Comparison of operative mortality and morbidity for initial and repeat coronary artery bypass grafting: The Coronary Artery Surgery Study (CASS) registry experience

Recent Advances in Coronary Artery Bypass Grafting Techniques and Outcomes: A Narrative Review

Coronary artery bypass grafting (CABG) has witnessed remarkable progress in recent years, driven by innovative techniques and refined approaches that have transformed patient outcomes and treatment paradigms. This review article comprehensively explores the latest advances in CABG techniques and their consequential impacts on patient outcomes. The advent of minimally invasive CABG techniques has revolutionized traditional surgical approaches. Robotic-assisted surgery and small thoracotomy methods offer reduced invasiveness, yielding shorter recovery times and improved patient satisfaction. Integrating CABG with percutaneous coronary intervention (PCI), hybrid procedures have emerged as a versatile strategy, providing tailored treatment solutions for complex coronary anatomies. The paradigm shift to off-pump CABG, which preserves the beating heart during surgery, has shown promise in reducing perioperative complications and neurocognitive deficits. Advances in graft selection, particularly the utilization of arterial grafts such as the internal thoracic artery and radial artery, have significantly enhanced graft patency rates and long-term survival. Adjunctive technologies, such as intraoperative imaging and graft flow assessment, have bolstered the precision of CABG procedures. Pharmacological agents have demonstrated their potential to improve graft outcomes. Surgical decision-making is now optimized based on patient characteristics and disease severity owing to the development of patient selection and risk stratification tools. Long-term results have also significantly improved. Patients undergoing CABG have higher survival rates, less angina, and better quality of life. Developing more resilient grafts through tissue engineering, using bioresorbable materials in graft fabrication, and using gene therapy to improve graft patency and overall cardiac recovery are all exciting future research directions. This review's summary of current developments in CABG procedures highlights their profoundly positive effects on patient outcomes. These developments can change the face of cardiovascular care by giving clinicians more tools to treat coronary artery disease (CAD) and enhance patients' quality of life.

Advances in the Post-coronary Artery Bypass Graft Management of Occlusive Coronary Artery Disease

Revascularisation of chronic total occlusion (CTO) represents one of the most challenging aspects of percutaneous coronary intervention, but advances in equipment and an understanding of CTO revascularisation techniques have resulted in considerable improvements in success rates. In patients with prior coronary artery bypass grafting (CABG) surgery, additional challenges are encountered. This article specifically explores these challenges, as well as antegrade methods of CTO crossing. Techniques, equipment that can be used and reference texts are highlighted with the aim of providing potential CTO operators adequate information to tackle additional complexities likely to be encountered in this cohort of patients. This review forms part of a wider series where additional aspects of patients with prior CABG should be factored into decisions and methods of revascularisation.

In-hospital outcomes and usage of embolic protection devices in percutaneous coronary intervention for coronary artery bypass grafts: Insights from a Japanese nationwide registry

OBJECTIVES

We evaluated the in-hospital outcomes of percutaneous coronary intervention (PCI) for bypass graft vessels (GV-PCI) compared with those of PCI for native vessels (NV-PCI) using data from the Japanese nationwide coronary intervention registry.

METHODS

We included PCI patients (N = 748,229) registered between January 2016 and December 2018 from 1,123 centers. We divided patients into three groups: GV-PCI (n = 2,745); NV-PCI with a prior coronary artery bypass graft (pCABG) (n = 23,932); and NV-PCI without pCABG (n = 721,552).

RESULTS

GV-PCI implementation was low, and most cases of PCI in pCABG patients were performed in native vessels (89.7%) in contemporary Japanese practice. The risk profile of patients with pCABG was higher than that of those without pCABG. Consequently, GV-PCI patients had a significantly higher in-hospital mortality than NV-PCI patients without pCABG after adjusting for covariates (odds ratio [OR] 2.36, 95% confidence interval [CI] 1.66-3.36, p < .001). Of note, embolic protection devices (EPDs) were used in 18% (n = 383) of PCIs for saphenous vein grafts (SVG-PCI) with a significant variation in its use among institutions (number of PCI: hospitals that had never used an EPD vs. EPD used one or more times = 240 vs. 345, p < .001). The EPDs used in the SVG-PCI group had a significantly lower prevalence of the slow-flow phenomenon after adjusting for covariates (OR 0.45, 95% CI 0.21-0.91, p = .04).

CONCLUSION

GV-PCI is associated with an increased risk of in-hospital mortality. EDP use in SVG-PCI was associated with a low rate of the slow-flow phenomenon. The usage of EPDs during SVG-PCI is low, with a significant variation among institutions.

Nodular Calcification in Saphenous Vein Graft Successfully Treated by Percutaneous Coronary Intervention

Nodular calcification is sometimes detected in the native coronary artery. However, it is very rare to find in a saphenous vein graft (SVG). We herein report a rare case of stable angina pectoris (AP) due to nodular calcification. A 75-year-old man who had previously undergone coronary artery bypass grafting was admitted to our hospital due to stable AP. On angiography, significant stenosis was detected in the proximal SVG. Based on the findings of coronary angiography and optical coherence tomography, a red thrombus was suspected at the culprit lesion. However, nodular calcification was also suspected, as there were calcifications around the lesion. As intravascular ultrasound showed the protruding calcification, which we judged to be a nodular calcification, the calcified SVG lesion was successfully treated by percutaneous coronary intervention without any complications. Nodular calcification should be considered as a potential cause of AP, even when located in a SVG.

Effect of Aortic Cross-Clamp Time on Myocardial Infarction after Coronary Bypass Surgery

Univariate and multivariate statistical analyses were applied to 1200 consecutive patients undergoing first-time myocardial revascularization. Forty-three patients (3.6%) developed evidence of myocardial infarction as judged by serial electrocardiograms and release of enzymes. Out of 23 preoperative and intraoperative potential risk factors for perioperative myocardial infarction, multivariate regression analysis revealed that duration of aortic cross-clamping was a powerful continuous variable risk factor. The relative risk increased twofold at 44 minutes compared to 17 minutes, approached three times the risk at 53 minutes, and reached more than six times the risk after 84 minutes of aortic cross-clamping. Two other independent predictors for perioperative myocardial infarction were identified: the presence of preoperative arterial hypertension and significant (> 75%) left main coronary artery stenosis. Left ventricular impairment, gender, age, severity of angina, and the number of distal anastomoses were not identified as risk factors for perioperative myocardial infarction. Our data indicate that the incidence of perioperative myocardial infarction may be reduced by consistent efforts to minimize aortic cross-clamp time without compromising the adequacy of myocardial revascularization.

