Long-Term Survival After Coronary Arterial Grafts in Patients With End-Stage Renal Disease

Clinical outcomes after coronary artery bypass grafting in patients with dialysis-dependent end-stage renal disease and an analysis of the related influencing factors

Perioperative and short/mid-term survival rates of dialysis-dependent patients with end-stage renal disease (ESRD), who undergo coronary artery bypass grafting (CABG), and the factors influencing mortality are not well evaluated In China. We retrospectively analyzed the perioperative and postoperative 1-, 3-, and 5-year survival rates of 53 dialysis-dependent ESRD patients who underwent CABG, and compared the factors related to perioperative mortality and all-cause mortality during the postoperative follow-up. Survival rates were expressed as Kaplan-Meier survival curves, and factors influencing the follow-up survival rates were analyzed using the log rank (Mantel-Cox) test. There were eight perioperative deaths, resulting in 15.1% mortality. Intraoperative intra-aortic balloon pump use (P = 0.01), advanced age (P = 0.0027), and high EuroSCORE II score (P = 0.047) were associated with increased perioperative mortality. Forty-five discharged patients were followed from 2 months to 10 years (median, 4.2 years) postoperatively. There were 19 all-cause deaths, including 10 cardiac deaths (10/19, 52.6%). Comparisons between groups indicated that the presence of peripheral artery disease (PAD) increased mortality during follow-up (P = 0.025); 1-, 3-, and 5-year survival rates were 93.3, 79.5, and 66.8%, respectively. The results of the long-rank analysis indicated that the presence of PAD was a risk factor for postoperative survival (log rank χ² = 4.543; P = 0.033). Dialysis-dependent patients with ESRD had high perioperative mortality and unsatisfactory short- and medium-term survival after CABG. PAD was a risk factor affecting patients' postoperative survival. Multidisciplinary teamwork is needed to enhance postoperative management and reduce complications, to improve postoperative survival in these patients.

The use of both internal thoracic arteries for coronary revascularization increases the estimate of post-operative lower limb ischemia in patients with peripheral artery disease

BACKGROUND

Patients with a history of peripheral arterial disease (PAD) undergoing coronary artery bypass grafting (CABG) exhibit higher rates of complications. There are conflicting data on the survival benefits for bilateral thoracic artery (BITA) grafting compared with left internal thoracic artery (LITA) CABG in patients with PAD. The aim of the study was to explore the influence of the use of BITA grafts vs. LITA for CABG on post-operative acute lower limb ischemia (ALLI) and main post-operative complications in patients with concomitant PAD.

METHODS

We used a propensity-score (PS) based analysis to compare outcomes between the two surgical procedures, BITA and LITA. The inverse probability of treatment weighting PS technique was applied to adjust for pre- and intra-operative confounders, and to get optimal balancing of the pre-operative data. The primary outcome was the estimate of postoperative ALLI. Secondary outcomes included overall death and death of cardiac causes within 30 days of surgery, stroke and acute kidney disease (AKD).

RESULTS

The study population consisted of 1961 patients. The LITA procedure was performed in 1768 patients whereas 193 patients underwent a BITA technique. The estimate of ALLI was 14% higher in the BITA compared to the LITA (p < 0.001) group. Thirty-day mortality, cardiac death, occurrence of stroke and AKI did not differ significantly between the groups.

CONCLUSIONS

The use of both ITAs led to a significant increase in ALLI. This result was most likely caused by the complete disruption of the ITA collateral providing additional blood supply to the lower extremities. Based on our data, BITA should be used with extreme caution in PAD patients. Further research on this topic is necessary to confirm our findings.

The long-term patency of a gastroepiploic artery bypass graft deployed in a semiskeletonized fashion: predictors of patency

OBJECTIVES

Whether or not using the gastroepiploic artery (GEA) is associated with improved outcomes of coronary artery bypass grafting (CABG) remains unclear. Previous research has shown that the short-term function of the GEA was strongly associated with the degree of native vessel stenosis. We assessed the association between long-term GEA patency and the degree of stenosis of the coronary artery.

METHODS

We retrospectively examined 517 patients who underwent CABG with an in situ semiskeletonized GEA from January 2000 to January 2015. In this cohort, 282 (54.5%) patients underwent distant radiological evaluations for >1 year post-surgery (range 1-18 years after surgery). Quantitative coronary angiography was used to measure the degree of stenosis of the native coronary artery. Preoperative angiographic parameters include the minimal lumen diameter (MLD) and the percentage of target vessel stenosis. A multivariable stepwise Cox proportional hazards regression analysis was used to identify predictors of angiographic occlusion.

