Background Use of one or more arterial grafts to revascularize two-vessel and three-vessel coronary artery disease has been shown to improve coronary artery bypass graft surgery (CABG) survival. Yet, ...the presumed long-term survival benefits of all-arterial CABG have not been quantified. Methods We compared propensity-adjusted 12-year survival in two contemporaneous multivessel primary CABG cohorts with all patients receiving 2 or more grafts: (1) all-arterial cohort (n = 612; 297 three-vessel disease 49%); and (2) single internal thoracic artery (ITA) plus saphenous vein (SV) cohort (n = 4,131; 3,187 three-vessel disease 77%). Results Early (30-day) deaths were similar for the all-arterial and ITA/SV cohorts (8 1.30% versus 69 1.67%) whereas late mortality was substantially greater for the ITA/SV cohort (85 13.9% versus 1,216 29.4%; p < 0.0001). The risk-adjusted 12-year survival was significantly better for all-arterial (with a risk ratio RR = 0.60; 95% confidence interval CI: 0.48 to 0.75; p < 0.001), but this benefit was true only for three-vessel disease (RR = 0.58; 95% CI: 0.43 to 0.78; p < 0.001) and not for two-vessel disease (RR = 0.97; 95% CI: 0.66 to 1.43; p = 0.89). The all-arterial survival benefit was also true for varying risk subcohorts: no diabetes mellitus (RR = 0.50; 95% CI: 0.37 to 0.69), diabetes mellitus (RR = 0.77; 95% CI: 0.56 to 1.07), ejection fraction 40% or greater (RR = 0.60; 95% CI: 0.45 to 0.78), and ejection fraction less than 40% (RR = 0.62; 95% CI: 0.40 to 0.98). Lastly, the multivariate analysis indicated a strong long-term effect of completeness of revascularization, particularly for all-arterial patients, so that compared with patients with two grafts, survival was significantly better when three grafts (RR = 0.54; 95% CI: 0.33 to 0.87) or four grafts (RR = 0.40; 95% CI: 0.21 to 0.76) were completed. Conclusions All-arterial revascularization is associated with significantly better 12-year survival compared with the standard single ITA with saphenous vein CABG operation, in particular for triple-vessel disease patients. The completeness of revascularization of the underlying coronary disease is critical for maximizing the long-term benefits of arterial-only grafting.
Background Increasing the number of arterial grafts for coronary artery bypass grafting (CABG) has been linked to improved late survival. Currently, it is not known if these long-term benefits are ...also true when sequential radial artery (RA) grafts are the primary means to maximizing arterial revascularization. Methods We compared late survival of 532 consecutive patients receiving sequential RA grafts (sequential RA group: 438 men; 462 with three-vessel disease) with that of a 4,131 contemporaneous internal thoracic artery (ITA) with saphenous vein (SV) multivessel CABG cohort (conventional group). Graft failure rates were determined from symptom-driven repeat angiography films in 122 sequential RA patients performed 2 to 4,317 days after surgery. Median survival sequential RA follow-up was 5.3 years (range, 0.5 to 12.3). Results The sequential RA patients received a total of 1,181 RA grafts (538 sequential 30 triple and 75 single) along with 636 SV and 533 ITA. Overall RA graft failure (80 of 272; 29%) was intermediate to that for ITA (7 of 121; 5.8%; p < 0.001) and vein (54 of 133, 41.6%; p = 0.032) grafts. Sequential versus nonsequential RA failure did not differ (77 of 252 31% versus 3 of 20 15%; p = 0.202), while failure of the proximal (36 of 123; 29%) and distal (40 of 129; 31%) components of sequential RA grafts were essentially identical. A total of 69 deaths (6 operative; 1.1%) have occurred in the sequential RA cohort. Unadjusted 10-year sequential RA cohort survival was 76.2% overall, and 79.0% for the 454 primary isolated CABG subgroup. The risk-adjusted 10-year survival using a logit propensity score was substantially better for the sequential RA cohort versus the conventional CABG cohort (risk ratio 95% confidence interval 0.61 0.44 to 0.85; p = 0.003). Conclusions Sequential RA grafting is a safe method for maximizing arterial revascularization and is associated with excellent 10-year survival that seems to be superior to conventional or ITA/SV CABG results. Also, the similar proximal and distal sequential RA patency mitigates concerns of a clinically significant effect of increased vasoreactivity of distal segments of RA conduits.
