Conduits' Biology Regulates the Outcomes of Coronary Artery Bypass Grafting

Sequential Grafting of the Left Internal Thoracic Artery to the Left Anterior Descending Artery and Graft Failure

BACKGROUND

There is concern that left internal thoracic artery (LITA)-to diagonal (D)-to left anterior descending artery (LAD) grafts may be more susceptible to failure compared with single LITA-LAD grafts.

METHODS

Pooled individual patient data from 8 clinical trials with systematic graft imaging were analyzed to assess the incidence of sequential LITA-D-LAD vs single LITA-LAD grafts. Mixed-effects multivariable logistic regression, adjusting for patient characteristics and clustering within trials, was used.

RESULTS

Of 3969 patients with LITA-LAD grafts, 283 patients (7.1%) received sequential LITA-D-LAD grafts. Patients with sequential LITA-D-LAD grafts were older (66 vs 65 years, P = .009) and more often men (88% vs 83%, P = .03). Overall, graft failure occurred in 9.3% of patients with LITA-LAD grafts, with more graft failure occurring in single (9.5%) than in sequential LITA-D-LAD grafts (6.4%, P = .08) at a median time to imaging of 1.0 years (interquartile range, 1.0-1.1 years). After multivariable adjustment, sequential LITA-D-LAD grafting was not associated with graft failure (adjusted odds ratio, 1.22; 95% CI, 0.68-2.18; P = .55). There was no difference between groups in mortality (2.8% vs 5.3%, P = .06), myocardial infarction (1.4% vs 1.6%, P = .90), revascularization (4.5% vs 7.3%, P = .08), or stroke (1.7% vs 1.2%, P = .40).

CONCLUSIONS

In selected patients, LITA-D-LAD grafting was not associated with higher risk of graft failure or adverse clinical events at 1 year.

Multi-Omics Profiling of Human Endothelial Cells from the Coronary Artery and Internal Thoracic Artery Reveals Molecular but Not Functional Heterogeneity

Major adverse cardiovascular events occurring upon coronary artery bypass graft surgery are typically accompanied by endothelial dysfunction. Total arterial revascularisation, which employs both left and right internal thoracic arteries instead of the saphenous vein to create a bypass, is associated with better mid- and long-term outcomes. We suggested that molecular profiles of human coronary artery endothelial cells (HCAECs) and human internal mammary artery endothelial cells (HITAECs) are coherent in terms of transcriptomic and proteomic signatures, which were then investigated by RNA sequencing and ultra-high performance liquid chromatography-mass spectrometry, respectively. Both HCAECs and HITAECs overexpressed molecules responsible for the synthesis of extracellular matrix (ECM) components, basement membrane assembly, cell-ECM adhesion, organisation of intercellular junctions, and secretion of extracellular vesicles. HCAECs were characterised by higher enrichment with molecular signatures of basement membrane construction, collagen biosynthesis and folding, and formation of intercellular junctions, whilst HITAECs were notable for augmented pro-inflammatory signaling, intensive synthesis of proteins and nitrogen compounds, and enhanced ribosome biogenesis. Despite HCAECs and HITAECs showing a certain degree of molecular heterogeneity, no specific markers at the protein level have been identified. Coherence of differentially expressed molecular categories in HCAECs and HITAECs suggests synergistic interactions between these ECs in a bypass surgery scenario.

