Trends in Reoperative Coronary Artery Bypass Graft Surgery for Older Adults in the United States, 1998 to 2017

Gender-Related Outcomes in Saphenous Vein Graft Interventions

BACKGROUND

Saphenous vein graft percutaneous coronary intervention (SVG-PCI) is a relatively common procedure in patients after coronary artery bypass grafting (CABG). Although internal mammary artery is considered optimal, SVG is still used in the majority of patients.

AIMS

Investigating the potential role of gender differences in the incidence and outcomes of SVG-PCI.

METHODS

The study was based on a prospectively collected registry of 1199 consecutive patients (169 female) who underwent SVG-PCI in a tertiary medical center between 2004 and 2023. Primary outcomes included MACE (death, myocardial infarction [MI], target vessel revascularization [TVR], stroke) and mortality, at 1 and 3 years.

RESULTS

Female patients were older (73.6 ± 9.1 years vs. 70.6 ± 9.7 years, p < 0.001), suffered from higher rates of diabetes mellitus, peripheral vascular disease, and congestive heart failure (78.1% vs. 61.3% p < 0.001, 13.6% vs. 7% p < 0.003, 66.3% vs. 51.8% p < 0.001 respectively). Additionally, female patients had lower trans-radial access use (11.9% vs. 19.3%, p < 0.025), and underwent SVG-PCI earlier following their CABG procedure (11.3 ± 6.2 years vs 12.9 ± 6.1 years, p < 0.003), as compared to male patients. There were no differences in MACE rates between the groups. Mortality was higher in the female group at 1 year (13.6% vs. 6.9%, p = 0.003), but no significant differences were observed at 3 years (24.3% vs. 20.9%, p = 0.320). Cox regression analysis identified age, renal function, ejection fraction, MI and trans-femoral as independent risk factors for mortality.

CONCLUSION

Gender-specific monitoring and early intervention, especially for women, are required for better management of graft patency, potentially improving long-term outcomes.

Gender differences in the incidence of saphenous vein graft intervention

BACKGROUND

Saphenous vein graft percutaneous coronary intervention (SVG PCI) following coronary artery bypass grafting (CABG) is commonly used procedure for patients presenting with acute coronary syndrome (ACS). Emerging evidence suggests gender-based differences influencing SVG intervention clinical outcomes. This study aimed to analyze the impact of gender and various patient characteristics, procedural intricacies, anatomical considerations, and perioperative factors as potential risk determinants for SVG failure post-CABG surgery.

METHODS

A retrospective, single-center, analysis was conducted on post-CABG patients at Barzilai Medical Center Ashkelon from 2010 to 2023 to assess gender-based differences in SVG PCI incidence.

RESULTS

Of the 72 ACS patients undergoing SVG PCI, a notably higher incidence was observed in men. However, graft failure occurred earlier in women compared to men (13.50 ± 6.59 SD years vs. 22.13 ± 5.66 SD years). Women exhibited a 1.2 times higher likelihood of earlier PCI than men (OR 1.24 CI 1.077 to 1.487, p = 0.0066) after adjusting for age, smoking, diabetes, hypertension, and hyperlipidemia.

CONCLUSION

Gender differences in the incidence of SVG PCI and graft failure denote the need for gender-tailored follow-up and early intervention to optimize graft patency and potentially enhance long-term clinical outcomes. Integrating gender-specific approaches into post-CABG management could significantly improve patient care and prognosis.

Ticagrelor with and without aspirin in patients with a prior coronary artery bypass graft undergoing percutaneous coronary intervention: the TWILIGHT-CABG study

BACKGROUND

Prior coronary artery bypass graft surgery (CABG) patients undergoing percutaneous coronary intervention (PCI) are often older and present with multiple comorbidities. Ticagrelor monotherapy after a short course of dual antiplatelet therapy (DAPT) has emerged as an effective bleeding-avoidance strategy among high-risk patients.

AIMS

We aimed to examine the effects of ticagrelor with or without aspirin in prior CABG patients undergoing PCI within the TWILIGHT trial.

METHODS

After 3 months of ticagrelor plus aspirin, patients were randomised to either aspirin or placebo, in addition to ticagrelor, for 12 months and compared by prior CABG status. The primary endpoint was Bleeding Academic Research Consortium (BARC) type 2, 3 or 5 bleeding. The key secondary endpoint was all-cause death, myocardial infarction (MI), or stroke.

RESULTS

Out of 7,119 patients, a total of 703 (10.8%) patients had prior CABG within the randomised cohort. Prior CABG patients had more comorbidities and a higher incidence of BARC type 2, 3, or 5 bleeding and death, MI or stroke at 1 year after randomisation, compared with patients without prior CABG. Ticagrelor monotherapy was associated with significantly less BARC 2, 3, or 5 bleeding among prior CABG patients compared with DAPT (4.9% vs 9.6%, hazard ratio [HR] 0.50, 95% confidence interval [CI]: 0.28 to 0.90; pinteraction=0.676) and similar rates of death, MI or stroke (10.0% vs 8.7%, HR 1.14, 95% CI: 0.70 to 1.87; pinteraction=0.484). When comparing target vessel type, treatment effects were consistent among graft- and native-vessel interventions.

CONCLUSIONS

In high-risk patients with prior CABG, ticagrelor monotherapy reduced bleeding without compromising ischaemic outcomes compared with ticagrelor plus aspirin.

Trends in Reoperative Coronary Artery Bypass Graft Surgery for Older Adults in the United States, 1998 to 2017

Background The likelihood of undergoing reoperative coronary artery bypass graft surgery (CABG) is important for older patients who are considering first-time CABG. Trends in the reoperative CABG for these patients are unknown. Methods and Results We used the Medicare fee-for-service inpatient claims data of adults undergoing isolated first-time CABG between 1998 and 2017. The primary outcome was time to first reoperative CABG within 5 years of discharge from the index surgery, treating death as a competing risk. We fitted a Cox regression to model the likelihood of reoperative CABG as a function of patient baseline characteristics. There were 1 666 875 unique patients undergoing first-time isolated CABG and surviving to hospital discharge. The median (interquartile range) age of patients did not change significantly over time (from 74 [69-78] in 1998 to 73 [69-78] in 2017); the proportion of women decreased from 34.8% to 26.1%. The 5-year rate of reoperative CABG declined from 0.77% (95% CI, 0.72%-0.82%) in 1998 to 0.23% (95% CI, 0.19%-0.28%) in 2013. The annual proportional decline in the 5-year rate of reoperative CABG overall was 6.6% (95% CI, 6.0%-7.1%) nationwide, which did not differ across subgroups, except the non-white non-black race group that had an annual decline of 8.5% (95% CI, 6.2%-10.7%). Conclusions Over a recent 20-year period, the Medicare fee-for-service patients experienced a significant decline in the rate of reoperative CABG. In this cohort of older adults, the rate of declining differed across demographic subgroups.