To assess downstaging rates in patients with United Network for Organ Sharing stage T3N0M0 hepatocellular carcinoma (HCC) treated with doxorubicin-eluting bead transarterial chemoembolization to meet ...Milan criteria for transplantation.
A single-center retrospective review of 239 patients treated with doxorubicin-eluting bead (DEB) chemoembolization between September 2008 and December 2011 was undertaken. Baseline and follow-up computed tomography or magnetic resonance imaging was assessed for response based on the longest enhancing axial dimension of each tumor (ie, modified Response Evaluation Criteria In Solid Tumors measurements), and medical records were reviewed. Fisher exact tests and exact logistic regression were used to test the association of patient and disease characteristics with downstaging.
After exclusions, 22 patients remained in the analysis, 17 of whom (77%) had their HCC downstaged to meet Milan criteria. Among those whose disease was downstaged, seven underwent transplantation, one remained listed for transplantation, six had disease progression beyond Milan criteria, two underwent conventional transarterial chemoembolization, and one underwent radiofrequency ablation. The seven patients who received transplants were still living, but recurrent HCC developed in two. Baseline age (P = .25), Model for End-stage Liver Disease score (P = .77), and α-fetoprotein (AFP) level (P = 1.00) were similar between patients with and without downstaged HCC. No associations were observed between the odds of downstaging and sex (P = .21), Child-Pugh class (P = .14), Child-Pugh class controlling for baseline tumor multiplicity (P = .15), Eastern Cooperative Oncology Group performance status (P = 1.00), tumor burden (P = .31), multiple tumors (P = .31), or hepatitis C virus infection (P = 1.00). Fifteen patients who did not receive transplants were alive at 1 year, with two progression-free. Baseline AFP levels differed between those who survived 1 year and those who did not (P = .02), but did not differ by progression-free survival status (P = .62).
T3N0M0 HCC treatment with DEB chemoembolization has a high likelihood (77%) of downstaging the disease to meet Milan criteria.
Background Coronary artery bypass grafting with concomitant coronary endarterectomy (CABG/CE) is used in patients with severe coronary atherosclerosis to revascularize otherwise ungraftable targets. ...This study investigates the efficacy of arterial versus vein grafting for CABG/CE surgery. Methods We reviewed our experience in 288 CABG/CE patients (63 ± 10 years, 207 men). A total of 1,056 grafts (275 internal thoracic artery ITA 26%; 221 radial 21%, 560 vein 53%) were constructed including 325 (31%) placed to CE targets. Results Eighteen of 288 patients died in-hospital (6.3%). Unadjusted one-year and five-year survival for the 270 discharged patients was 95.2% and 83.0%, respectively. Survival (0 to 7 years) was significantly better for patients with radial (n = 154) versus no-radial (n = 134) artery grafting ( p = 0.021). Multivariate Cox regression analysis associated increased number of arterial grafts (hazard ratio HR = 0.64 0.44 to 0.92; HR 95% confidence interval) to improved survival, while RCA endarterectomy (HR = 1.8 1.0 3.3; p = 0.054) was associated with worse survival. Repeat angiography (495 days median) in 68 patients encompassed 78 CE (38 vein, 24 ITA, and 16 radial) and 162 non-CE (84 vein, 40 ITA, and 38 radial) grafts. Graft failure was similar ( p = 0.37) for radial (10 of 54 19%) and ITA (7 of 64 11%), and worst for vein (50 of 122 41%; p < 0.001). For CE targets, graft failure was worse for vein (55% vs 35%; p = 0.05) and unchanged for arterial (13% vs 15%; p = 0.88) grafts. Conclusions Combined CABG/CE is associated with good long-term outcomes. Increased arterial grafting achieved by radial artery utilization confers a survival benefit in this high-risk population. The latter is probably derived from superior radial versus vein graft patency.
