OBJECTIVES
Coronary artery bypass grafting (CABG) has historically demonstrated higher hospital mortality in women compared with men. The influence of gender on long-term outcomes has not been ...clearly defined.
METHODS
A retrospective analysis of 4584 consecutive CABG patients was conducted: 3647 men (1761 single internal mammary artery, SIMA; 1886 bilateral IMA, BIMA) and 937 women (608 SIMA and 329 BIMA). Propensity-score analysis and optimal matching algorithms were used to create matched groups for baseline risk factors between men and women (SIMA: 602 men and 602 women; BIMA: 328 men and 328 women). Cross-sectional follow-up (6 weeks to 32.1 years; mean 12.8 years) was 96.7% complete.
RESULTS
Hospital mortality was higher in unmatched female vs male patients (SIMA 36/608; 5.9 vs 72/1761; 4.1%; BIMA 11/329; 3.3 vs 47/1886; 2.5%; P = 0.010). However, in the matched groups the increased hospital mortality for females approached statistical significance in the SIMA but not in the BIMA patients. (SIMA male 21/602, 3.5%; female 35/602, 5.8%; P = 0.055; BIMA male 12/328; 3.7%; female 11/328; 3.4%; P = 0.832). When propensity matched for baseline variables, the female SIMA patients experienced prolonged survival compared with their male counterparts. (male vs female, 20-year survival 17.0 ± 2.0 vs 26.4 ± 2.3%; median 10.4 vs 11.4; P = 0.043.) However, long-term survival between the matched male and the female BIMA patients was comparable (male vs female, 20-year survival 31.3 ± 3.6 vs 30.1 ± 3.6%; median 13.7 vs 13.7; P = 0.790).
CONCLUSIONS
When liberally applied, BIMA grafting ameliorates both the increased perioperative mortality in female patients and the reduced long-term survival of male patients, effectively reversing the negative influence of gender on both short- and long-term outcomes of CABG surgery.
Ischemic heart disease is currently the leading cause of death globally, with coronary artery bypass grafting among the most common operations performed worldwide. More extensive use of arterial ...grafts has been advocated because of their high long-term patency, long-term survival benefit, and freedom from reinterventions. Despite this, the saphenous vein is the most frequently used conduit in patients undergoing coronary artery bypass surgery since its introduction over 50 years ago. Consequently, the saphenous vein remains an indispensable conduit in coronary artery bypass grafting and maintaining its long-term patency is one of the most crucial challenges in cardiovascular surgery. This situation led to the development of the no-touch saphenous vein harvesting technique, where the vein is harvested completely with its pedicle of surrounding tissue. Several studies report a superior long-term patency rate, slower progression of atherosclerosis, and better clinical outcomes whilst employing no-touch harvesting technique. The success of the technique is multifactorial, including the decreased risk for graft spasm—and the need for manual distension—preservation of the vaso vasorum and an intact endothelium, reducing neointimal hyperplasia and subsequent atherosclerosis. Furthermore, the intact perivascular tissue, including the surrounding cushion of fat, may act as a “natural external stent”, providing mechanical support preventing the graft from kinking. We are convinced that the use of arterial grafts, in combination with the no-touch saphenous vein graft, will significantly improve the results of coronary artery bypass grafting. This is important for achieving a comprehensive and evidence-based balance between the major treatment strategies of ischemic heart disease, explicitly coronary artery bypass grafting and percutaneous coronary intervention. The no-touch technique is becoming increasingly popular among surgeons, with further studies to be initiated worldwide.
The Gatti and the bilateral internal mammary artery (BIMA) scores were created to predict the risk of deep sternal wound infection (DSWI) after bilateral internal thoracic artery (BITA) grafting.
