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Hess CN, Lopes RD, Gibson CM, Hager R, Wojdyla DM, Englum BR, Mack MJ, Califf RM, Kouchoukos NT, Peterson ED, Alexander JH. Saphenous vein graft failure after coronary artery bypass surgery: insights from PREVENT IV. Circulation 2014; 130:1445-51. [PMID: 25261549 DOI: 10.1161/circulationaha.113.008193] [Citation(s) in RCA: 155] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Coronary artery bypass grafting success is limited by vein graft failure (VGF). Understanding the factors associated with VGF may improve patient outcomes. METHODS AND RESULTS We examined 1828 participants in the Project of Ex Vivo Vein Graft Engineering via Transfection IV (PREVENT IV) trial undergoing protocol-mandated follow-up angiography 12 to 18 months post-coronary artery bypass grafting or earlier clinically driven angiography. Outcomes included patient- and graft-level angiographic VGF (≥75% stenosis or occlusion). Variables were selected by using Fast False Selection Rate methodology. We examined relationships between variables and VGF in patient- and graft-level models by using logistic regression without and with generalized estimating equations. At 12 to 18 months post-coronary artery bypass grafting, 782 of 1828 (42.8%) patients had VGF, and 1096 of 4343 (25.2%) vein grafts had failed. Demographic and clinical characteristics were similar between patients with and without VGF, although VGF patients had longer surgical times, worse target artery quality, longer graft length, and they more frequently underwent endoscopic vein harvesting. After multivariable adjustment, longer surgical duration (odds ratio per 10-minute increase, 1.05; 95% confidence interval, 1.03-1.07), endoscopic vein harvesting (odds ratio, 1.41; 95% confidence interval, 1.16-1.71), poor target artery quality (odds ratio, 1.43; 95% confidence interval, 1.11-1.84), and postoperative use of clopidogrel or ticlopidine (odds ratio, 1.35; 95% confidence interval, 1.07-1.69) were associated with patient-level VGF. The predicted likelihood of VGF in the graft-level model ranged from 12.1% to 63.6%. CONCLUSIONS VGF is common and associated with patient and surgical factors. These findings may help identify patients with risk factors for VGF and inform the development of interventions to reduce VGF. CLINICAL TRIAL REGISTRATION URL http://www.clinicaltrials.gov. Unique identifier: NCT00042081.
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Affiliation(s)
- Connie N Hess
- From the Duke Clinical Research Institute, Duke Medicine, Durham, NC (C.N.H., R.D.L., R.H., D.M.W., B.R.E., E.D.P., J.H.A.); Harvard Medical School, Harvard University, Boston, MA (C.M.G.); Baylor Health Care System, Baylor, TX (M.J.M.); Duke Translational Medicine Institute, Duke Medicine, Durham, NC (R.M.C.); and Missouri Baptist Medical Center, St. Louis, MO (N.T.K.)
| | - Renato D Lopes
- From the Duke Clinical Research Institute, Duke Medicine, Durham, NC (C.N.H., R.D.L., R.H., D.M.W., B.R.E., E.D.P., J.H.A.); Harvard Medical School, Harvard University, Boston, MA (C.M.G.); Baylor Health Care System, Baylor, TX (M.J.M.); Duke Translational Medicine Institute, Duke Medicine, Durham, NC (R.M.C.); and Missouri Baptist Medical Center, St. Louis, MO (N.T.K.)
| | - C Michael Gibson
- From the Duke Clinical Research Institute, Duke Medicine, Durham, NC (C.N.H., R.D.L., R.H., D.M.W., B.R.E., E.D.P., J.H.A.); Harvard Medical School, Harvard University, Boston, MA (C.M.G.); Baylor Health Care System, Baylor, TX (M.J.M.); Duke Translational Medicine Institute, Duke Medicine, Durham, NC (R.M.C.); and Missouri Baptist Medical Center, St. Louis, MO (N.T.K.)
| | - Rebecca Hager
- From the Duke Clinical Research Institute, Duke Medicine, Durham, NC (C.N.H., R.D.L., R.H., D.M.W., B.R.E., E.D.P., J.H.A.); Harvard Medical School, Harvard University, Boston, MA (C.M.G.); Baylor Health Care System, Baylor, TX (M.J.M.); Duke Translational Medicine Institute, Duke Medicine, Durham, NC (R.M.C.); and Missouri Baptist Medical Center, St. Louis, MO (N.T.K.)
| | - Daniel M Wojdyla
- From the Duke Clinical Research Institute, Duke Medicine, Durham, NC (C.N.H., R.D.L., R.H., D.M.W., B.R.E., E.D.P., J.H.A.); Harvard Medical School, Harvard University, Boston, MA (C.M.G.); Baylor Health Care System, Baylor, TX (M.J.M.); Duke Translational Medicine Institute, Duke Medicine, Durham, NC (R.M.C.); and Missouri Baptist Medical Center, St. Louis, MO (N.T.K.)
| | - Brian R Englum
- From the Duke Clinical Research Institute, Duke Medicine, Durham, NC (C.N.H., R.D.L., R.H., D.M.W., B.R.E., E.D.P., J.H.A.); Harvard Medical School, Harvard University, Boston, MA (C.M.G.); Baylor Health Care System, Baylor, TX (M.J.M.); Duke Translational Medicine Institute, Duke Medicine, Durham, NC (R.M.C.); and Missouri Baptist Medical Center, St. Louis, MO (N.T.K.)
