Role of statin therapy in the coronary bypass patient

Frequency of Use of Statins and Aspirin in Patients With Previous Coronary Artery Bypass Grafting

Coronary artery bypass grafting (CABG) is commonly performed to treat ischemic heart disease, but long-term benefits are limited by failed patency of bypass grafts. Both statin medications and aspirin hold class I indications for all post-CABG patients and should be continued indefinitely unless contraindications exist. Unfortunately, there are limited data regarding long-term usage of these essential medications. We assessed the utilization rates of statins and aspirin among post-CABG patients referred for coronary angiography. Analysis of post-CABG patients presenting to Thomas Jefferson University for a cardiac catheterization procedure at least 3 years after surgery was performed. Inpatient and outpatient records were reviewed to assess prescribing patterns of these medications, as well as other pertinent clinical and laboratory data. The study population was 381 consecutive patients presenting at a mean of 11 ± 6 years from CABG. Mean age was 69 ± 11 years and 78% were men. A total 67% of patients were being prescribed a statin, whereas 75% were prescribed aspirin. Only 52% were prescribed both at the time of catheterization. Patients prescribed a statin had a significantly lower mean low-density lipoprotein (87 vs 106 [p <0.01]) and total cholesterol values (151 vs 162 [p <0.01]). A total of 35% of patients had low-density lipoprotein ≥100. Only 43% of saphenous vein grafts in the patients not on statin medications remained patent. In conclusion, long-term statin and aspirin use after CABG remains suboptimal despite clear guideline recommendations and clinical trial evidence of their effectiveness.

Impact of statins and beta-blocker therapy on mortality after coronary artery bypass graft surgery

BACKGROUND

We conducted a retrospective cohort study of patients after first-time isolated coronary artery bypass graft surgery (CABG) and assessed the impact of a discharge regimen including beta-blockers and statin therapy and their relationship to long-term all cause mortality and major adverse cardiovascular events (MACE).

METHODS

We identified patients age >18 years, undergoing first time isolated CABG from 1993 to 2005. Patients were identified using the Cardiovascular Information Registry (CVIR). We collected follow-up information at 30, 60, 90 days and yearly follow-up. The registry is approved for use in research by the institutional review broad.

RESULTS

We identified 5,205 patients who underwent single isolated CABG between January 1993 and December 2005. The mean age was 64.5±9.7 years and over 70% were male. There was a significant difference in the low density lipoproteins (LDL) concentration between those with or without statin medications (134±41.9 mg/dL) (no statin) vs. 126±44.8 mg/dL (with statin), P=0.001. A discharge regimen with statin therapy was associated with and overall reduction in 30 day, 1 year and long-term mortality. In addition, overall the triple ischemic endpoint of death, myocardial infarction (MI) and stroke was also significantly lower in the statin vs. no-statin group. In addition, statin and beta-blockers exerted synergistic effect on overall mortality outcomes short-term and in the long-term. We note that the predictors of overall death include no therapy with statin therapy and age [hazard ratios (HR) 1.1, 95% CI: 1.04-1.078, P<0.001] and presence of renal failure (HR 2.0, P=0.005). The estimated 11-year Kaplan Meier curves for mortality between the two groups starts to diverge immediately post discharge after single isolated CABG and continue to diverge through out the follow-up period.

CONCLUSIONS

A post-discharge regimen of statins independently reduces overall and 1 year mortality. These results confirm those of earlier studies within a contemporary surgical population and support the current clinical guidelines.

Understanding the volume-outcome effect in cardiovascular surgery: the role of failure to rescue

IMPORTANCE

To effectively guide interventions aimed at reducing mortality in low-volume hospitals, the underlying mechanisms of the volume-outcome relationship must be further explored. Reducing mortality after major postoperative complications may represent one point along the continuum of patient care that could significantly affect overall hospital mortality.

OBJECTIVE

To determine whether increased mortality at low-volume hospitals performing cardiovascular surgery is a function of higher postoperative complication rates or of less successful rescue from complications.