Background Studies in patients undergoing coronary artery bypass grafting (CABG) have shown an increased long-term mortality rates associated with perioperative blood transfusions. However, some ...studies in other patient populations have shown no effect on death or even a lowered mortality rate in patients receiving blood transfusions, which suggests that the effects of blood transfusion may be disease-dependent. Methods Data of all patients who underwent valve operations with or without associated CABG between October 2, 1991, and November 14, 2007, were obtained from the department's database and analyzed using logistic regression for 30-day and Cox models for long-term mortality to determine the effects of transfusion on death. To control for the potential interaction between transfusion and complications and sicker patients being more likely to receive blood, we separately analyzed the data for the different valve populations and used propensity analysis to control for sicker patients being more likely to receive blood. Results Of 1823 patients who underwent valve operations, the operation was isolated in 993 and combined with CABG in 830. By 30 days, 125 patients (6.9%) had died, and 717 (39%) were dead at follow-up. After controlling for type of operation and factors that influenced the transfusion decision, transfusion was associated with increased death only in patients who had combined valve and CABG, and not in isolated valve operations. Conclusions Transfusion had no effect on the mortality rate after isolated valve operations but was associated with increased mortality when valve operations were combined with CABG.
Objective We investigated whether use of radial artery versus saphenous vein grafts during coronary artery bypass grafting reoperations is associated with a significant long-term survival benefit. ...Methods We reviewed a series of 347 consecutive coronary artery bypass grafting reoperations (1996–2007; 270 78% male patients; age, 65.3 ± 9.2 years). Internal thoracic artery grafts were used in 248 (71%) patients at the time of the first coronary artery bypass grafting operation and in 154 (44%) patients at reoperation. Patients were grouped based on whether a functional radial artery graft was present after coronary artery bypass grafting reoperation (radial artery cohort, n = 203 59%) or not (saphenous vein cohort, n = 144 41%). Median time to reoperation was similar for the radial artery (10.3 years) and saphenous vein (10.1 years) cohorts ( P = .55). Angiographic data were used to ascertain the number and type of grafts that remained functional from initial coronary artery bypass grafting. Survival data (≤12 years) were time segmented based on multiphase hazard modeling at 90 days, and late survival was then analyzed by using proportional hazard Cox regression, with risk adjustment based on a radial artery–use propensity score computed from 48 covariates, including time to reoperation, month of surgical intervention, and total arterial and vein grafts after reoperation. Propensity-matched and propensity quintile comparisons were also done. Results Follow-up was similar for the radial artery versus saphenous vein cohorts (5.7 ± 3.4 vs 5.8 ± 4.0 years, P = .86), and 112 (50 in the radial artery and 62 in the saphenous vein cohorts) deaths were documented. Early mortality (≤90 days) did not differ for the radial artery (7.4%) and saphenous vein (12.5%) cohorts ( P = .14). Unadjusted late outcomes were superior for the radial artery versus saphenous vein cohorts, with survival of 97.3% versus 92.9%, 84.9% versus 77.2%, and 74.1% versus 60.3% at 1, 5, and 10 years, respectively. Propensity-adjusted radial artery survival was superior, with a hazard ratio of 0.58 ( P = .04), and this result was confirmed in a propensity-matched comparison. Conclusions We conclude that the use of radial artery as opposed to saphenous vein grafting for reoperative coronary artery bypass grafting, either with or without concomitant internal thoracic artery grafts, is associated with a substantial improvement in late survival. This benefit is likely derived from the increased overall number of arterial grafts.