The Influence of Prior Median Sternotomy on Outcome of Heart Transplantation

This study is a retrospective analysis of the influence of previous cardiac surgery on the outcome of heart transplantation in 118 consecutive recipients from January 1988 to December 1996. Group 1 consisted of 67 patients who had no previous sternotomy, group 2 was 33 patients who had one previous sternotomy, and group 3 was 18 patients who had two or more previous sternotomies. The three groups were demographically similar apart from the indication for transplantation and the sex distribution. Preoperative hemodynamic data, except systolic pulmonary artery pressure, were similar among the three groups. There was no significant difference in hospital mortality, 1-year and 5-year actuarial survival rates, incidence of renal dysfunction requiring dialysis, prolonged respiratory support, elevated total bilirubin, re-exploration for bleeding, incidence of mediastinitis, or postoperative hospital stay between the groups. The rejection-free and infection-free survival rates were similar in the three groups. However, previous sternotomy resulted in significantly longer cardiopulmonary bypass times and increased requirement for blood and blood products. The use of a cell saver limited the need for stored red blood cells. This study demonstrated no survival disadvantage of previous sternotomy in patients undergoing heart transplantation.

The impact of diabetes mellitus on long-term clinical outcomes after percutaneous coronary saphenous vein graft interventions in the drug-eluting stent era

OBJECTIVES

We aimed to compare early and late clinical outcomes in diabetic and nondiabetic patients who underwent saphenous vein graft (SVG) percutaneous coronary interventions (PCI) with the use of drug-eluting stents (DES).

BACKGROUND

Patients with diabetes mellitus are shown to have less favorable outcomes after SVG intervention with the use of bare metal stents. In the DES era, the impact of diabetes mellitus on restenosis and clinical outcomes post-SVG intervention is not clearly defined.

METHODS

From our institutional PCI registry database, we retrospectively analyzed 477 consecutive patients with prior coronary artery bypass graft surgery undergoing SVG PCI with the implantation of DES stratified by the presence or absence of diabetes mellitus. The primary end-point was 1-year major adverse cardiac event (MACE) rate, defined as death, Q wave myocardial infarction, and target lesion revascularization.

RESULTS

Baseline clinical characteristics, including mean graft age (120 ± 77 vs. 131 ± 86 months, P = 0.14), were similar between groups, save for a higher prevalence of systemic hypertension and chronic renal insufficiency, and higher body mass index in the diabetic group. Among the 604 SVG lesions treated with DES, the angiographic and procedural characteristics were well matched between groups except for the higher rate of distal protection device use (32% vs. 29%, P = 0.007) in the diabetic group. The rates of 1-year MACE (21% vs. 15%, P = 0.12) and all-cause mortality (7.6% vs. 6.7%, P = 0.86) were similar between groups. After adjustment for the relevant clinical co-variables, diabetic status was not associated with the composite end-point.

CONCLUSION

In conclusion, DES, when used for the treatment of vein graft lesions, equate the short- and long-term outcomes between diabetic and nondiabetic patients, suggesting that DES should be considered the default stent in diabetic populations undergoing PCI for the treatment of SVG lesions.

Saphenous vein graft intervention

Saphenous vein grafts are commonly used conduits for surgical revascularization of coronary arteries but are associated with poor long-term patency rates. Percutaneous revascularization of saphenous vein grafts is associated with worse clinical outcomes including higher rates of in-stent restenosis, target vessel revascularization, myocardial infarction, and death compared with percutaneous coronary intervention of native coronary arteries. Use of embolic protection devices is a Class I indication according to the American College of Cardiology/American Heart Association guidelines to decrease the risk of distal embolization, no-reflow, and periprocedural myocardial infarction. Nonetheless, these devices are underused in clinical practice. Various pharmacological agents are available that may also reduce the risk of or mitigate the consequences of no-reflow. Covered stents do not decrease the rates of periprocedural myocardial infarction and restenosis. Most available evidence supports treatment with drug-eluting stents in this high-risk lesion subset to reduce angiographic and clinical restenosis, although large, randomized trials comparing drug-eluting stents and bare-metal stents are needed.

Positive family history of coronary atherosclerosis and serum triglycerides may predict repeated coronary artery bypass surgery

OBJECTIVE

Cardiovascular risk factor profile of patients in need of repeated coronary artery bypass surgery (redo CABG) seldom differ from patients having only single coronary artery bypass surgery (CABG). The aim of this study was to analyse the influence of positive family history for coronary artery disease in respect to redo CABG vs CABG in a case-control setting.

DESIGN

One hundred and eighty four patients undergoing redo CABG between 1990-1998 were identified from the computed registry of the Department of Cardiothoracic Surgery in Tampere University Hospital. One hundred and eighty four age, gender and operation date matched patients with CABG were selected for control.

RESULTS

According to chi-square analysis, positive family history for coronary artery disease was more common in Study group, 60.4% versus 49.5% (p<0.05). Preoperative systolic blood pressure was 135.5+/-1.4 mmHg versus 133.5+/-1.5 mmHg (ns), preoperative diastolic blood pressure was 81.2+/-0.8 mmHg versus 82.8+/-0.9 mmHg (ns), serum total cholesterol was 5.8+/-0.1 mmol/L versus 6.6+/-1.2 mmol/L and preoperative blood glucose was 5.6+/-0.2 mmol/L versus 5.3+/-0.2 mmol/L (ns) in Controls and Study group, respectively. However, serum triglyceride level was significantly higher in Study group 2.8+/-0.2 mmol/L versus 2.0+/-0.1 mmol/L (p<0.000). In regression analysis, only positive family history (OR=2.4; 95% CI=1.1-5.1; p<0,02) and high serum triglyceride level (>or=2 mmol/L, OR=1.6; 95% CI=1.2-2.2; p<0,02) were independent predictors for redo CABG.

CONCLUSION

According to this study, positive family history for coronary atherosclerosis at the presence of high serum triglyceride level is significantly predicting the need for future redo CABG as compared with age, gender and operation time matched controls of CABG.

A comparison of the radial and the femoral approach in vein graft PCI. A retrospective study

BACKGROUND

Transradial PCI is a safe and effective method of percutaneous revascularization. However, there is limited data on the efficacy of the transradial approach for saphenous vein graft (SVG) PCI.

METHODS

We studied 334 patients who underwent SVG PCI between January 2000 and December 2003, and compared the radial (132 patients) and the femoral (202 patients) approach.