DESIGN, SETTING, AND PARTICIPANTS

We used patient-level data from 119434 Medicare fee-for-service beneficiaries aged 65 to 99 years undergoing coronary artery bypass grafting, aortic valve repair, or abdominal aortic aneurysm repair between January 1, 2005, and December 31, 2006. For each operation, we first divided hospitals into quintiles of procedural volume. We then assessed hospital risk-adjusted rates of mortality, major complications, and failure to rescue (ie, case fatality among patients with complications) within each volume quintile.

EXPOSURE

Hospital procedural volume.

MAIN OUTCOMES AND MEASURES

Hospital rates of risk-adjusted mortality, major complications, and failure to rescue.

RESULTS

For each operation, hospital volume was more strongly related to failure-to-rescue rates than to complication rates. For example, patients undergoing aortic valve replacement at very low-volume hospitals (lowest quintile) were 12% more likely to have a major complication than those at very high-volume hospitals (highest quintile) but were 57% more likely to die if a complication occurred.

CONCLUSIONS AND RELEVANCE

High-volume and low-volume hospitals performing cardiovascular surgery have similar complication rates but disparate failure-to-rescue rates. While preventing complications is important, hospitals should also consider interventions aimed at quickly recognizing and managing complications once they occur.

Simvastatin attenuates the endothelial pro-thrombotic shift in saphenous vein grafts induced by Advanced glycation endproducts

BACKGROUND

Advanced glycation endproducts (AGEs) and its receptors (RAGEs) are heterogeneous signaling proteins associated to diabetes and responsible of endothelial alterations leading to atherosclerosis progression and graft failure. The aim of this study was to investigate the role of statin in reducing AGEs related endothelial damage.

METHODS

Endothelial cell(EC) obtained from leftovers of saphenous vein grafts of non-diabetic patients were incubated with AGEs (2 and 20 μM) and subsequently treated with Simvastatin. Neutrophils (PNM) adherence, ROS production and RAGE and peroxisome proliferator-activated receptors-gamma (PPAR-γ) expression were analyzed. As clinical validation of the in vitro findings, ECs of diabetic patients in optimized glycaemic control administered with a 3 weeks Simvastatin regimen were similarly processed.

RESULTS

Simvastatin blunted the rise in PMN adhesion and ROS generation following stimulation of saphenous vein EC culture with AGEs in vitro. This effect was time dependent and was associated to an increase in PPAR-γ induction paralleled by a decrease in RAGEs expression. Parallely, data from diabetic patients administered with Simvastatin showed a similar significant reduction in PNM adhesion and ROS generation. Simvastatin treatment significantly decreased RAGEs expression in ECs from diabetic patients and determined a slight increase in PPAR-γ expression but the latter failed to reach statistical significance. Interference in the function of these two crucial pathways might be at the root of the statin antinflammatory and antithrombotic effect in the context of AGEs-associated damage.

CONCLUSIONS

Despite the recently raised warning on the use of statins in the diabetic population, this study elucidates their cornerstone position in endothelial homeostasis of saphenous grafts in patients with controlled diabetes.

Temporal network based analysis of cell specific vein graft transcriptome defines key pathways and hub genes in implantation injury

