterial grafts, including (a) graft diameter, (b) the thickness of the wall and of the intimal hyperplasia, (c) the anatomic structure of the graft, (d) the usable length of the graft and whether it can be used as a pedicle graft, (e) the incidence of vasospasm, and (f) the incidence of atherosclerosis and occlusion rate both in situ and in the grafts. 2. General risk factors for coronary artery disease such as diabetes mellitus, hypertension, and hypercholesterolemia. 3. Anatomy and pathologic status of the target coronary artery, and disease status of the native coronary artery, such as the degree of stenosis, the quality of the wall, the flow capacity of the runoff, and the size of the vessel. 4. Vessel match between the graft and the target coronary artery. 5. The flow pattern through the graft, which may also be related to the patency. 6. Technical considerations, which depend primarily on the operative technique of the surgeon. 7. Function of endothelium and smooth muscle: in particular, preservation of endothelial function during the preparation of the graft is crucial to long-term patency.
Circulation, 1979
Early and late (range 5-73 months, average 2.5 years) postoperative arteriographic studies were performed in 85 patients after saphenous vein aortocoronary bypass surgery. In a prior study (< 2 weeks postoperative) of 570 patients with 1197 grafts, arteriography revealed 89.6% early patency of grafts. Late follow-up in 85 patients discharged with all grafts patent revealed 92.2% still patent, an annual mean graft attrition rate (percent of grafts closed/year) of 3.2%/year. This mean graft attrition rate was only slightly affected by regrouping patients according to the interval between the two postoperative studies; however, recurrent angina pectoris was influenced by vein graft attrition. Thus, in 36 patients restudied because of recurrent angina pectoris, the attrition rate was 6.1%/year, compared with 1.1%/year in 49 patients without angina. Progressive coronary artery disease (41% vs 18%), graft closure (22% vs 4%) and incomplete revascularization (39% vs 16%) were significantly more frequent in those with recurrent angina. The frequency of progressive coronary disease was directly related to the duration of follow-up (i.e., the longer the follow-up the higher the frequency of progressive disease). The mean annual rate of progressive coronary disease in arteries not grafted was 11.8%/year. Kinking or graft stenosis was observed in 3.1% of grafts in the early study, while late localized graft narrowing was observed in 8%. At late follow-up, most patent grafts were uniformly narrowed and foreshortened. The mean graft diameter decreased by 17% at late follow-up, and 25% of grafts had at least 25% reduction in mean diameter; however, the mean graft diameter/mean recipient artery diameter ratio exceeded 1.0 in all but one graft. The graft/artery diameter ratio at late follow-up was over 1.5 in 71% of the grafts. The mean graft blood flow determined by cinedensitometric methods revealed a 30% or more reduction in blood flow in 35% of grafts, compared with early postoperative measurements.
Arterial Grafts in Coronary Artery Bypass Surgery
2016
Coronary artery bypass grafting (CABG) is the optimal surgical treatment for multi-vessel coronary artery disease. CABG operation has successful shortand intermediate-term results, but the long-term results are variable. The variability of results in long-term particularly depends on the nature of the vascular grafts used. Angiographic studies in long-term have showed that patency rates of arterial grafts were superior to patency rates of vein grafts. Numerous studies documented an incremental survival and events free benefit by utilizing increased number of arterial grafts during CABG. Long survival has improved by total arterial revascularization compared to using left internal thoracic artery (LITA) and saphenous vein grafts (85% to 90% at 10 years versus 75% to 80%, respectively). Total arterial revascularization patients also have lower rate of cardiac-related events including new myocardial infarction, recurrence of angina, severe arrhythmia, congestive heart failure requiring...