Apolipoprotein A-I vascular gene therapy reduces vein-graft atherosclerosis

Coronary artery venous bypass grafts typically fail because of atherosclerosis driven by lipid and macrophage accumulation. Therapy for vein-graft atherosclerosis is limited to statin drugs, which are only modestly effective. We hypothesized that transduction of vein-graft endothelium of fat-fed rabbits with a helper-dependent adenovirus expressing apolipoprotein AI (HDAdApoAI) would reduce lipid and macrophage accumulation. Fat-fed rabbits received bilateral external jugular vein-to-carotid artery interposition grafts. Four weeks later, one graft per rabbit (n = 23 rabbits) was infused with HDAdApoAI and the contralateral graft with HDAdNull. Grafts were harvested 12 weeks later. Paired analyses of grafts were performed, with vein graft cholesterol, intimal lipid, and macrophage content as the primary endpoints. HDAd genomes were detected in all grafts. APOAI mRNA was median 63-fold higher in HDAdApoAI grafts versus HDAdNull grafts (p < 0.001). HDAdApoAI grafts had a mean 15% lower total cholesterol (by mass spectrometry; p = 0.003); mean 19% lower intimal lipid (by oil red O staining; p = 0.02); and mean 13% lower expression of the macrophage marker CD68 (by reverse transcriptase-mediated quantitative PCR; p = 0.008). In vivo transduction of vein-graft endothelium achieves persistent APOAI expression and reduces vein-graft cholesterol, intimal lipid, and CD68 expression. Vascular gene therapy with APOAI has promise for preventing vein-graft failure caused by atherosclerosis.

Persistent median artery on computed tomographic arteriovenous fistulograms in patients on haemodialysis

INTRODUCTION

Cadaveric studies suggest an increasing prevalence of the persistent median artery (PMA) over a prolonged timeframe. The aim of this retrospective cross-sectional study was to evaluate the PMA prevalence in haemodialysis patients who had computed tomographic fistulograms (CTFs), and if present, their calibres and origins.

METHODS

All consecutive adult patients referred for an upper limb CTFs for assessment of arteriovenous fistula (AVF) dysfunction from 2006 to 2021 were included. Patients whose CTF did not include the forearm were excluded. PMA was identified as an artery running alongside the median nerve between flexor digitorum superficialis and flexor digitorum profundus. Patient demographics, presence of PMA including size and origin were recorded.

RESULTS

A PMA was found in 91/170 (53.5%) CTFs (7:3 male-to-female ratio, mean age 71-years). When stratified by age, prevalence increased with decreasing age; 51% in >70-year-olds, 54% in 50-70-year-olds and 67% in <50-year-olds. The average PMA diameter was 2.2 mm proximally and 1.8 mm distally. No stenosis was observed in the PMAs.

CONCLUSION

The PMA prevalence appears to increase with decreasing age and is a frequently encountered anatomical variant. Radiologists assessing forearm vasculature need to be aware of this anatomical variant and potentially include it in their future reports. Further research into the PMA may make its potential use as arterial conduits for AVF, potential donor grafts for coronary artery bypass surgery or additional vascular access options possible. Whether the reducing prevalence with age reflects an overall increasing prevalence is yet to be determined.

Evaluating the Arteriotomy Size of a New Sutureless Coronary Anastomosis Using a Finite Volume Approach

OBJECTIVES

The ELANA® Heart Bypass creates a standardized sutureless anastomosis. Hereby, we investigate the influence of arteriotomy and graft size on coronary hemodynamics.

METHODS

A computational fluid dynamics (CFD) model was developed. Arteriotomy size (standard 1.43 mm2; varied 0.94 - 3.6 mm2) and graft diameter (standard 2.5 mm; varied 1.5 - 5.0 mm) were independent parameters. Outcome parameters were coronary pressure and flow, and fractional flow reserve (FFR).

RESULTS

The current size ELANA (arteriotomy 1.43 mm2) presented an estimated FFR 0.65 (39 mL/min). Enlarging arteriotomy increased FFR, coronary pressure, and flow. All reached a maximum once the arteriotomy (2.80 mm2) surpassed the coronary cross-sectional area (2.69 mm2, i.e. 1.85 mm diameter), presenting an estimated FFR 0.75 (46 mL/min). Increasing graft diameter was positively related to FFR, coronary pressure, and flow.

CONCLUSION

The ratio between the required minimal coronary diameter for application and the ELANA arteriotomy size effectuates a pressure drop that could be clinically relevant. Additional research and eventual lengthening of the anastomosis is advised.