RESULTS

Mean EF (55.6+/-18.6% radial versus 58.1+/-16.8% femoral), lesion location (proximal, mid, distal: 22.6/50.6/26.7% versus 22.6/44.5/32.9% respectively) and lesion type (B1/B2/C: 3.4/4.1/92.5% versus 0.4/3.1/96.5%) were similar in both groups (P>0.05). Five patients had a failed radial attempt (3.8%) and were switched to the femoral approach. Mean fluoroscopy time (20.4+/-12.2 versus 18.4+/-10.2 min), procedural time (60.0+/-27.2 versus 61.6+/-24.9 min) and the use of contrast (223+/-91 versus 234+/-91 ml) IIB/IIIA inhibitors (27.2 versus 33.2%), and stenting (81.5 versus 81.3%) were similar in both groups, whereas 5 or 6 French sheaths were used more often in the radial group (83.4 versus 64.9%, P<0.01). Angiographic success (93.9 versus 92.9%), in hospital MACE (radial:5 MI (3.8%) versus femoral: 1 death (0.5%) and 7 MI (3.5%) and major vascular complications (0.7 versus 0.5%) were also similar.

CONCLUSIONS

The radial approach in SVG PCI is as fast and successful as the femoral.

Long-term histological and immunohistochemical findings in human venous aorto-coronary bypass grafts

The aim of the present study was to analyse the long-term histology and immunohistochemistry of the plaque composition and cellular infiltration of SVGs (saphenous vein grafts) containing metallic stents. Percutaneous interventions in SVGs have a worse long-term clinical outcome compared with stenting of coronary arteries. Whether the pathological features of old degenerated SVGs condition the efficacy of drug-eluting stents is also unknown. Histology and immunohistochemistry of seven SVGs in the coronary circulation containing 12 metallic stents implanted 5 to 61 months before retrieval were analysed in patients undergoing a second aorto-coronary bypass surgery at a mean time of 11±6 years. The pathology of the old SVGs showed an important thrombotic and necrotic composition of the plaque, with plaque protrusion through the stent wires and a fragile media layer that could easily be damaged by stent placement with subsequent neointimal proliferation; indeed, stents with medial fracture had significantly greater mean neointimal thickness than those without (1.37±0.68 compared with 0.81±0.47 mm2; P<0.02). Neointimal inflammatory cell density correlated with increased neointimal thickness in patent vessels (r2=0.43, P<0.001). Immunostaining showed the total absence of ERs (oestrogen receptors), a poor cellular proliferative state as indicated by the presence of the Ki-67 marker, and persistent inflammation close to the stent wires as revealed by KP-1 and ACE (angiotensin-converting enzyme) immunostaining in most inflammatory cells in contact with the metal. These pathological findings may contribute to the more severe progression of disease and worse clinical outcome observed after conventional stented angioplasty of SVGs and might also interfere with the efficacy of drug-eluting stents in this specific atherosclerotic milieu.

Does Re-operation have an Effect on Outcome Following Heart Transplantation?

OBJECTIVE

Previous cardiac operation has traditionally been considered as a potential risk factor for patients undergoing heart transplantation. This study aimed to evaluate the outcome of patients undergoing heart transplantation as a second cardiac procedure and compare it with primary heart transplantation, using meta-analytical methodology.

METHODS

A literature search was undertaken to identify relevant comparative studies. Outcomes of interest were classified into four categories: (a) intra-operative times; (b) post-operative outcomes; (c) resources; (d) actuarial outcomes.

RESULTS

Seven studies matched the selection criteria, reporting on 1004 patients. Six hundred and twenty-three had transplantation as primary operation and 381 as re-operation. The 1-year, 2-year, and 5-year mortality were similar for the two groups (HR=0.85, p=0.54; HR=0.97, p=0.88; and HR=1.04, p=0.92, respectively). Total operative, cold-ischaemic, by-pass, and cross-clamp times were significantly longer for the re-operation group by 59.44 (p<0.001), 14.62 (p=0.05), 25.24 (p<0.001), and 7.93 (p<0.001)min, respectively. Both ICU and hospital stay were longer for the re-operation group but only the former was statistically significant (WMD=1.37; p=0.02). Post-operative complications were similar, except re-exploration rate and blood transfusion requirement, which were higher in the re-operation group (OR=3.51; p<0.001 and WMD=2.21; p<0.001, respectively).

CONCLUSIONS

Heart transplantation following previous cardiac operation is technically demanding requiring longer operative times compared to primary heart transplantation. It does not, however, add a significant risk to the survival of the patient, and associated morbidity is not significantly compromised.

Clinical correlates of long-term mortality after percutaneous interventions of saphenous vein grafts

BACKGROUND

Increasing number of patients undergo percutaneous intervention of saphenous vein grafts (SVGs). However, the clinical factors associated with long-term mortality after SVG interventions are currently less known. Accordingly, the goal of present study was to evaluate clinical correlates of long-term mortality and to develop a simple bedside tool for risk stratification in patients undergoing SVG interventions.

METHODS

We analyzed 1019 patients undergoing SVG interventions from the Duke Cardiovascular Disease Database (1986-2003). Cox proportional hazards model was used to identify baseline variables associated with long-term mortality, and the model variables were then used to construct a nomogram for survival probability at 4 years.

RESULTS

At a median follow-up of 4 years, 24% of those undergoing SVG interventions died (interquartile range 2-7 years). Independent correlates of death at follow-up on multivariable analysis included presenting heart rate (hazard ratio [HR] 1.02, 95% CI 1.01-1.03), diabetes (HR 1.73, 95% CI 1.37-2.18), presenting heart failure (HR 1.62, 95% CI 1.27-2.06), age (per 10-year increase, HR 1.29, 95% CI 1.13-1.46), peripheral vascular disease (HR 1.59, 95% CI 1.23-2.04), renal insufficiency (HR 2.01, 95% CI 1.36-2.97), patent internal mammary graft (HR 0.67, 95% CI 0.53-0.86), body mass index < or = 25 kg/m2 (HR 0.91, 95% CI 0.85-0.97), carotid bruit (HR 1.44, 95% CI 1.12-1.85), S3 ventricular gallop (HR 1.83, 95% CI 1.11-3.03), and hypertension (HR 1.38, 95% CI 1.04-1.83) (c-index 0.83). Bootstrap validation confirmed excellent internal validity of the model (mean c-index 0.84, 95% CI 0.80-0.85).

CONCLUSION

Long-term survival after SVG intervention is poor, with one fourth of patients dying at median follow-up of 4 years. The nomogram developed using the model variables provides a method for clinicians to advise patients undergoing SVG interventions regarding their long-term prognosis, thereby enhancing discharge and long-term follow-up planning and setting up of realistic expectations.

Large Vessel — Sternum Adhesion After Cardiac Surgery; A Risk-Factor Analysis

PURPOSE

To study the clinical results of resternotomy in patients with dense and direct adhesion between the large vessels and the sternum, and define the morphologic features of the adhesion.