RESULTS

The cumulative patency rate of the GEA was 79.3% at 10 years. A multivariable analysis showed that an MLD (hazard ratio 4.43, 95% confidence interval 3.25-6.82; P < 0.001) was an independent risk factor of GEA occlusion. A time-dependent receiver operating characteristic (ROC) curve analysis identified that an MLD >1 mm was set as the cut-off value for graft occlusion. Patients with an MLD <1 mm had a 10-year patency rate of 89.8%.

CONCLUSIONS

The long-term patency of the semiskeletonized GEA was acceptable. The target vessel MLD obtained using quantitative coronary angiography was a strong predictor of patency. Good long-term patency can be expected for an MLD <1 mm.

Bilateral versus single internal thoracic artery grafting in hemodialysis patients

BACKGROUND

The use of the bilateral internal thoracic arteries (BITAs) during myocardial revascularization reportedly provides a survival benefit over using a single internal thoracic artery (SITA). However, the advantages in chronic hemodialysis patients, who generally have multiple comorbidities, is unclear.

METHODS

Outcomes of chronic hemodialysis patients who underwent isolated coronary artery bypass grafting (CABG) using a SITA with additional saphenous vein grafts (SVGs) (n = 33) or BITAs (n = 30) for left-side revascularization were retrospectively reviewed.

RESULTS

With the exception of the rate of diabetes mellitus (SITA vs. BITA: 84.8% vs. 50.0%; p = 0.003), the two groups showed similar patient characteristics. Using the off-pump technique, revascularization was completed without manipulation of the ascending aorta in 45.7% of patients in the BITA group, whereas all patients in the SITA group required aortic manipulation (p < 0.001). Of note, the incidence of extensive aortic calcification (>50% of ascending aorta circumference) was not uncommon (14.3%). The in-hospital mortality (3.0% vs. 0%, p = 0.336) and complication rates (including deep wound infection, re-exploration and stroke) were similar in both groups. The 5-year estimated survival rates for freedom from overall death in the SITA and BITA groups were 42.4% and. 57.4%, respectively (p = 0.202).

CONCLUSIONS

BITA grafting was able to achieve revascularization with minimal manipulation of the diseased ascending aorta without increasing the complication rate. The long-term survival benefit of BITA grafting, however, was unclear in dialysis patients, especially because such patients have a relatively short life expectancy.

Efficacy of Carperitide in Hemodialysis Patients Undergoing Cardiac Surgery

PURPOSE

Recently, performance of cardiac surgery in hemodialysis patients has increased, but the mortality rate is high.

METHODS

We retrospectively examined the early and long-term outcomes in 128 dialysis patients who underwent cardiac surgery with or without carperitide infusion and were followed for 2 years. Sixty-three patients received carperitide infusion during surgery and 65 patients did not.

RESULTS

The hospital mortality rate was 1.6% in the carperitide group and 12.3% in the non-carperitide group, being significantly lower in the carperitide group. The 2-year actuarial survival rate was 90.5% ± 3.7% in the carperitide group, and 76.9% ± 5.2% in the non-carperitide group, while the major adverse cardiovascular and cerebrovascular events (MACCE)-free rate at 2 years postoperatively was 90.5% ± 3.7% in the carperitide group and 67.7% ± 5.8% in the non-carperitide group.

CONCLUSIONS

These findings suggest that carperitide improves the early postoperative outcome in dialysis patients undergoing cardiac surgery, as has already been demonstrated in non-dialysis patients. An early postoperative cardioprotective effect of carperitide and improvement of renal function in oliguric patients might have contributed to this outcome. However, this was a retrospective study, so a prospective investigation is required to demonstrate the mechanisms involved. In addition, further evaluation of the long-term results would be desirable.

Coronary Revascularization in Patients with CKD Stage 5D: Pragmatic Considerations

Coronary revascularization decisions for patients with CKD stage 5D present a dilemma for clinicians because of high baseline risks of mortality and future cardiovascular events. This population differs from the general population regarding characteristics of coronary plaque composition and behavior, accuracy of noninvasive testing, and response to surgical and percutaneous revascularization, such that findings from the general population cannot be automatically extrapolated. However, this high-risk population has been excluded from all randomized trials evaluating outcomes of revascularization. Observational studies have attempted to address long-term outcomes after surgical versus percutaneous revascularization strategies, but inherent selection bias may limit accuracy. Compared with percutaneous strategies, surgical revascularization seems to have long-term survival benefit on the basis of observational data but associates with substantially higher short-term mortality rates. Percutaneous revascularization with drug-eluting and bare metal stents associates with a high risk of in-stent restenosis and need for future revascularization, perhaps contributing to the higher long-term mortality hazard. Off-pump coronary bypass surgery and the newest generation of drug-eluting stent platforms offer no definitive benefits. In this review, we address the nuances, complexities, and tradeoffs that clinicians face in determining the optimal method of coronary revascularization for this high-risk population.