...Both scores were evaluated retrospectively in two consecutive series of patients undergoing isolated multi-vessel coronary surgical procedures-i.e., the Trieste (n = 1,122; BITA use, 52.1%; rate of DSWI, 5.7%) and the Besançon cohort (n = 721; BITA use, 100%; rate of DSWI, 2.5%). Baseline patient characteristics were compared between the two validation samples. For each score, the accuracy of prediction and predictive power were assessed by the area under the receiver-operating characteristic curve (AUC) and the Goodman-Kruskal gamma coefficient, respectively.
There were significant differences between the two series in terms of age, gender, New York Heart Association functional class, chronic lung disease, left ventricular function, surgical priority, and the surgical techniques used. In the Trieste series, accuracy of prediction of the Gatti score for DSWI was higher than that of the BIMA score (AUC, 0.729 vs. 0.620, p = 0.0033). The difference was not significant, however, in the Besançon series (AUC, 0.845 vs. 0.853, p = 0.880) and when only BITA patients of the Trieste series were considered for analysis (AUC, 0.738 vs. 0.665, p = 0.157). In both series, predictive power was at least moderate for the Gatti score and low for the BIMA score.
The Gatti and the BIMA scores seem to be useful for pre-operative evaluation of the risk of DSWI after BITA grafting. Further validation studies should be performed.
Coronary endarterectomy (CE) emerged as a necessity to achieve complete surgical myocardial revascularization in patients with diffusely diseased coronary arteries and it also serves as aid to ...coronary bypass grafting (CABG). The safety and postoperative prognosis of this procedure are still matters of debate. There are no clear preoperative indications, a standard technique has not yet been established as gold standard and the postoperative management differs depending on each institution. CE of the left anterior descending artery (LAD) is technically challenging and potentially hazardous with high risk of postoperative myocardial infarction. In this article, we describe the open technique for CE of the LAD with its specific details, which we believe could be the safest and the best reproductible option. To better understand the profile of a patient requiring such a procedure we present the case of a 73-years old male with diffused coronary artery disease (CAD) and a short review of literature.
Abstract
Aims
The objective of the Randomized comparison of the Outcome of single vs. Multiple Arterial grafts: Quality of Life (ROMA:QOL) trial is to evaluate the impact of coronary artery bypass ...graft surgery (CABG) on quality of life (QOL). The primary hypothesis of ROMA:QOL is that participants in the multiple arterial graft (MAG) will report time-varying changes in QOL that will be lower in the post-operative recovery period and higher after 12 months compared to patients in the single arterial graft (SAG). The secondary hypotheses are that both groups will have improvements in symptoms at 12 months, and that compared to the SAG group, participants in the MAG group will experience better physical functioning and physical and mental health symptoms.
Methods and Results
An estimated 2111 participants will be enrolled from the parent ROMA trial from 13 countries. Outcome assessments include the Seattle Angina Questionnaire (SAQ) (primary outcome), Short Form-12v2, EuroQol-5D (EQ-5D)-5L, PROMIS-29, and PROMIS Neuropathic Pain measured at baseline, first post-operative visit, 6, 12, 24, 36, 48, and 60 months. The analysis for the primary outcome, the change in the SAQ from baseline to 12 months, will be compared across all time-points between the two treatment arms.
Conclusion
The ROMA:QOL trial will answer whether there are differences in QOL, physical and mental health symptoms overall for CABG, by MAG and SAG intervention arms, by sex, and between patients with and without diabetes.
Graphical Abstract
Graphical Abstract
Coronary artery bypass grafting (CABG) was first used in the late 1960s. This revolutionary procedure created hope among ischemic heart disease patients. Multiple conduits are used and the golden ...standard is the left internal mammary artery to the left anterior descending artery. Although all approaches were advocated by doctors, the use of saphenous vein grafts became the leading approach used by the majority of cardiac surgeons in the 1970s. The radial artery graft was introduced at the same time but was not as prevalent due to complications. It was reintroduced into clinical practice in 1989. The procedure was not well received initially but it has since shown superiority in patency as well as long-term survival after CABG. This review provides a summary of characteristics, technical features and patency rates of the radial artery graft in comparison with venous conduits. Current studies and research into radial artery grafts and saphenous vein grafts for CABG are explored. However, more studies are required to verify the various findings of the positive effects of coronary artery bypass grafting with the help of radial arteries on mortality and long-lasting patency.