METHODS

Between 2000 and 2003, 67 patients with a history of cardiac surgery underwent median resternotomy. We studied each patient's profile and the measurements taken from preoperative computed tomography scans. We then conducted multivariate logistic regression analysis to determine the predictive morphologic features of adhesion between the large vessels and the sternum in these 67 patients.

RESULTS

Twenty (29.9%) of the 67 patients had direct adhesion between the large vessels and the sternum. Sternal re-entry was performed without injury to the large vessels in 18 (90%) but the aorta was injured in 2 (10%) patients, resulting in catastrophic hemodynamic disorder and operative death in one. Multivariate logistic regression analysis revealed that an extracardiac conduit and a high occupying rate of the aorta and pulmonary artery in the mediastinal space were significant morphologic factors.

CONCLUSION

The morphologic features of large vessels to sternal dense adhesion as possible risk factors for injury to the large vessels are the presence of an extracardiac conduit and a large ascending aorta or pulmonary artery in relation to the mediastinal space.

Comparison of effectiveness and safety of drug-eluting stents versus vascular brachytherapy for saphenous vein graft in-stent restenosis

We investigated the safety and efficacy of drug-eluting stents (DESs) for the treatment of patients who presented with in-stent restenosis (ISR) of saphenous vein grafts (SVGs) and compared the in-hospital and 6-month clinical outcomes of DESs with those of intravascular brachytherapy and balloon angioplasty alone. Records of 187 patients who presented with ISR of SVGs were analyzed. Of these, 34 consecutive patients were treated with DES implantation, 93 were treated with intravascular brachytherapy (n = 60 with gamma-radiation, n = 33 with beta-radiation), and 60 patients underwent conventional treatment with balloon angioplasty alone. Clinical and angiographic characteristics at baseline were comparable between groups. The DES group had less non-Q-wave myocardial infarction than did the intravascular brachytherapy and balloon angioplasty groups (0%, 20%, and 26%, p = 0.003 and <0.001, respectively). At 6 months, death occurred in 0% of the DES group, 2% of the intravascular brachytherapy group, and 5% of the balloon angioplasty group (p = 0.36 and <0.18, respectively). Target lesion revascularization/major adverse cardiac events were similar in the intravascular brachytherapy and DES groups (12% and 3%, p = 0.13) and significantly decreased compared with patients who were treated with balloon angioplasty alone (55%, p <0.001 for the 2 comparisons). The results of this retrospective analysis suggest that DES implantation is at least as effective and safe as intravascular brachytherapy for the treatment of SVG ISR and that these treatment modalities are superior to balloon angioplasty alone.

Sequential Subxyphoid and Thoracotomy Incisions With Graft Pull Through for Targeted Redo Multivessel Surgical Revascularization

We report on a technique for redo coronary artery bypass using sequential subxyphoid and left thoracotomy access and a vascular graft pull through for proximal anastomosis to the descending aorta. This technique can be used safely on the beating heart when previously implanted grafts to the anterior ventricular wall are patent or whenever resternotomy for redo multivessel coronary artery bypass is undesirable or contraindicated.

Mechanical protection of cardiac microcirculation during percutaneous coronary intervention of saphenous vein grafts

Saphenous vein bypass grafts permeability is one of the most important limitations of open heart surgery. The risks associated with surgical re-intervention are greater than those associated with the initial procedure. While native coronary arteries usually have fixed, fibrotic or calcified atherosclerotic plaques, the disease in the vein grafts contains soft material. When this material is compressed during percutaneous angioplasty, there is an unfavorable immediate outcome due to distal embolization of thrombus and plaque debris. In addition, the risk of post-procedure adverse events are higher when the grafts have a long time of implantation, due to a greater risk of branch occlusion or no-reflow at the adjacent microcirculation. The clinical consequence is a Non-Q-Wave Myocardial Infarction that is reflected in the increased serum cardiac enzymes. It is because of this complication that the distal protection devices were developed. The purpose of this paper is to review and discuss the current data on the distal protection devices available now for the treatment of degenerative saphenous vein graft disease. Currently, there are two distal protection devices approved in the United States: the Guardwire Balloon and Aspiration (Export) System and the Filter Wire EX. Other devices like the Triactiv System, Angioguard XP/ECW, DOW, MedNova Cardioshield, Medtronic-AVE DPD and the E-Trap Filter are still being studied. The first observational studies showed the safety and efficacy of the approved devices. A large randomized trial initially confirmed a significant decrease of in-hospital and 30-day cardiac adverse events, mainly Non-Q-Wave Myocardial Infarction, when angioplasty was performed with the assistance of the Guardwire System. Subsequently, another randomized study showed an equivalence between the Guardwire System and the Filter Wire EX. Distal protection devices have an acceptable performance, however, further technological improvements are warranted for a quick preparation, delivery and/or retrieval of these devices.

Drug-eluting stenting is superior to bare metal stenting in saphenous vein grafts

This study compared the outcomes of percutaneous coronary intervention (PCI) of saphenous vein grafts (SVGs) with drug-eluting stents (DES) with bare metal stents (BMS). PCI of degenerated SVG is associated with worse outcomes and high incidence of in-stent restenosis compared with PCI of native coronary arteries. There is a paucity of data on the outcomes of PCI of SVG with DES. Data from 223 consecutive patients who underwent PCI of SVG were imputed into a dedicated clinical database. We assessed the clinical outcomes at a mean follow-up of 9.1+/-2.1 months. A total of 139 patients underwent PCI of SVG with DES and 84 patients with BMS. The mean age of the SVG was 7.6+/-3.8 years in the DES group and 7.7+/-2.8 years in the BMS group (P=0.38). Procedural success was achieved in all patients except for one patient in the BMS group who underwent emergent coronary artery bypass graft surgery for SVG dissection. There were no other in-hospital cardiac events in both groups. There was one cardiac death in the DES group and three deaths in the BMS group (P=0.03). When compared to the BMS, PCI of SVG with DES was associated with a lower incidence of myocardial infarction (4.3% vs. 20.2%; P=0.04) and target vessel revascularization (10.1% vs. 36.9%; P=0.035). When compared with BMS, PCI of SVG with DES was associated with a lower incidence of death, myocardial infarction, and target vessel revascularization.

Percutaneous coronary intervention: historical perspectives, current status, and future directions

In the twenty-six years since Gruntzig introduced a simple balloon angioplasty technique, percutaneous coronary intervention has undergone extraordinary growth and has now surpassed bypass surgery in frequency of performance. Several critical breakthrough technologies account for this remarkable progress: intracoronary stents have increased success rates and reduced restenosis, adjunctive antiplatelet therapy has reduced periprocedural complications, and restenosis after stent placement has been effectively treated with local radiation. Most recently, drug-eluting stents coated with cell-cycle inhibitors have shown great promise for further reducing restenosis, possibly to negligible levels.