Bilateral internal mammary artery grafting: rationale and evidence

Coronary artery bypass graft (CABG) surgery remains the preferred mode of revascularization in patients with complex multi-vessel coronary artery disease. The left internal mammary artery (IMA) and saphenous vein are the most commonly utilized conduits in CABG surgery and are still considered to be the gold standard by most surgeons. However, there is emerging evidence that use of bilateral IMAs is associated with significantly better long-term outcomes and the benefit increases with time from surgery. In spite of this incremental beneficiary effect, most surgeons are reluctant to use both IMAs, because it is technically more demanding, time-consuming and is associated with marginally higher sternal wound infection rates. This review highlights the histological features, physiological characteristics and genomics of IMAs that provide the basis for the use of these vessels during CABG surgery. Additionally, the superiority of the bilateral IMAs with regard to patency and long-term outcomes is also discussed in detail. Furthermore, the safety of using bilateral IMAs with regard to early postoperative outcomes with special reference to deep sternal wound infections has been addressed. The present review provides enough evidence to convince more surgeons about the advantages of bilateral IMA grafting.

Percutaneous coronary intervention versus coronary artery bypass grafting in patients with end-stage renal disease requiring dialysis (5-year outcomes of the CREDO-Kyoto PCI/CABG Registry Cohort-2)

Ischemic heart disease is a major risk factor for morbidity and mortality in patients with end-stage renal disease. However, long-term benefits of percutaneous coronary intervention (PCI) relative to coronary artery bypass grafting (CABG) in those patients is still unclear in the drug-eluting stent era. We identified 388 patients with multivessel and/or left main disease with end-stage renal disease requiring dialysis among 15,939 patients undergoing first coronary revascularization enrolled in the Coronary REvascularization Demonstrating Outcome Study in Kyoto PCI/CABG Registry Cohort-2 (PCI: 258 patients and CABG: 130 patients). The CABG group included more patients with 3-vessel (38% vs 57%, p <0.001) and left main disease (10% vs 34%, p <0.001). Preprocedural Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery score in the CABG group was significantly higher than that in the PCI group (23.5 ± 8.7 vs 29.4 ± 11.0, p <0.001). Unadjusted 30-day mortality was 2.7% for PCI and 5.4% for CABG. Cumulative 5-year all-cause mortality was 52.3% for PCI and 49.9% for CABG. Propensity score-adjusted all-cause mortality was not different between PCI and CABG (hazard ratio [HR] 1.33, 95% confidence interval [CI] 0.85 to 2.09, p = 0.219). However, the excess risk of PCI relative to CABG for cardiac death was significant (HR 2.10, 95% CI 1.11 to 3.96, p = 0.02). The risk of sudden death was also higher after PCI (HR 4.83, 95% CI 1.01 to 23.08, p = 0.049). The risk of myocardial infarction after PCI tended to be higher than after CABG (HR 3.30, 95% CI 0.72 to 15.09, p = 0.12). The risk of any coronary revascularization after PCI was markedly higher after CABG (HR 3.78, 95% CI 1.91 to 7.50, p <0.001). Among the 201 patients who died during the follow-up, 94 patients (47%) died from noncardiac morbidities such as stroke, respiratory failure, and renal failure. In patients with multivessel and/or left main disease undergoing dialysis, 5-year outcomes revealed that CABG relative to PCI reduced the risk of cardiac death, sudden death, myocardial infarction, and any revascularization. However, the risk of all-cause death was not different between PCI and CABG.

Bilateral internal thoracic artery grafting for peripheral arterial disease patients

BACKGROUND

Peripheral arterial disease (PAD) is known to have a poor prognosis. Some reports have also described poor late results after coronary artery bypass grafting (CABG). However, there have been few reports about whether bilateral internal thoracic artery grafting improves the long-term survival of PAD patients after CABG. We performed this study to clarify whether or not this is the case.

METHODS

One hundred and thirty-six PAD patients who underwent elective CABG with two or more grafts were enrolled in this study. Patients were divided into two groups, 71 patients in the bilateral internal thoracic artery (BITA) group and 65 patients in the single internal thoracic artery (SITA) group. The maximum follow-up period was 19 years, with a mean of 5.7 ± 4.4 years.