Survival and Independent Predictors of Mortality Following Coronary Artery Bypass Graft Surgery in a Single-Unit Practice in the United Kingdom Over 20 Years

BACKGROUND

 The types of graft conduits and surgical techniques may impact the long-term outcomes of patients after coronary artery bypass graft (CABG) revascularization. This study observed a long-term survival rate following CABG surgery over 20 years in the United Kingdom.

METHODS

 A total of 2979 isolated CABG patients were studied from 1999 to 2020, and postoperative data were obtained from the hospital-recorded mortality by the data quality team of the information department. Postdischarge survival was estimated using the Kaplan-Meier method, and statistical significance was obtained with log-rank tests and the Gehan-Breslow test, and the Holm-Sidak method was used for multiple pairwise comparisons.

RESULTS

 The study observed male predominance (80%), and the median age was statistically significant (P <0.001) among the groups, 66 years (interquartile range 58-73) and 72 years (interquartile range 66-78) in survivor and non-survivor groups, respectively. In the Holm-Sidak method analysis, the best survival rate (mean 18.7 years) was observed in the total arterial group with significantly decreased survival for the mixed arterial and venous group (mean 16.12 years) and only the vein group (10.44 years). The Cox regression model observed that the New York Heart Association (NYHA) class III-IV (HR 1.57), chest re-exploration (HR 2.14), preoperative dialysis (HR 3.13), and redo surgery (HR 3.04) were potential predictors of the postoperative mortality (P ≤0.05).

CONCLUSION

 In our series over 20 years, albeit off-pump and on-pump CABG observed similar survival rates, the total arterial myocardial revascularization population has significantly better long-term survival benefits.

Angiographic Outcomes for Arterial and Venous Conduits Used in CABG

Coronary artery bypass grafting is the most commonly performed cardiac surgical procedure. Conduit selection is crucial to achieving early optimal outcomes, with graft patency being likely the main driver to long-term survival. We present a review of current evidence on the patency of arterial and venous bypass conduits and of differences in angiographic outcomes.

Sex differences in saphenous vein graft patency: A systematic review and meta-analysis

BACKGROUND

Saphenous vein grafts (SVG) are the most commonly used conduits in coronary artery bypass grafting (CABG). Graft failure is observed in up to 50% of SVG at 10 years after surgery. Whether a difference in SVG patency rates exists between men and women remains unclear.

METHODS

We performed a study-level meta-analysis to evaluate sex-related differences in follow-up patency rates of SVG after CABG. A systematic literature search was conducted to identify studies on CABG that reported follow-up SVG patency rates in men and women. The primary outcome was SVG patency rates by sex at follow-up.

RESULTS

Seventeen studies totaling 8235 patients and 14,781 SVG grafts were included. There was no significant difference in follow-up SVG patency rates between men and women (incidence rate ratio 0.96, 95% confidence interval 0.90-1.03, p = .24), with mean angiographic follow-up of 33.5 months (standard deviation 29.2). Leave-one-out and cumulative analysis were consistent with the main analysis. We concluded that follow-up SVG patency rate is similar between men and women undergoing CABG.

Quantification of the internal mammary artery size in Aboriginal and Torres Strait islanders

BACKGROUND

Variation in size of the internal mammary artery has been demonstrated in ethnic groups, but not reported in Aboriginal patients. We hypothesised that the left internal mammary artery is smaller in Aboriginal patients compared to non-Aboriginal patients and aimed to determine the impact on survival following coronary artery bypass graft (CABG) surgery.

METHODS

Left internal mammary artery size was compared between Aboriginal (n = 345) and non-Aboriginal (n = 1819) in 2343 patients undergoing CABG at Flinders Medical Centre from January 2010 to June 2021. To determine the association with-survival we used Kaplan-Meier survival analysis and Cox proportional hazard models adjusted for preoperative variables.

RESULTS

There was a significant difference in left internal mammary artery (LIMA) size-Aboriginal 1.8 ± 0.4 mm; non-Aboriginal 2.1 ± 0.4 mm (P < 0.001)-and left anterior descending (LAD) artery size-Aboriginal 1.7 ± 0.3 mm; non-Aboriginal 1.9 ± 0.3 mm (P < 0.001). Aboriginal patients were more likely to have the LIMA discarded (9.3% vs. 0.4%) and to receive a LAD vein graft (17% versus 3%) (P < 0.001). There was no difference in 30-day mortality or survival <5 years.