OBJECTIVES
We compared the histological and morphometric properties of the right and left internal thoracic arteries and examined risk factors for intimal hyperplasia.
METHODS
Paired segments of the ...right and left internal thoracic arteries obtained from 72 patients were studied. The transverse sections just distal to the most distal anastomoses were microscopically examined.
RESULTS
No significant difference was found between the right and left internal thoracic arteries in the median value of the lumen area (1.60 vs 1.52 mm2, P = 0.33, intimal area (0.07 vs 0.05 mm2, P = 0.80), width of intima (23 vs 21 m, P = 0.88, width of media (149 vs 148 m, P = 0.49), intima-to-media ratio (0.19 vs 0.17, P = 0.96) or percentage of luminal narrowing (3.6 vs 3.6, P = 0.86). No atherosclerotic lesion or medial calcification was seen in either artery. Intimal hyperplasia was identified in 72 segments from 50 patients. In a multivariate logistic regression model, estimated glomerular filtration rate (GRF) was significantly associated with intimal hyperplasia (odds ratio 1.35 per 10-ml/min/1.73 m2 increase, 95% confidence interval 1.16-1.56, P < 0.01). In multivariate linear regression models, estimated GRF was significantly associated with the intima-to-media ratio ( -coefficient −0.009, 95% confidence interval −0.013 to −0.005, P < 0.01) and percentage of luminal narrowing ( -coefficient −0.011, 95% confidence interval −0.014 to −0.008, P < 0.01).
CONCLUSIONS
The right and left internal thoracic arteries have equivalent histological and morphometric properties. Lower estimated GRF is significantly associated with intimal hyperplasia.
Although improved long-term outcomes obtained with the use of arterial grafts for coronary revascularization in comparison with the traditional association of a single arterial and saphenous vein ...grafts have been demonstrated in the overall population, the efficacy of this newer technique in the elderly is difficult to prove because their shorter life expectancy due to advanced heart disease, associated with severe comorbidities. Moreover, more widespread use of this technique is limited by the concerns on the potential morbidity, particularly the longer time required to perform the operation and the possibility of deep sternal wound infection in case of bilateral internal thoracic artery harvesting due to the decreased blood supply to the sternum and surrounding tissues.The review of the recent literature indicates that the use of bilateral internal thoracic arteries in very elderly patients should not be considered routinely. It seems reasonable to avoid it in octogenarians in the presence of well-known predictors of sternal complications such as diabetes, morbid obesity, and severe chronic lung disease.There is also still controversy about the superiority of the radial artery over the saphenous vein graft as a second or third conduit for surgical myocardial revascularization, although the majority of recent studies seem to support more liberal use of the radial artery as second arterial conduit in the elderly. Although a clinical benefit of arterial graft revascularization cannot be formally excluded for elderly patients, the increased complexity of this technique suggests that careful clinical judgment is necessary to select grafts for individual patients.
Background Vascular access has always been the Achilles repair of hemodialysis. Developments in health care have carried forward patients requiring management who have no veins appropriate for ...formation of arteriovenous fistula or insert of central venous catheters. This study reports arterioarterial prosthetic loop (AAPL) graft as an effective access for hemodialysis patients with venous occlusion.
Objective To assess AAPL graft regarding primary and secondary patency rates and incidence of complications.
Patients and methods This study was performed on 20 patients with the end-stage renal diseases. The age of the patients ranged between 47 and 72 years, with a mean age of 57.9 years.
Results The primary patency rates were 100, 100, 95, 90, and 80%, respectively, and the secondary patency rates were 100, 100, 100, 95.0, and 95.0% at 1, 3, 6, 9, and 12 months, respectively.
Conclusion AAPL can offer an efficient access for hemodialysis in such special group of patients with unsuitable arteriovenous access or having cardiac insufficiency.
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