RESULTS

We investigated the long-term results based on three factors; survival, freedom from cardiac death, and freedom from cardiac events. The 3-, 5- and 10-year survival rates in the BITA group were 83.0, 74.2, and 43.1%, respectively. And those in the SITA group were 79.4, 67.7, and 32.3%, respectively. There were no significant differences between the two groups (p = 0.5843). There were also no statistically significant differences between the two groups in terms of the freedom from cardiac death (p = 0.8589) or in the freedom from cardiac events (p = 0.9445).

CONCLUSION

No long-term advantage was observed for CABG with BITA in comparison to SITA alone in patients with PAD.

Outcomes following cardiac surgery in patients with preoperative renal dialysis

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was that whether patients who are dependent on chronic dialysis have higher morbidity and mortality rates than the general population when undergoing cardiac surgery. These patients often require surgery in view of their heightened risk of cardiac disease. Altogether 278 relevant papers were identified using the below mentioned search, 16 papers represented the best evidence to answer the question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses were tabulated. Dialysis-dependent (DD) patients undergoing coronary artery bypass grafting (CABG) or valve replacement have higher morbidity but acceptable outcomes. There is some evidence to show that outcomes after off-pump coronary artery bypass grafting (OPCAB) are better than after on-pump coronary artery bypass grafting (ONCAB) and that results are worse in DD patients with diabetic nephropathy. Patients undergoing combined procedures have a higher mortality.

Total arterial coronary revascularization-patient selection, stenoses, conduits, targets

Graft patency determines prognosis in coronary artery bypass grafting (CABG). Numerous reports over the past 20 years have documented superior patencies and prognosis when multiple arterial grafts are used, yet less than 10% of CABG have multiple arterial grafts. Several conduits have been proposed, with varying degrees of success. Saphenous vein grafts (SVG) begin to fail with intimal hypertrophy and then atheroma after 5 years, with patency rates of 50% to 60% at 10 years, and <30% at 15 years. In contrast, left internal thoracic artery (LITA) patency is >95% at 10 years and >90% at 20 years. The radial artery is extremely versatile and can reach all territories, but is muscular and vulnerable to spasm and competitive flow. Similarly, the right gastroepiploic artery is also muscular, and is best suited to the posterior descending coronary artery, especially in reoperations and is also affected by competitive flow. In addition, bilateral internal thoracic artery grafting (BITA) grafts and total arterial revascularization (TACR) can be performed with identical perioperative mortality (1%) and perioperative morbidity to LITA + SVG. Importantly, survival is superior-85% to 90% at 10 years versus 75% to 80% respectively. BITA/TACR patients also suffer fewer late cardiac events and reoperations, with superior results for older patients, those requiring urgent surgery, diabetics, patients with renal dysfunction and in reoperations. Contraindications to BITA include obesity, insulin dependent diabetics, and severe chronic obstructive airways disease. As such, arterial grafts have better patencies and clinical results. BITA/TACR is often underutilized, but can be achieved in the majority of patients. Opportunities exist to enhance BITA/TACR use in CABG to the potential benefit of our patients.

Heart surgery in end-stage renal disease: is outcome worse for african american patients?

General results of open heart surgery in end-stage renal disease patients (ESRD) have been well-documented. However, it is unknown if the African American subgroup with known decreased access to advanced healthcare services and a higher prevalence rate of ESRD have a worse long-term survival after heart surgery. Thirty of 150 African American patients who underwent open heart surgery by a single surgeon at an urban community hospital between 1996 and 2010 were identified to have ESRD and were on chronic maintenance hemodialysis prior to surgery. Clinical and outcome data from both groups were retrospectively analyzed. There were no significant differences in the baseline demographic characteristics of the patients, but the ESRD cohort showed a significantly higher prevalence of peripheral vascular and cardiovascular diseases [P < 0.001]. Compared to the non-ESRD subjects, the predicted logistic EuroSCORE was 16.4% vs. 9.4%, [P < 0.001], while the observed 30 days operative mortality was 16.6% vs. 4.2% [P < 0.02], respectively. In isolated coronary artery bypass graft cases, operative mortality was 20.8% and 3.0%, respectively. The 5- and 10-year post-surgery survival was 40% and 25% vs. 72% and 57% [P < 0.01], respectively, in the ESRD and non-ESRD groups. Operative mortality and survival was worse in ESRD patients compared to non-ESRD patients based on their preoperative risk scores. Although the operative mortality of our ESRD patients was high, long-term survival was comparable to reports from both the United States Renal Data System and a Japanese ESRD cohort.