Acute aortic dissection (AAD) can cause limb ischemia due to branch vessel occlusion. A minority of patients have persistent ischemia after central aortic repair and require peripheral arterial ...revascularization. We investigated whether the need for limb revascularization is associated with adverse outcomes.
We reviewed our cases of AAD from 2000 to 2014 and identified patients with malperfusion syndromes (coronary, cerebral, spinal, visceral, renal, or peripheral ischemia). Patients with DeBakey I/II (Stanford type A) dissection had urgent open repair of the ascending aorta. Patients with DeBakey III (Stanford type B) dissection were initiated on anti-impulse medical therapy and had either open aortic repair or thoracic endovascular aortic repair for malperfusion syndromes. Patients with persistent lower limb ischemia after aortic repair usually had either extra-anatomic bypass grafting or iliac stenting. Some DeBakey III patients had peripheral revascularization without central aortic repair. We performed univariate and multivariate analysis to determine the effects of need for limb revascularization and clinical outcomes.
We treated 1,015 AAD patients (501 49.4% DeBakey I/II and 514 50.6% DeBakey III) with a mean age of 59.7 ± 14.5 years (67.5% males). Aortic repair was performed in all DeBakey I/II patients and in 103 (20.0%) DeBakey III patients. Overall 30-day mortality was 11.3%. Lower limb ischemia was present in 104 (10.3%) patients and was more common in DeBakey I/II compared with DeBakey III dissections (65.4% vs. 34.6%; odds ratio OR 2.1, confidence interval CI 1.4-3.2; P = 0.001). Among the 40 patients who required limb revascularization, there was no difference in need for revascularization between DeBakey I/II and III patients. Patients requiring limb revascularization were more likely to have mesenteric ischemia compared with the rest of the cohort in both DeBakey I/II (P = 0.037) and DeBakey III dissections (P < 0.001) with worse 10-year survival (21.9 % vs. 59.2%, P < 0.001). When adjusted for other malperfusion syndromes, patients with limb revascularization had similar long-term survival compared to uncomplicated dissection patients (P = 0.960).
Patients requiring lower limb revascularization after treatment for AAD are more likely to have mesenteric ischemia and worse survival. The need for limb revascularization is a marker for more extensive dissection and should prompt evaluation for visceral malperfusion.
Objective: This study was designed to determine the effect of ketorolac on mortality after cardiac surgery. Design: A retrospective multivariable analysis with propensity matching and propensity ...scoring. Setting: A tertiary care university-affiliated medical center. Participant: Eleven hundred eighty-six patients undergoing isolated coronary artery bypass surgery. Main Results: Between January 1, 2002, and November 1, 2004, 168 patients undergoing isolated coronary artery bypass surgery received ketorolac, whereas 1,018 patients did not. There were 2 deaths (1%) in the ketorolac group compared with 104 (10%) in the nonketorolac group ( p < 0.001). Within 90 days of surgery, there was 1 death (1%) in the ketorolac group compared with 51 (5%) in the nonketorolac group ( p = 0.01). By Cox modeling, ketorolac use was associated with a 7-fold lower risk of death ( p = 0.02). In the patients who survived at least 90 days, there was 1 death (1%) in the ketorolac group compared with 53 (5%) in the nonketorolac group ( p = 0.01). By Cox modeling, ketorolac use was associated with a 2.4-fold lower risk of death ( p = 0.03) in the late hazard period. In the propensity-matched groups, Kaplan-Meier survival was better in patients who received ketorolac ( p = 0.02). Conclusion: The use of ketorolac was associated with a statistically significant decrease in mortality at follow-up.
Reply Schwann, Thomas A., MD; Zacharias, Anoar, MD; Riordan, Christopher J., MD ...
The Annals of thoracic surgery,
2008, Letnik:
85, Številka:
5
Journal Article
PDF