Vein graft failure occurs between 1 and 6 months after implantation due to obstructive intimal hyperplasia, related in part to implantation injury. The cell-specific and temporal response of the transcriptome to vein graft implantation injury was determined by transcriptional profiling of laser capture microdissected endothelial cells (EC) and medial smooth muscle cells (SMC) from canine vein grafts, 2 hours (H) to 30 days (D) following surgery. Our results demonstrate a robust genomic response beginning at 2 H, peaking at 12-24 H, declining by 7 D, and resolving by 30 D. Gene ontology and pathway analyses of differentially expressed genes indicated that implantation injury affects inflammatory and immune responses, apoptosis, mitosis, and extracellular matrix reorganization in both cell types. Through backpropagation an integrated network was built, starting with genes differentially expressed at 30 D, followed by adding upstream interactive genes from each prior time-point. This identified significant enrichment of IL-6, IL-8, NF-κB, dendritic cell maturation, glucocorticoid receptor, and Triggering Receptor Expressed on Myeloid Cells (TREM-1) signaling, as well as PPARα activation pathways in graft EC and SMC. Interactive network-based analyses identified IL-6, IL-8, IL-1α, and Insulin Receptor (INSR) as focus hub genes within these pathways. Real-time PCR was used for the validation of two of these genes: IL-6 and IL-8, in addition to Collagen 11A1 (COL11A1), a cornerstone of the backpropagation. In conclusion, these results establish causality relationships clarifying the pathogenesis of vein graft implantation injury, and identifying novel targets for its prevention.

Vein graft failure: current clinical practice and potential for gene therapeutics

Autologous saphenous vein is commonly used as a conduit to bypass atherosclerotic lesions in coronary and femoral arteries. Despite the wide use of arterial conduits, which are less susceptible to complications and failure, as alternative conduits, the saphenous vein will continue to be used in coronary artery bypass grafting until acceptable alternative approaches are evaluated. Hence, preservation of vein graft patency is essential for the long-term success. Gene therapy is attractive in this setting as an ex-vivo technology to genetically manipulate the conduit before grafting. The use of safe and efficient vectors for delivery is a necessity as well as a strategy to improve patency in the long term. Here, we review the current clinical practice, the pathogenesis of bypass graft failure and adenovirus-mediated gene therapy strategies designed to improve late vein graft failure by modulation of smooth muscle cells in the vein wall.

Sustained reduction of vein graft neointima formation by ex vivo TIMP-3 gene therapy

BACKGROUND

Coronary artery vein graft failure, resulting from thrombosis, intimal thickening, and atherosclerosis, is a significant clinical problem, with approximately 50% of vein grafts failing within 10 years. Intimal thickening is caused by migration of vascular smooth muscle cells from the media to the intima, where they proliferate. Interventions using gene transfer to inhibit vascular smooth muscle cells proliferation and migration are attractive because ex vivo access to the graft is possible. The involvement of matrix-degrading metalloproteinases in intimal thickening is well established, and we previously showed that adenoviral-delivered overexpression of an endogenous inhibitor, the tissue inhibitor of metalloproteinases-3 (TIMP-3), significantly retarded intimal thickening in short-term autologous porcine arteriovenous interposition grafts (28 days). However, it is essential to determine whether this approach will provide longer-term benefits.

METHODS AND RESULTS

We assessed whether a recombinant adenovirus that overexpresses TIMP-3 (RAdTIMP-3) affects vein graft intimal thickening in the longer term (at 3 months). Porcine saphenous veins were subjected to luminal infection with 2.5×10(10) pfu/mL RAdTIMP-3 or RAd60 (control virus) or vehicle control, for 30 minutes before implantation into the carotid artery. Analysis of grafts harvested 3 months after delivery revealed that RAdTIMP-3-infected grafts had significantly reduced intimal areas compared with both controls (3.2 ± 0.4 mm(2) versus 5.6 ± 0.7 mm(2) and 5.9 ± 0.5 mm(2), RAdTIMP-3, RAd60, and vehicle, respectively). Medial areas were also significantly decreased by TIMP-3 (3.8 ± 0.3 mm(2) versus 6.7 ± 1.0 mm(2) and 5.2 ± 0.4 mm(2), RAdTIMP-3, RAd60, and vehicle, respectively).

CONCLUSIONS

Overexpression of TIMP-3 provides a sustained retardation of vein graft intimal thickening and highlights the translational potential for ex vivo TIMP-3 gene therapy.

Simvastatin exerts favourable effects on neointimal formation in a mouse model of vein graft

BACKGROUND

Simvastatin inhibits human saphenous vein neointima formation in human saphenous vein organ cultures. However, it is not known if simvastatin actually inhibits vein graft intima hyperplasia in vivo, and the underlying mechanisms behind that. In this study, we used a murine vein graft model to address these issues.