Next-Generation HydroGel Films as Tissue Sealants and Adhesion Barriers

BACKGROUND

The development of conveniently sprayed, tissue-adherent, inert hydrogel films has made possible the creation of novel products that can serve a dual function, as a surgical sealant to achieve immediate hemostasis, and as a barrier to prevent adhesion formation over time.

METHODS

A sprayable, in situ formed absorbable hydrogel film was evaluated as a tissue sealant in a heparinized canine carotid artery graft model. PTFE grafts with leaking end-to-side anastomoses were treated with the synthetic sealant, and hemostasis was evaluated upon restoration of blood flow. Also, the hydrogel films were evaluated as an adhesion barrier in a rabbit pericardial abrasion model.

RESULTS

The sprayable, in situ forming hydrogel film was shown to immediately seal carotid-PTFE anastomoses in six of six applications. Hydrogel application in a rabbit pericardial abrasion model resulted in a statistically significant reduction in the number and tenacity of adhesions.

CONCLUSIONS

This novel in situ formed sprayable hydrogel film has demonstrated a dual function as an effective tissue sealant and as an adhesion barrier in cardiovascular preclinical models. These next generation synthetic biomaterials are currently undergoing clinical investigations.

Comparison of creatine kinase elevation and outcome of comparison of percutaneous coronary intervention for saphenous vein graft in-stent restenosis versus de novo stenosis

Percutaneous coronary intervention of saphenous vein grafts is associated with distal embolization. We aimed to compare potential differences in patients undergoing percutaneous coronary intervention for in-stent restenosis with de novo saphenous vein graft lesions. Myocardial necrosis was associated with higher mortality regardless of lesion type.

Multimodality targeted approach in redo off-pump coronary artery bypass surgery

Records of 86 patients who underwent off-pump redo coronary revascularization between December 1997 and December 2000, were analyzed. Approaches included median sternotomy (47), anterolateral thoracotomy for left anterior descending artery and diagonal targets (35), posterolateral thoracotomy for the obtuse marginal with proximal anastomosis on descending aorta (3), and a combined subxiphoid-anterior thoracotomy approach (1) for right gastroepiploic artery-to-left anterior descending artery anastomosis. The mean age was 61.82 years. There were 2 (2.3%) operative deaths. Complications included perioperative myocardial infarction in 4 patients and reexploration for bleeding in one. Blood transfusion was required in 12 patients. The mean length of hospital stay was 5 +/- 2 days. A multimodality targeted approach for off-pump redo coronary artery bypass offers a less invasive but safer method of myocardial revascularization, with decreased complications, lower blood product requirement, and early hospital discharge.

Coronary reoperations: recurrence of angina and clinical outcome with and without cardiopulmonary bypass

BACKGROUND

We compared our experience of minimal tissue dissection and target vessel revascularization without cardiopulmonary bypass (CPB) with the standard procedure of total dissection of the heart and complete revascularization with CPB in patients who had elective reoperative coronary artery bypass grafting (redo-CABG).

METHODS

We analyzed recurrence of angina and clinical outcome in 118 patients who had elective redo-CABG between January 1995 and April 2002. Seventy-four patients had redo-CABG with CPB, and 44 patients had redo-CABG without CPB.

RESULTS

Perioperative outcome was comparable with regard to morbidity and mortality rates. At follow-up, the mean Canadian Cardiovascular Society score was 1.3 +/- 0.6 in patients who had redo-CABG with CPB and 1.7 +/- 0.8 in patients who had redo-CABG without CPB (p = 0.02). At follow-up, patients who had redo-CABG without CPB had a higher rate of recurrence of angina (log rank = 0.001) and higher use of nitrates (p = 0.015). Target vessel revascularization was an independent predictor of recurrence of angina in younger patients (< 75 years; p = 0.012) but not in the elderly (> or = 75 years; p = 0.142).

CONCLUSIONS

In elective redo-CABG patients, minimal tissue dissection and target vessel revascularization without cardiopulmonary bypass did not add significant benefit with regard to perioperative morbidity and mortality. The unsatisfactory relief of symptoms does not seem to justify target vessel revascularization by a less invasive approach. Therefore, this technique should be offered exclusively to patients at high risk with complete revascularization using CPB, such as the elderly.

Intravascular gamma radiation for in-stent restenosis in saphenous-vein bypass grafts

BACKGROUND

Intracoronary radiation therapy is effective in reducing the recurrence of in-stent stenosis in native coronary arteries. We examined the effects of intravascular gamma radiation in patients with in-stent restenosis of saphenous-vein bypass grafts.

METHODS

A total of 120 patients with in-stent restenosis in saphenous-vein grafts, the majority of whom had diffuse lesions, underwent balloon angioplasty, atherectomy, additional stenting, or a combination of these procedures. If the intervention was successful, the patients were randomly assigned in a double-blind fashion to intravascular treatment with a ribbon containing either iridium-192 or nonradioactive seeds. The prescribed dose, delivered at a distance of 2 mm from the source, was 14 to 15 Gy in vessels that were 2.5 to 4.0 mm in diameter and 18 Gy in vessels with a diameter that exceeded 4.0 mm. The primary end points were death from cardiac causes, Q-wave myocardial infarction, revascularization of the target vessel, and a composite of these events at 12 months.

RESULTS

Revascularization and radiation therapy were successfully accomplished in all patients. At six months, the restenosis rate was lower in the 60 patients assigned to the iridium-192 group than in the 60 assigned to the placebo group (21 percent vs. 44 percent, P=0.005). At 12 months, the rate of revascularization of the target lesion was 70 percent lower in the iridium-192 group than in the placebo group (17 percent vs. 57 percent, P<0.001), and the rate of major cardiac events was 49 percent lower (32 percent vs. 63 percent, P<0.001).

CONCLUSIONS

The results of our study support the use of gamma-radiation therapy for the treatment of in-stent restenosis in patients with bypass grafts.

Incidence and risk factors predictive of unstable angina resulting from restenosis after percutaneous angioplasty of saphenous vein grafts

BACKGROUND

The current study was designed to determine the incidence and risk factors for unstable angina resulting from restenosis in patients undergoing percutaneous transluminal coronary angioplasty (PTCA) of saphenous vein graft (SVG), about which little data are available.