Anesthesiology and Pain Medicine, 2015
Background: Patency of the revascularization conduit is an essential predictor of long-standing survival after coronary artery bypass grafting. Objectives: We have conducted this study to compare the mid-term patency rates of radial artery (RA), left internal thoracic artery (LITA) and also saphenous vein (SV) grafts in asymptomatic patients following coronary artery bypass graft surgery (CABG) undergoing total IV anesthesia. Patients and Methods: In this study, 30 three-vessel disease patients with 104 RA, LITA, and SV grafts used concomitantly for primary isolated non-emergent CABG surgery were assessed. The primary end point was CT angiographic graft patency rate. After 53.5 (24-97) months' follow-up, graft patency was assessed using 128-slice CT coronary angiography. Logistic regression analysis was used to detect the independent predictors of graft failure. Results: A total of 104 grafts, including 30 LITA, 44 SV, and 30 RA grafts, were studied. Cumulative graft patency rates were 93.3% in LITA, 83.3% in RA, and 70.5% in SV grafts. Statistically significant difference was found between the LITA and the SV graft patency rates (P = 0.019), whereas the difference between the RA conduit patency and the LITA or SV graft patency rates did not have any statistical significance (P = 0.424 and P = 0.273, respectively). Independent predictors of RA grafts occlusion were native coronary stenosis < 70% and female gender. Conclusions: In our patients, the RA grafts had an acceptable patency rate in 2 to 5 years' follow-up. Although the SV grafts had a relatively higher patency rate than RA grafts in our asymptomatic patients, the patency rates in RA and SV grafts were close to each other. The RA graft function was poor in the patients with a higher number of risk factors and in the females.
Scoring system for predicting saphenous vein graft patency in coronary artery bypass grafting
Texas Heart Institute journal / from the Texas Heart Institute of St. Luke's Episcopal Hospital, Texas Children's Hospital, 2010
The initial and long-term benefits of coronary artery bypass grafting depend upon maintaining the coronary blood flow supplied by the graft. In order to devise a scoring system for predicting graft patency, we evaluated presumptive correlations between saphenous vein graft patency and the characteristics of saphenous veins that were used as conduits in coronary revascularization.We prospectively evaluated 1,000 saphenous vein segments that were implanted in 403 consecutive patients who underwent on-pump coronary artery bypass grafting at our hospital from January 2006 through February 2009. Branches, varicosity, diameter, and wall thickness were evaluated, and a scoring system was created in order to obtain a value for each characteristic. The patients were postoperatively monitored for 1 year, and graft patency was then evaluated with the use of 64-slice multidetector computed tomography.Lesions were found in 12.3% of the grafts. All of the evaluated characteristics of the grafts h...
Angiographic Assessment of Sequential and Individual Coronary Artery Bypass Grafting
Journal of Cardiac Surgery, 2003
In trying to answer the question about the controversial use of sequential grafts, we determined the mid-term angiographic outcome of patients in whom coronary artery bypass was performed with different types of vein grafts. Methods: A total of 1034 coronary anastomoses on 724 saphenous vein grafts (SVGs) (apart from 497 left internal mammarian artery (LIMA) anastomoses) were assessed in 509 patients in an average of 55.4 ∓ 17.6 months after coronary artery bypass grafting. Results: The patency rates of sequential conduits were markedly higher than those of individual ones (86.6% vs 69.6%, p = 0.0001). Also, the anastomoses on the sequential conduits had better patency rates (80.6% vs 69.6%, p = 0.0001). This difference was even more pronounced in coronary arteries of poor quality/small (<1.5 mm) diameter (68.9% vs 51.6%) for the sequential and individual grafts, respectively (p = 0.03). Also, the patency of the entire sequential conduit was lower when most distally located anastomosis was of poor runoff (45.2%). Conclusions: The patency of a sequential vein conduit is generally superior than that of an individual one, especially for poor runoff coronary vessels, provided that the most distally located anastomosis is performed on a good coronary artery in terms of quality and diameter. Using a minimal length of SVG is another advantage. However, failure of a single sequential conduit jeopardizes all of the anastomoses along that graft segment. Besides, being technically more demanding, technical expertise in performing a sequential anastomosis is probably among the important predictors of patency
Twenty-Year follow-up of saphenous vein aortocoronary artery bypass grafting
The Annals of Thoracic Surgery, 1992