METHODS AND RESULTS

Vein grafting was performed among C57BL/6 J mice treated with low-dose (2 mg kg(-1)) or high-dose (20 mg kg(-1)) simvastatin or vehicle subcutaneously 72 h before and then daily after surgery. As compared to the vehicle, simvastatin dose-dependently significantly inhibited vein graft intima hyperplasia 4 weeks after surgeries. Immunohistochemistry studies suggested that vein graft neointima was mainly composed of vascular smooth muscle cells (VSMCs), and the rate of proliferating cell nuclear antigen (PCNA)-positive cells in the intima of vein grafts was significantly lower in simvastatin-treated groups than in control group. We isolated VSMC from mouse vena cava, simvastatin significantly reduced VSMC proliferation, and platelet-derived growth factor (PDGF)-induced VSMC migration in a dose-dependent manner.

CONCLUSION

Simvastatin inhibits neointima formation of mouse vein graft under normocholesterolaemic condition in vivo, the mechanisms might be associated with inhibitory effects of simvastatin on VSMC proliferation and migration.

Endovascular stenting of an extracranial-intracranial saphenous vein high-flow bypass graft: Technical case report

Background:

The authors describe a case of endovascular stenting of an extracranial–intracranial saphenous vein high-flow bypass graft in the management of a complex bilateral carotid aneurysm case.

Case Description:

A 43-year-old woman was admitted with progressive visual field restriction and headache. Imaging studies revealed bilateral supraclinoid carotid aneurysms. The right carotid aneurysm was clipped and the left one was treated by an endovascular procedure, after performing an internal carotid artery–middle cerebral artery (ICA-MCA) saphenous vein bypass graft. A few months following the bypass procedure, a 70–80% stenosis of the graft was discovered and treated endovascularly with a stenting procedure. Follow-up at 36 months after the first operation showed the patency of the venous graft and no neurological deficits.

Conclusions:

Endovascular stenting of the extracranial–intracranial saphenous vein high-flow bypass graft is technically feasible when postoperative graft occlusion is discovered.

Statins therapy: a review on conventional and novel formulation approaches

BACKGROUND AND OBJECTIVE

High levels of cholesterol lead to atherosclerosis, a factor predisposing to the development of coronary artery disease. Statin drugs, i.e. HMG-CoA reductase inhibitors, have been known since the end of the last century for their benefits against cardio- and cerebrovascular diseases and are widely used clinically. This review aims at compiling the research inputs being made for developing therapeutically efficacious dosage forms that have the potential to surmount the limitations of conventional dosage forms of statins.

KEY FINDINGS

Statin drugs can reduce the endogenous synthesis of cholesterol and prevent the onset and development of atherosclerosis, and are therefore used as an effective treatment against primary hypercholesterolemia. At present, statin drugs are most often administered orally, on a daily basis. After administration, the bioavailability and the general circulation of statin drugs is fairly low due to the first-pass metabolism in the liver and clearance by the digestive system. Extensive pharmaceutical research in understanding the causes of low oral bioavailability has led to the development of novel technologies to address these challenges.

SUMMARY

These technologies vary from conventional dosage forms to nanoparticulate drug-delivery systems, and have the potential to cause improvements in bioavailability and consequently therapeutic efficacy.

Effect of preoperative statin therapy on myocardial protection and morbidity endpoints following off-pump coronary bypass surgery in patients with elevated C-reactive protein level

BACKGROUND

The aim of this study was to investigate the effects of preoperative statin therapy on myocardial protection and morbidity endpoints following off-pump coronary bypass graft surgery (OPCAB) in patients with elevated serum high-sensitivity C-reactive protein (hs-CRP) levels.