METHODS AND RESULTS

A retrospective analysis of a consecutive series of 212 patients undergoing PTCA of SVG was performed. Procedural success was achieved in 200 patients (94.3%) who formed the study group. During a follow-up of 16.8 +/- 10.2 months, 24.5% of patients presented with unstable angina resulting from restenosis. There was a higher prevalence of dyslipidemia (81. 6% vs 51.2%, P <.0002) and greater postprocedural residual stenosis (14.2% +/- 12.6% vs 7.1% +/- 11.0%, P =.007) in patients with unstable angina caused by restenosis compared with the remaining patient population. By multivariate analysis, dyslipidemia (odds ratio [OR] 3.55, 95% confidence interval [CI] 1.64-8.39, P <.002) and to a lesser extent postprocedural residual stenosis (OR 1.04, 95% CI 1.01-1.07, P <.05) were predictive of unstable angina resulting from restenosis. Among dyslipidemic patients, those not on lipid-lowering drugs during the index procedure had a significantly higher incidence of unstable angina caused by restenosis than did those on lipid-lowering drugs (P <.05).

CONCLUSION

Unstable angina caused by restenosis presents in as many as one fourth of patients undergoing PTCA of SVG. Dyslipidemia strongly, and to a lesser extent postprocedural residual stenosis, predicts its occurrence. Scrupulous attention to these modifiable risk factors may help reduce the incidence of unstable angina after SVG angioplasty.

Stent placement for non-STRESS/BENESTENT lesions: a critical review

Stenting lesions with favorable characteristics as required for inclusion in the STRESS/BENESTENT trials have yielded superior results to that of PTCA alone. Results for less favorable lesions such as in small vessels, diffuse disease, ostial disease, and saphenous vein grafts are less well established. This review seeks to analyze available data for stent placement in this subset of non-STRESS/BENESTENT lesions.

Off-pump redo coronary artery bypass grafting

BACKGROUND

Conventional redo coronary artery bypass grafting is associated with significant morbidity. The danger of reoperation is mainly in reopening the sternum and in the manipulation of the heart and the old grafts. Therefore, off-pump redo coronary artery bypass grafting with a patient-specific approach in selected cases seems an ideal technique.

METHODS

Between October 1995 to September 1999, 50 patients with mean age of 61.8+/-8 years underwent reoperative coronary artery bypass grafting without cardiopulmonary bypass. Isolated left internal mammary artery (LIMA) to left anterior descending artery (LAD) anastomosis was carried out in 25 cases through left anterior minithoracotomy. In 1 patient LIMA was grafted on a previous vein graft to LAD, which was critically stenosed proximally but distal anastomosis was patent. In another case LIMA was grafted to Ramus intermedius branch. Midsternotomy approach was used to carry out LAD and right coronary artery grafting in 21 cases. In 2 patients a posterolateral thoracotomy approach was used to bypass obtuse marginal branches without cardiopulmonary bypass; in these cases proximal anastomosis was performed on the descending aorta.

RESULTS

Mortality rate was 4% (2 deaths). Two patients sustained perioperative myocardial infarction. No patient was reexplored for hemorrhage and 38 patients did not require homologous blood transfusion. Sixteen patients underwent check angiogram and all of them were found to have patent redo grafts. Cardiac recovery room stay was 22+/-7 hours and hospital stay 5+/-2 days.

CONCLUSIONS

In selected patients, reoperative coronary artery bypass grafting can be performed without cardiopulmonary bypass with a low perioperative morbidity and mortality and satisfactory graft patency.

Acute thrombotic-ischemic coronary syndromes: the usefulness of TEC

Transluminal extraction catheter (TEC) is a percutaneous device that performs simultaneous thrombus aspiration and plaque excision. Clinical indications for its application are acute myocardial infarction, unstable angina, and stable angina caused by atherosclerotic, thrombotic lesions located within native coronary arteries and degenerated saphenous vein grafts. The device is useful in management of ischemic patients with contraindications to either pharmacologic thrombolytics or platelet GPIIb/IIIa receptor inhibitors, and can also effectively be used in combination with these agents. A successful TEC procedure requires careful patient selection, strict adherence to recommended indications, optimal equipment selection, familiarity with mechanical components of the device, full understanding of safe and efficacious techniques for deployment and activation, as well as recognition of unique associated angiographic manifestations such as the "empty-pouch phenomenon." As with other debulking devices, the incidence of restenosis post-TEC appears to be directly related to acute luminal gain at the time of procedure and therefore requires the need for adjunct stenting. This communication describes and illustrates various clinical, technical, and angiographic aspects of TEC procedure in patients with acute ischemic-thrombotic coronary syndromes. Cathet. Cardiovasc. Intervent. 48:406-420, 1999.

Long-term follow-up after coronary artery bypass grafting reoperation

BACKGROUND

Coronary artery bypass grafting (CABG) reoperation is being performed with increasing frequency.

OBJECTIVE

To determine the clinical outcome and the long-term results of a second CABG.

SETTING

An 1100-bed urban university-affiliated hospital.

DESIGN

Retrieval of data on selected parameters from medical records before surgery and prospective follow-up afterwards.

PATIENTS AND METHODS

We studied the outcomes of 498 consecutive patients who underwent CABG reoperation in our institution from January 1978 to December 1989 and who were followed postoperatively. Their perioperative mortality, morbidity, and long-term follow-up results were re-evaluated. The end points of the study were December 1997, 15 years of follow-up, or the patient's death.

RESULTS

The perioperative mortality rate was 3%. The cumulative survival rates were 90.1%, 74%, and 63.4% at the 5-year, 10-year, and 15-year follow-ups, respectively. The cardiac event-free survival rates were 91.5%, 83.4%, and 67.8% at the 5-year, 10-year, and 15-year follow-ups, respectively. The risk factors adversely affecting long-term survival were advanced age, hypertension, and a low left ventricular ejection fraction (LVEF).

CONCLUSIONS

The long-term results of cumulative survival and cardiac event-free survival in patients who underwent CABG reoperation are good. Although this reoperation is safe overall, advanced age, hypertension, and a decreased LVEF significantly increase the surgical risk.

Adjunctive abciximab improves outcomes during recanalization of totally occluded saphenous vein grafts using transluminal extraction atherectomy

Degenerative disease of aortocoronary saphenous vein grafts is a major cause of late morbidity and mortality in patients after coronary bypass surgery. We previously described a technique for recanalization of totally occluded grafts using extraction atherectomy (TEC) as a primary modality. While success was comparable to overnight urokinase, distal embolization, no-reflow, and non-Q myocardial infarction were common. Recently, abciximab has been used adjunctively in angioplasty and stenting with a reduced incidence of periprocedural complications. In order to determine whether abciximab can reduce the incidence of distal embolization, no-reflow, and myocardial infarction during TEC in totally occluded saphenous vein grafts, we compared patients treated with adjunctive abciximab with control subjects not receiving the drug. Male patients with previous coronary bypass surgery, class III-IV angina, and totally occluded saphenous vein grafts serving a vascular territory with ischemia not approachable by standard catheter-based techniques underwent TEC with or without adjunctive abciximab. Recanalization of the graft was achieved in 8/10 (80%) of subjects without abciximab, but complete success was achieved in only 5/10 (50%). In contrast, all procedures in the abciximab group were completely successful, without embolization or no-reflow. Our results suggest that TEC with adjunctive abciximab may be a highly effective approach for management of totally occluded saphenous vein grafts.