| | - Michael J Mack
- From the Duke Clinical Research Institute, Duke Medicine, Durham, NC (C.N.H., R.D.L., R.H., D.M.W., B.R.E., E.D.P., J.H.A.); Harvard Medical School, Harvard University, Boston, MA (C.M.G.); Baylor Health Care System, Baylor, TX (M.J.M.); Duke Translational Medicine Institute, Duke Medicine, Durham, NC (R.M.C.); and Missouri Baptist Medical Center, St. Louis, MO (N.T.K.)
| | - Robert M Califf
- From the Duke Clinical Research Institute, Duke Medicine, Durham, NC (C.N.H., R.D.L., R.H., D.M.W., B.R.E., E.D.P., J.H.A.); Harvard Medical School, Harvard University, Boston, MA (C.M.G.); Baylor Health Care System, Baylor, TX (M.J.M.); Duke Translational Medicine Institute, Duke Medicine, Durham, NC (R.M.C.); and Missouri Baptist Medical Center, St. Louis, MO (N.T.K.)
| | - Nicholas T Kouchoukos
- From the Duke Clinical Research Institute, Duke Medicine, Durham, NC (C.N.H., R.D.L., R.H., D.M.W., B.R.E., E.D.P., J.H.A.); Harvard Medical School, Harvard University, Boston, MA (C.M.G.); Baylor Health Care System, Baylor, TX (M.J.M.); Duke Translational Medicine Institute, Duke Medicine, Durham, NC (R.M.C.); and Missouri Baptist Medical Center, St. Louis, MO (N.T.K.)
| | - Eric D Peterson
- From the Duke Clinical Research Institute, Duke Medicine, Durham, NC (C.N.H., R.D.L., R.H., D.M.W., B.R.E., E.D.P., J.H.A.); Harvard Medical School, Harvard University, Boston, MA (C.M.G.); Baylor Health Care System, Baylor, TX (M.J.M.); Duke Translational Medicine Institute, Duke Medicine, Durham, NC (R.M.C.); and Missouri Baptist Medical Center, St. Louis, MO (N.T.K.)
| | - John H Alexander
- From the Duke Clinical Research Institute, Duke Medicine, Durham, NC (C.N.H., R.D.L., R.H., D.M.W., B.R.E., E.D.P., J.H.A.); Harvard Medical School, Harvard University, Boston, MA (C.M.G.); Baylor Health Care System, Baylor, TX (M.J.M.); Duke Translational Medicine Institute, Duke Medicine, Durham, NC (R.M.C.); and Missouri Baptist Medical Center, St. Louis, MO (N.T.K.).
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Carranza CL, Ballegaard M, Werner MU, Hasbak P, Kjær A, Kofoed KF, Lindschou J, Jakobsen JC, Gluud C, Olsen PS, Steinbrüchel DA. Endoscopic versus open radial artery harvest and mammario-radial versus aorto-radial grafting in patients undergoing coronary artery bypass surgery: protocol for the 2 × 2 factorial designed randomised NEO trial. Trials 2014; 15:135. [PMID: 24754891 PMCID: PMC4033613 DOI: 10.1186/1745-6215-15-135] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2013] [Accepted: 04/07/2014] [Indexed: 11/17/2022] Open
Abstract
Background Coronary artery bypass grafting using the radial artery has, since the 1990s, gone through a revival. Observational studies have indicated better long-term patency when using radial arteries. Therefore, radial artery might be preferred especially in younger patients where long time patency is important. During the last 10 years different endoscopic techniques to harvest the radial artery have evolved. Endoscopic radial artery harvest only requires a small incision near the wrist in contrast to open harvest, which requires an incision from the elbow to the wrist. However, it is unknown whether the endoscopic technique results in fewer complications or a graft patency comparable to open harvest. When the radial artery has been harvested, there are two ways to use the radial artery as a graft. One way is sewing it onto the aorta and another is sewing it onto the mammary artery. It is unknown which technique is the superior revascularisation technique. Methods/Design The NEO Trial is a randomised clinical trial with a 2 × 2 factorial design. We plan to randomise 300 participants into four intervention groups: (1) mammario-radial endoscopic group; (2) aorto-radial endoscopic group; (3) mammario-radial open surgery group; and (4) aorto-radial open surgery group. The hand function will be assessed by a questionnaire, a clinical examination, the change in cutaneous sensibility, and the measurement of both sensory and motor nerve conduction velocity at 3 months postoperatively. All the postoperative complications will be registered, and we will evaluate muscular function, scar appearance, vascular supply to the hand, and the graft patency including the patency of the central radial artery anastomosis. A patency evaluation by multi-slice computer tomography will be done at one year postoperatively. We expect the nerve conduction studies and the standardised neurological examinations to be able to discriminate differences in hand function comparing endoscopic to open harvest of the radial artery. The trial also aims to show if there is any patency difference between mammario-radial compared to aorto-radial revascularisation techniques but this objective is exploratory. Trial registration ClinicalTrials.gov identifier: NCT01848886. Danish Ethics committee number: H-3-2012-116. Danish Data Protection Agency: 2007-58-0015/jr.n:30–0838.
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Affiliation(s)
- Christian L Carranza
- Department of Cardio-thoracic Surgery, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
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