METHODS

Of the 492 patients who underwent multivessel OPCAB from March 2007 to February 2009, the records of 144 patients whose baseline hs-CRP level > 2 mg/L were reviewed. According to the history of preoperative statin therapy for at least one week, patients were classified as either statin group or control group (72 subjects each). Preoperative and operative characteristics and postoperative data including troponin (Tn)-T level and major morbidity endpoints were obtained and compared. Major morbidity endpoints were defined as permanent stroke, renal dysfunction, hemostatic re-exploration, deep sternal wound infection, and the number of patients requiring prolonged ventilation.

RESULTS

Preoperative and operative characteristics were similar between the two groups. There were no significant differences in the incidence of morbidity endpoints between the two groups, except for the number of patients requiring dialysis, which was significantly lower in the statin group (8 vs. 1, P = 0.033). Tn-T level at 24 h after surgery was also significantly lower in the statin group.

CONCLUSIONS

In this study, we observed beneficial effects of preoperative statin therapy for at least one week in terms of less myocardial enzyme release and fewer patients requiring dialysis following OPCAB in patients whose preoperative hs-CRP was elevated.

New therapeutic possibilities for vein graft disease in the post-edifoligide era

Vein graft neointimal hyperplasia involves proliferation and migration of vascular smooth muscle cells into the vessel intima, and ultimately engenders accelerated atherosclerosis and vein graft failure. Since a myriad of stimuli provoke smooth muscle cell proliferation, molecular therapies for vein graft disease have targeted mechanisms fundamental to all cell proliferation - the 'cell-cycle' machinery. Preclinically, the most successful of these therapies has been edifoligide (E2F decoy), a double-stranded oligodeoxynucleotide that binds to the transcription factor known as E2F. Recently, PRoject of Ex vivo vein GRaft Engineering via Transfection (PREVENT) III and IV demonstrated that edifoligide failed to benefit human vein grafts employed to treat lower-extremity ischemia and coronary heart disease, respectively. The clinical failure of edifoligide calls into question previous models of vein graft disease and lends credence to recent animal studies demonstrating that vein graft arterialization substantially involves the immigration into the vein graft of a variety of vascular progenitor cells. Future vein graft disease therapies will likely target not only proliferation of graft-intrinsic cells, but also immigration of graft-extrinsic cells.

Endoscopic radial artery harvesting for U-clip high-flow EC-IC bypass: technical report

INTRODUCTION

Bypass and aneurysm trapping constitute a well-known surgical solution for aneurysms that are not suitable for clipping or coiling. New techniques are available that make EC-IC bypass procedures easier, safer and, possibly, less invasive. The nitinol self-closing U-Clip device (Medtronic, Inc., Minneapolis) has been designed to facilitate the interrupted suture technique by eliminating the need for suture management, knot tying, and surgical assistance.

MATERIALS AND METHODS

We present two consecutive U-clip bypass procedures in which the radial artery graft was harvested endoscopically.

RESULTS

This novel bypass technique employs endoscopy to minimise arm injury due to radial artery harvesting and self-closing U-clips to simplify the intracranial micro-anastomosis and reduce the temporary occlusion time. Angiography confirmed bypass patency in all patients.

DISCUSSION

Combined with the innovative use of U-clips, these two examples illustrate how new technologies can simplify EC-IC bypass surgery while yielding a better cosmetic and functional outcome.

Cerebral revascularization for ischemia, aneurysms, and cranial base tumors

This article extensively reviews the history, indications for bypass, choice of grafts, techniques, complications, and results after cerebral revascularization. The current role and future perspectives of cerebral revascularization are discussed. The results of 295 direct revascularization procedures in 285 patients (130 tumors and 115 aneurysms from 1988 to 2006; 40 cases of ischemia from 1994 to 2006) and 26 pial synangiosis procedures (for moyamoya syndrome in children from 1997 to 2007) have been summarized. Current operative techniques are illustrated with drawings and video clips.