The clinical records of our first 100 patients to undergo saphenous vein aortocoronary bypass grafting were reviewed. The procedures were performed between March 19, 1970, and March 30, 1972. The patient population included 84 men, and the mean age was 51.4 years. There were 12 patients with single-vessel disease, 36 with double-vessel disease, and 52 with triple-vessel disease, for an average of 2.4 involved vessels per patient. Fortyeight patients were judged to have diffuse atherosclerotic disease. Twelve patients had left main coronary artery stenoses. Each patient received an average of 1.8 saphenous vein grafts. Thirty-six patients underwent repeat coronary artery bypass grafting after an average of 132.8 months and received an average of 3.5 grafts. This resulted in cumulative reoperative rates of 5%, 14%, 27%, and 36% at 5, 10, 15, and 20 years, respectively. The 5-, lo-, 15-, and 20-year survival rates were 89.8%, 68.4%, 53.1%, and 40.8%, respectively. Survival was not significantly related to the cause of death, cardiac-related causes being predominant. There were no significant ince the initial report by Favaloro [l], aortocoronary S artery bypass grafting (CABG) has become commonplace. A vast body of literature is available regarding the risks, benefits, and long-term survival. Much has changed since the early days of this operation with improvements in surgical technique, lighting, magnification, suture material, cardiopulmonary bypass techniques, and myocardial protection. The use of arterial conduits, such as the internal mammary artery [2, 31 and more recently the right gastroepiploic artery [4], has been shown to improve graft patency rates. In contrast to the 40% to 60% patency rate for vein grafts at 10 to 12 years postoperatively, arterial graft patency exceeds 90% [2]. Several articles have been published regarding the 5-year [>lo], 10-year [3, 5-14], and even 15-year [15, 161 survival rates after CABG. Factors determining survival are controversial. Age (8
Interventional Cardiology Journal, 2016
We aimed to develop a new simple angiographic score that would predict short-and mid-term patency problems of coronary artery bypass grafts (CABG). Methods: We enrolled 249 patients who underwent CABG. The Distal Vessel Quality (DVQ) score was calculated according to 1/visibility, 2/diameter, and 3/size of the distal vessel as angiographically evaluated at baseline. Each variable was quantified from 0 (worst) to 3 (best) and the DVQ score resulted from the addition of these values. Results: At 5-year of follow-up 16% of the patients had been admitted due to a coronary event and, after angiography, occlusion of 67 grafts (9.2%) was demonstrated (median time from surgery: 1.4 [IQR: 0.5-1.7] years). In 67% of the cases, a diseased graft was the responsible for the event. Venous grafts were 2.5 times more frequently occluded than arterial grafts (p=0.098). Indeed, the use of arterial grafts (OR=0.217, 95% CI [0.064-0.737], p=0.014) and higher values of DVQ score (OR=0.555, 95% CI [0.370-0.832], p=0.004) were independent predictors of bypass graft patency at 5-year follow-up. To remark, bad correlation of DVQ and syntax scores was found (R=0.228) and the last failed to predict the risk of early graft malfunction. Conclusions: The DVQ score is a new simple tool that may help to predict outcomes of coronary bypass grafts. Lower values of this score suggest limited benefit of bypass grafting. Therefore, the DVQ score could help to improve outcomes of cardiac surgery by improving the selection of patients. External validation of these results is warranted.
Functional Angiographic Evaluation of Individual, Sequential, and Composite Arterial Grafts
The Annals of Thoracic Surgery, 2006
Background. To help optimize graft arrangement, we examined the effects of target vessel characteristics, conduit type, and interactions between the target vessels on the occurrence of flow reversal or occlusion. Methods. The postoperative angiograms of 458 patients after total arterial revascularization with an off-pump, no aortic manipulation technique beginning in December 2000 were reviewed. Reverse flow was defined as the lack of opacification of a distal anastomotic site during graft angiography, but clear retrograde graft opacification during native coronary angiography. We analyzed characteristics of the target coronary branches, and bypass conduits. The potential interactions between coronary branches and sequential anastomoses were categorized as those with two 75% stenotic branches (situation 1); one 75% stenotic branch at the end of the graft and a 99% to 100% stenotic branch at the middle of the graft (situation 2); and a composite Y (or K) graft with one end to a 75% stenotic branch and the other to a 99% to 100% stenotic branch (situation 3). Results. A total of 18 bypasses (1.1%) were occluded while reverse flow was found in 4.5% (74 of 1,627). In a multivariate analysis of the 521 bypass conduits having more than two distal anastomoses, the predictors of reverse flow or occlusion were a right coronary artery target with 75% or less stenosis (p ؍ 0.006), more than three distal anastomoses with a conduit (p ؍ 0.005), situation 1 (p ؍ 0.04), situation 2 (p<0.0001), and situation 3 (p < 0.0001). Conclusions. Interactions between coronary branches and graft arrangement play important roles in flow distribution. Graft arrangement should be adjusted for each patient to minimize reverse flow.