CONCLUSION

This study supports the hypothesis that the left internal mammary artery is smaller in Aboriginal patients compared to non-Aboriginal patients. Although Aboriginal patients were more likely to receive a venous conduit to the LAD, we observed no difference in survival up to 5 years. This data contrasts with reported outcomes of other ethnic groups.

Short-Term Evaluation of a Novel No-Touch Technique for Harvesting Saphenous Veins With Long-Shafted Ultrasonic Scalpel

OBJECTIVE

Saphenous vein grafts (SVGs) are widely used as bypass conduits in coronary artery bypass grafting. Compared with the conventional technique, the "no-touch" technique, wherein the saphenous veins are harvested with the surrounding tissue, may improve SVG patency; however, there are concerns regarding wound complications. To address this issue, we describe our novel no-touch technique with separate skin incisions using a long-shafted ultrasonic scalpel and report the clinical outcomes.

METHODS

We enrolled 66 male patients who underwent isolated coronary artery bypass grafting between April 2016 and April 2021. There were 30 and 36 patients treated using our no-touch technique and the conventional technique, respectively. The participants underwent coronary angiography before discharge and were followed clinically. SVG samples were taken for pathological examination.

RESULTS

SVGs harvested using our no-touch technique displayed preservation of the vessel wall structure and surrounding tissues. Our no-touch technique demonstrated no inferiority in patency compared with the conventional technique, and there was no SVG occlusion in the no-touch group. The frequency of leg wound complications was higher in the no-touch group than the conventional group, but no surgical site infections and severe complications occurred in the no-touch group.

CONCLUSIONS

SVGs harvested using our novel no-touch technique had similar pathological characteristics to those harvested using the original no-touch technique reported previously. Our no-touch technique maintained SVG patency and caused no severe wound complications. However, a large-scale, longitudinal study is required to accurately assess the clinical outcomes of our no-touch technique.

Sutureless versus Hand-Sewn Coronary Anastomoses: A Systematic Review and Meta-Analysis

BACKGROUND

Sutureless coronary anastomotic devices are intended to facilitate minimally invasive coronary artery bypass grafting (MICS-CABG) by easing and eventually standardizing the anastomotic technique. Within this systematic review and meta-analysis, we aim to determine patency and to evaluate safety outcomes for the sutureless anastomoses.

METHODS

CENTRAL, MEDLINE, and EMBASE were searched from database start till August 2021 in a predefined search strategy combining the key concepts: 'coronary artery bypass grafting', 'sutureless coronary anastomoses', and 'hand-sewn coronary anastomoses' by the Boolean operation 'AND'. Study characteristics, patient demographics, interventional details, and all available outcome data were extracted. A meta-analysis was performed on patency at longest follow-up. Safety outcomes were presented.

RESULTS

A total of eleven trials towards six sutureless anastomotic devices were included, comprising 3724 patients (490 sutureless and 3234 hand-sewn). There was no significant difference in patency at a mean follow-up duration of 546.3 (range 1.5-2691) days, with a risk ratio of 0.77 (95% CI 0.55-1.06). MACE was reported in 4.5% sutureless and 3.9% hand-sewn patients, including all-cause mortality (resp. 1.3 vs. 1.9%), myocardial infarction (resp. 1.6 vs. 1.7%), and coronary revascularization (resp. 1.8 vs. 0.5%). Incomplete hemostasis occurred in 24.8% of the sutureless anastomoses. Intra-operative device failure forced conversion to hand-sewn or redo-anastomosis in 5.8% of the sutureless cases.

CONCLUSION

Based on the systematic review and meta-analysis including six devices, we conclude that sutureless coronary anastomotic devices appear safe and effective when used by well-trained and dedicated surgical teams.