Safety and cost-effectiveness of MIDCABG in high-risk CABG patients

BACKGROUND

Myocardial revascularization without cardiopulmonary bypass has been proposed as a potential therapeutic alternative in high-risk patients undergoing coronary artery bypass grafting. To evaluate this possibility we compared 15 high-risk (HR) patients in whom minimally invasive direct coronary artery bypass grafting was used as the method of revascularization with 41 consecutive patients who underwent conventional coronary artery bypass grafting during 1 month.

METHODS

Patients undergoing myocardial revascularization without cardiopulmonary bypass were significantly older than their low-risk (LR) counterparts (72.2 +/- 11.6 versus 63.3 +/- 9.7 years, p = 0.006). The demographic profile for HR versus LR patients was as follows: female patients, 60.0% versus 26.8%, p = 0.02; diabetes, 20.0% versus 24.4%, p = 0.7; prior stroke, 33.3% versus 7.4%, p = 0.03; chronic obstructive pulmonary disease, 60.0% versus 9.8%, p < 0.0001; peripheral vascular disease, 33.3% versus 12.2%, p = 0.03, congestive heart failure, 26.6% versus 9.8%, p = 0.09; impaired left ventricular (ejection fraction < 0.40), 40.0% versus 17.0%, p = 0.07; urgent operation, 86.6% versus 46.3%, p < 0.0001; and redo operation, 20.0% versus 0%, p = 0.003.

RESULTS

There were no deaths in the HR group and one death in the LR group. The average intensive care unit stay was 1.1 +/- 0.5 days in HR patients versus 1.6 +/- 1.6 days in LR individuals (p = 0.2), and the average hospital stay was 6.1 +/- 1.8 versus 7.3 +/- 4.4 days, respectively (p = 0.3). We used an acuity risk score index developed by the Adult Cardiac Care Network of Ontario to predict outcome in the HR group. The expected intensive care unit stay in HR patients was 4.1 +/- 1.2 days (versus the observed stay of 1.1 +/- 0.5 days, p < 0.0001), and the expected hospital stay was 12.5 +/- 1.5 days (versus the observed stay of 6.1 +/- 1.8 days, p < 0.0001). The expected mortality in the HR group was 6.1% versus 0%, p = 0.3. A cost regression model was used to examine predicted versus actual cost (in Canadian dollars) for the HR patient cohort (based on Ontario Ministry of Health funding). The expected cost for the HR cohort would have been $11,997 per patient. In contrast, the average cost for these 15 patients was $5,997 per patient, an estimated cost saving of 50%.

CONCLUSIONS

Myocardial revascularization without cardiopulmonary bypass appears to be a safe and cost-effective therapeutic modality for HR patients requiring myocardial revascularization.

Long-term results of reoperations for recurrent angina with internal mammary artery versus saphenous vein grafts

OBJECTIVE

To evaluate the long term results of coronary reoperations for recurrent angina with internal mammary (thoracic) arteries versus vein grafts.

DESIGN

Inception cohort of 103 patients with a mean follow up of 7.1 years (range 1.0-11.6).

SETTING

Regional cardiothoracic centre.

PATIENTS

Among 103 consecutive patients, mean (SD) age 61.8 (9.7) years, who were reoperated for recurrent angina between January 1982 and December 1991, 53 patients had unilateral or bilateral internal mammary artery (IMA) grafting supplemented or not with saphenous vein (SV) grafts (group A), and 50 patients underwent reoperative coronary surgery using SV grafts only (group B). The two groups were comparable in terms of demographic and clinicopathological data.

MEASUREMENTS AND RESULTS

Operative mortality was 5.6% (95% confidence interval 4.6 to 6.6) for group A, and 10% (8.2 to 11.8) for group B (p > 0.05). Probability of freedom from new recurrence of angina was 86% at 5 and 10 years in group A, compared with 56% and 25% respectively in group B (p = 0.005). Freedom from cardiac events was estimated to be 81% at 5 and 10 years in group A, v 52% and 20% for group B, respectively. Actuarial survival was 95% v 93% at 3 years, 95% v 85% at 5 years, and 88% v 71% at 10 years after reoperation (p > 0.05).

CONCLUSIONS

The long term results of IMA are superior to SV grafts in terms of freedom from new recurrence of angina and other cardiac events. The IMA is thus the conduit of choice in coronary revascularisation.

Restenosis in human vein bypass grafts

The restenosis rate in vein bypass grafts is higher than in native coronary arteries, and both the cascade of regulatory factors and the vessel reaction may be altered. In this study, vein bypass atherectomy specimens were classified as primary (n = 10) or restenotic (n = 12). Immunohistochemistry with 11 primary antibodies showed low levels of proliferation in both tissues and similar amounts of extracellular matrix components in both primary and restenotic specimens at the time points at which tissue was removed for clinical reasons. Inflammation appeared increased in restenotic specimens. Using in situ hybridization, transforming growth factor-beta1 messenger RNA was detected in both primary and restenotic tissue, with a trend to higher expression in restenosis (8.4 +/- 5.3 vs. 9.4 +/- 7.4 grains/nucleus) and further increased expression in multiple compared with single restenoses (15.1 +/- 6.1 vs. 5.6 +/- 5.1 grains/nucleus, P < 0.05). Hence, there were no great differences in cell proliferation or extracellular matrix formation between primary and restenosis vein graft tissue, in contrast to previously described findings in arterial tissue. This suggests that primary vein graft tissue is already in a chronic 'restenosis-like' state and subsequent injury creates minimal additional upregulation.

One-year follow-up of recanalization of totally occluded aortocoronary saphenous vein grafts using transluminal extraction atherectomy

Recanalization of totally occluded aortocoronary saphenous vein grafts with extraction atherectomy was successful in 80% of patients. Whereas all patients with unsuccessful procedures were dead at 1 year, 75% of those with successful procedures are alive and free of events.

Management and prevention of cardiovascular hemorrhage associated with mediastinitis

OBJECTIVE

To elucidate the causes of cardiovascular hemorrhage associated with mediastinitis and to review recommendations for prevention and treatment.