Aspirin in coronary artery bypass surgery: new aspects of and alternatives for an old antithrombotic agent

The success of coronary artery bypass graft surgery (CABG) depends mainly on the patency of the graft vessels. Aortocoronary vein graft disease is comprised of three distinct but interrelated pathological processes: thrombosis, intimal hyperplasia and atherosclerosis. Early thrombosis is a major cause of vein graft attrition during the first month after CABG, while during the remainder of the first year, intimal hyperplasia forms a template for subsequent atherogenesis, which thereafter predominates. Platelets play a crucial role in the pathophysiology of graft thrombosis and aspirin is the primary antiplatelet drug that has been shown to improve vein graft patency within the first year after CABG. Nevertheless, a significant number of grafts still occlude in the early postoperative period despite 'appropriate' aspirin treatment. Moreover, laboratory investigations showed that the expected inhibition of platelet function is not always achieved. This has been called 'aspirin nonresponse' or 'aspirin resistance', although a uniform definition is lacking. The finding that a considerable number of patients show an impaired antiplatelet effect of aspirin after CABG brought new insight into the discussion concerning poor patency rates of bypass grafts: the early period after CABG shows a coincidence of an increased risk for bypass thrombosis (amongst others, due to platelet activation and endothelial cell disruption of the graft) and an increased prevalence of aspirin resistance. Hitherto, the underlying mechanisms of aspirin resistance are uncertain and largely hypothetical; amongst others, increased platelet turnover, enhanced platelet reactivity, systemic inflammation, and drug-drug interaction are discussed. Up to now available data concerning the clinical outcome of aspirin resistant CABG patients are limited, and there is evidence that platelets of patients with graft thrombosis are more likely to be resistant to aspirin compared with patients without thrombotic events. Many publications concerning aspirin resistance are available today, but reports addressing this topic in CABG patients are sparse. This review summarises recent insights into the antiplatelet treatment after CABG and describes the clinical benefit, but also the therapeutic failure of the well-established drug aspirin. Moreover, possible pharmacological approaches to improve antithrombotic therapy in aspirin nonresponders among CABG patients are discussed.

Use of radial artery grafts in extracranial-intracranial revascularization procedures

Cerebral revascularization procedures have been used in the clinical management of actual or threatened cerebral ischemic states and unclippable cerebral aneurysms. An alternative to a low-flow bypass graft (for example, with the superficial temporal artery) is the use of high-flow grafts created using the saphenous vein (SV) or radial artery (RA). These high-flow grafts are particularly useful when otherwise adequate collateral flow is insufficient to enable sacrifice of the parent vessel without the risk of cerebral ischemia. In their clinical series of 13 patients who underwent high-flow bypass with an RA graft, the authors describe 8 women and 5 men whose ages ranged from 44 to 69 years (mean 57.84 +/- 9.05 years). Indications for RA graft bypass were unclippable aneurysms in 10 patients and occlusive cerebrovascular disease in 3 patients. The authors review the properties of the 2 most common conduits, the SV and RA grafts. They present the technique of high-flow extracranial-intracranial bypass produced using RA grafts in the management of occlusive atherosclerotic disease and complex intracranial aneurysms that are not otherwise amenable to either clip ligation or coil occlusion.

Comparison of the efficacies of five different statins on inhibition of human saphenous vein smooth muscle cell proliferation and invasion

Statins (HMG-CoA reductase inhibitors) exhibit beneficial effects on the vasculature independently of their cholesterol-lowering properties. These pleiotropic effects underlie the ability of statins to reduce intimal hyperplasia in saphenous vein (SV) bypass grafts by attenuating smooth muscle cell (SMC) invasion and proliferation. Although all statins can effectively lower cholesterol, the pleiotropic effects of individual statins may well differ. We therefore compared the concentration-dependent effects of 4 lipophilic statins (simvastatin, atorvastatin, fluvastatin, and lovastatin) and 1 hydrophilic statin (pravastatin) on the proliferation and invasion of SMC cultured from SV of 9 different patients undergoing coronary artery bypass grafting (CABG). The lipophilic statins inhibited SV-SMC proliferation over a 4-day period with an order of potency of fluvastatin > atorvastatin > simvastatin > lovastatin (IC50 range = 0.07 to 1.77 microM). Similarly, these statins also inhibited SV-SMC invasion through an artificial basement membrane barrier (fluvastatin > atorvastatin > simvastatin >> lovastatin; IC50 range = 0.92 to 26.9 microM). In contrast, the hydrophilic pravastatin had no significant effect on SV-SMC proliferation at concentrations up to 10 microM, nor did it attenuate SV-SMC invasion (up to 30 microM). Our data provide strong evidence that individual statins possess differential pleiotropic effects on SV-SMC function. This may be of clinical relevance in the selection of individual statins for the treatment of CABG patients.