SUMMARY BACKGROUND DATA

Mediastinal debridement with immediate or early coverage using healthy, vascularized tissue has lead to greatly reduced morbidity and mortality for patients with mediastinitis. Myocardial hemorrhage has been anecdotally reported.

PATIENTS AND METHODS

Over a 36-month period, 7 patients developed massive cardiovascular bleeding after undergoing debridement for poststernotomy mediastinitis. Causes included puncture or erosion by a sternal edge in three and tearing at the myocardial-sternal interface in four.

RESULTS

Five patients survived and remain infection-free at an average of 24 months of follow-up. In these patients, ventricular defects were closed with pledgeted sutures and muscle transposition was used concomitantly to reinforce the repair. This involved a slide of the left pectoralis major muscle and turnover of the right pectoralis in three patients, bilateral sliding in one patient, and bilateral pectoralis and an omental flap in one patient who required additional coverage of the lower mediastinum.

CONCLUSIONS

When a patient who has undergone mediastinal debridement shows evidence of significant bleeding, we recommend application of pressure for control of hemorrhage, expeditious return to an operating room with available cardiopulmonary bypass, and immediate muscle coverage with healthy, well-vascularized tissue. Finally, early sternectomy might largely prevent this life-threatening complication.

[Reoperative coronary artery bypass grafting without cardiopulmonary bypass]

Between October 1995 and February 1997, 2 men and 4 women aged 53 to 75 years (mean, 66.3) underwent reoperative coronary artery bypass grafting without cardiopulmonary bypass. Isolated reoperative circumflex or intermediate artery bypass was performed through a left thoracotomy (n = 2), reoperative bypass to the left anterior descending coronary artery was performed through a median sternotomy (n = 3), and bypass to the right coronary artery was performed through an upper median laparotomy (n = 1). Single coronary bypass grafting utilizing arterial grafts (left internal thoracic artery: 3, right gastroepiploic artery: 3) was performed in all cases. There were no operative deaths. All cases required neither cathecolamine nor intraaortic balloon pumping). Peri/post operative blood transfusion was necessary in only one case. Postoperative coronary angiography revealed that the 6 arterial grafts were patent. Reoperative coronary artery bypass grafting without cardiopulmonary bypass can be performed with low perioperative morbidity and mortality, easy postoperative management, satisfactory graft patency, and good symptomatic improvement.

Transluminal extraction catheter atherectomy followed by immediate stenting in treatment of saphenous vein grafts

OBJECTIVES

The purpose of this study was to evaluate the effectiveness of transluminal extraction catheter (TEC) atherectomy followed by immediate Palmaz-Schatz coronary stenting of coronary bypass vein grafts.

BACKGROUND

Degeneration of saphenous vein coronary bypass grafts has become a common problem. Repeat bypass surgery is associated with greater risk and a poorer outcome than the initial operation. Moreover, percutaneous interventional procedures in vein grafts have been associated with high procedural complication rates, including distal embolization, and high restenosis rates. TEC atherectomy may reduce distal embolization, and stenting may reduce restenosis rates.

METHODS

We evaluated the procedural, hospital and clinical outcomes of TEC atherectomy followed by immediate Palmaz-Schatz coronary stenting of 53 vein grafts in 49 consecutive patients. The strategy was to limit instrumentation to extraction debulking and to stabilizing the site with stent deployment before using balloon dilation for optimal gain in lumen diameter.

RESULTS

Results are shown as mean value (95% confidence interval [CI]). The mean graft age was 9.2 years (95% CI 7.9 to 10.5), and 1.0 (95% CI 1 to 1) TEC cutter (2.2 mm [95% CI 2.1 to 2.3]) and 1.7 (95% CI 1.4 to 2.0) Palmaz-Schatz coronary stents/ vein graft were used. The procedural success rate was 98%, with a minimal lumen diameter at baseline of 1.3 mm (95% CI 1.1 to 1.5), increasing to 3.9 mm (95% CI 3.6 to 4.2) (p < 0.05) after the TEC-stent procedure. Procedural complications occurred infrequently: graft perforation in 1 (2%) of 53 patients and distal embolization in 1 (2%) of 53 (same patient). In-hospital complications included non-Q wave myocardial infarction in two patients and death after a successful procedure in three (6%) (n = 1 each: massive bleeding from the catheter site; sepsis; and acute myocardial infarction with asystole in the distribution of the stented vessel). The event-free survival rate to hospital discharge was 90%. Clinical follow-up (13 months [95% CI 11 to 15]) was available for all patients. There were five (11%) revascularization procedures (three bypass grafts and two percutaneous transluminal coronary interventions), four (9%) nonfatal myocardial infarctions and five (11%) deaths, for a cumulative rate of 28% for any adverse outcome occurring in 13 of 46 patients.

CONCLUSIONS

TEC atherectomy followed by immediate Palmaz-Schatz coronary stenting of stenoses in old (> 9 years) saphenous vein grafts can be successfully performed, with a low incidence of procedural and hospital complications. Clinical restenosis rates are low and less than those previously reported; however, late morbid cardiac events are still frequent in this high risk group of patients. These observational findings suggest that this technique may improve percutaneous management of vein graft disease, but optimal long-term management strategies remain to be determined.

Outcome of reoperative coronary bypass surgery versus coronary angioplasty after previous bypass surgery

BACKGROUND

The immediate and long-term outcomes of reoperative coronary artery bypass surgery (CABG) (n = 1561) and catheter-based coronary intervention (angioplasty) (n = 2613) were compared in patients from Emory University Hospitals who had previous CABG.

METHODS AND RESULTS

The surgical and angioplasty procedures and statistical methods were standard. Data were collected prospectively and entered into a computerized database. Followup was by letter, telephone, or additional events resulting in readmission. In the angioplasty group, 2.9% required in-hospital CABG. Hospital mortality was 1.2% after angioplasty versus 6.8% after repeat CABG (P < .0001). Recurrent angina was noted frequently at about 4 years and was more common after angioplasty. One-, 5-, and 10-year mortalities were 11%, 24%, and 49% after CABG versus 6%, 22%, and 38% after angioplasty. Survival corrected for baseline differences did not vary with the choice of procedure. There were more additional procedures after angioplasty. Patients undergoing angioplasty may be divided into those with procedures only in native coronary arteries (n = 1545), only in vein grafts (n = 869), and a mixture (n = 199), with respective 10 year survivals of 66%, 56%, and 65% (P < .0001).

CONCLUSIONS

These patients have a high incidence of events both in-hospital and in the long term. Although initial mortality was higher after CABG, after baseline differences were accounted for, there was no difference in the long term. Patients more frequently have additional procedures after angioplasty. Choice of therapy should consider clinical and angiographic suitability and patient preference.