Patterns and predictors of statin use after coronary artery bypass graft surgery

OBJECTIVES

The benefits of statin therapy for patients with coronary artery disease have been well documented, including those occurring after coronary artery bypass graft surgery. The purposes of this study were to assess statin prescription rates in patients who have undergone coronary artery bypass graft surgery and to identify the determinants of postoperative statin administration.

METHODS

A retrospective cohort of 9284 Medicare patients aged 65 years or older who underwent coronary artery bypass graft surgery (1995-2004) was assembled by using linked hospital and pharmacy claims data. Rates of statin use after hospital discharge were calculated, and predictors of postoperative statin use were identified by using generalized estimating equations.

RESULTS

Overall, 35.9% of patients received statins within 90 days of coronary artery bypass graft surgery discharge. Use of statins within 90 days after coronary artery bypass graft surgery steadily improved during the study period, from 13.1% in 1995 to 60.9% in 2004. Patient factors independently associated with an increase in postoperative statin therapy included preoperative statin use (odds ratio, 7.69), later year of operation (odds ratio, 1.22 per additional year), and additional postoperative medications (odds ratio, 1.16 per additional medication). Factors independently associated with a decrease in postoperative statin therapy included peripheral vascular disease (odds ratio, 0.60), diabetes mellitus (odds ratio, 0.67), stroke (odds ratio, 0.77), and older age (odds ratio, 0.96 per additional year). Surgeon and hospital characteristics were not independently associated with postoperative statin use.

CONCLUSIONS

Statins are considerably underused after coronary artery bypass graft surgery, although recent prescription rates are increasing. Patterns of use do not appear to correlate with coronary artery disease risk. These findings highlight the need for targeted quality improvement initiatives to increase the rate of statin administration to this at-risk population.

High-flow Bypass Grafts in the Management of Complex Intracranial Aneurysms

THE MAJORITY OF intracranial aneurysms can be treated by either endovascular coiling or microsurgical clipping. A small group of aneurysms may require vascular bypass or reconstruction for their management. A variety of vascular reconstruction techniques are available, including direct suture, patch grafting, local reimplantations, side to side anastomosis, and bypass grafts. Bypass grafts may include low-flow (superficial temporal to middle cerebral) and high-flow bypass grafts using either the radial artery or saphenous vein. In this article, the indications and techniques of high-flow bypasses and concurrent aneurysm management are discussed. Troubleshooting of these bypasses is also illustrated. Seven intraoperative videos have been provided to demonstrate the various techniques of radial artery graft harvesting, cervical exposure of carotid vessels, bypasses, and concurrent aneurysm management.

Can Statins Reduce Perioperative Morbidity and Mortality in Patients Undergoing Non-Cardiac Vascular Surgery?

AIMS

To determine whether statins can reduce perioperative morbidity and mortality in patients undergoing non-cardiac vascular surgery.

METHODS

A search using Pubmed was performed to identify reports in English. The search terms were: "statins", "perioperative morbidity", "perioperative mortality" and "vascular surgery". We excluded studies dealing with the effect of statins in cardiac surgery. Retrieved articles were manually searched.

RESULTS

Current evidence shows that statins decrease perioperative morbidity and mortality in patients undergoing non-cardiac vascular surgery. Any benefit probably occurs soon (within a month) after initiating treatment.

CONCLUSIONS

Appropriately designed trials need to confirm the beneficial effect of perioperative statin therapy in various patient categories. The optimal duration and dose of perioperative statin therapy should be defined.

Pharmacologic modulation of operative risk in patients who have cardiac disease

Cardiac complications continue to compose a major proportion of serious postoperative morbidity and mortality, and it is appropriate, therefore, that this area has received a lot of attention in the search for pharmacologic modulation of surgical outcomes. Despite numerous studies, conclusive data does not exist, making it difficult to recommend a course of action. beta-blockade has not only made it into national protocols, but is even considered as a quality assessment measure. However, the data are not quite as conclusive as it may sometimes appear. There have been few studies, with a small number of negative outcomes, and, at times, significant methodological concerns. The positive outcomes of meta-analyses rest essentially on a single trial in a highly selected patient population. Although use of beta-blockers in patients who have documented coronary artery disease and are undergoing major vascular procedures appears supported, it is premature to recommend beta-blockade for all patients with cardiac risk. Because these drugs are not without risks, it might be advisable to be restrained in their use until the results of the large-scale randomized POISE trial are available. For clonidine and statins, the data are even more tenuous, and largely based on retrospective reviews (with the exception of postprocedure use of statins, which is well supported). Here again, the results of large-scale prospective trials must become available before recommendations can be made. Finally, promising data indicate that it might be possible to modulate by pharmacologic means the neurocognitive decline that is frequently associated with cardiac surgery, and which is often considered by patients to be the most troublesome complication of the intervention.

Surgical treatment of coronary multivessel disease

Coronary artery bypass grafting has had a significant impact on the treatment of angina, and has been the 'gold standard' since 1969. Its use and efficacy has been increased by revascularization in cardiac arrest and the use of the internal mammary artery. In parallel, catheter techniques have evolved by means of balloon dilatation and additional stenting. This has effected the referral to surgery despite the development of new arterialization techniques and minimally invasive surgery. As competing techniques, an acceptable equilibrium between surgery and stenting will be found within the next years.

Preoperative statin treatment is associated with reduced postoperative mortality and morbidity in patients undergoing cardiac surgery: An 8-year retrospective cohort study

BACKGROUND

Cardiac surgical procedures can be associated with significant morbidity and mortality. Recently, it has been recognized that statins might induce multiple biologic effects independent of lipid lowering that could potentially ameliorate adverse surgical outcomes. Accordingly, this study tested the central hypothesis that pretreatment with statins before cardiac surgery would reduce adverse postoperative surgical outcomes.

METHODS

Demographic and outcomes data were collected retrospectively for 3829 patients admitted for planned cardiac surgery between February 1994 and December 2002. Statin pretreatment occurred in 1044 patients who were comparable with non-statin-pretreated (n = 2785) patients with regard to sex, race, and age. Primary outcomes examined included postoperative mortality (30-day) and a composite morbidity variable.

RESULTS

The odds of experiencing 30-day mortality and morbidity were significantly less in the statin-pretreated group, with unadjusted odds ratios of 0.43 (95% confidence interval [CI], 0.28-0.66) and 0.72 (95% CI, 0.61-0.86), respectively. Risk-adjusted odds ratios for mortality and morbidity were 0.55 (95% CI, 0.32-0.93) and 0.76 (95% CI, 0.62-0.94), respectively, by using a logistic regression model and 0.51 (95% CI, 0.27-0.94) and 0.71 (95% CI, 0.55-0.92), respectively, in the propensity-matched model, demonstrating significant reductions in 30-day morbidity and mortality. In a subsample of patients undergoing valve-only surgery (n = 716), fewer valve-only patients treated with statins experienced mortality, although these results were not statistically significant (1.96% vs 7.5%).

CONCLUSIONS

These findings indicate that statin pretreatment before cardiac surgery confers a protective effect with respect to postoperative outcomes.