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Goldstein DJ, Chang HL, Mack MJ, Voisine P, Gammie JS, Marks ME, Iribarne A, Vengrenyuk Y, Raymond S, Taylor BS, Dagenais F, Ailawadi G, Chu MWA, DiMaio JM, Narula J, Moquete EG, O'Sullivan K, Williams JB, Crestanello JA, Scavo V, Puskas JD, Acker MA, Gillinov M, Gelijns AC, O'Gara PT, Moskowitz AJ, Alexander JH, Bagiella E. Intimal hyperplasia, saphenous vein graft disease, and clinical outcomes: Insights from the CTSN VEST randomized trial. J Thorac Cardiovasc Surg 2024; 167:1782-1792.e5. [PMID: 36494209 PMCID: PMC10148927 DOI: 10.1016/j.jtcvs.2022.10.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Diffuse intimal hyperplasia and graft irregularity adversely affect the long-term patency of saphenous vein grafts (SVGs) and clinical outcomes of patients undergoing coronary artery bypass grafting (CABG). The VEST trial evaluated the efficacy of external graft support in limiting the development of intimal hyperplasia (IH) at 1 year postsurgery. In the present secondary analysis, we explored the associations between graft disease and IH and clinical events. We also examined risk factors for early graft occlusion. METHODS VEST is a within-patient randomized, multicenter trial that enrolled 224 patients with multivessel coronary disease undergoing CABG surgery, of whom 203 were evaluated by 1 year postsurgery. Intimal hyperplasia, lumen uniformity, graft stenosis, and graft perfusion were measured by intravascular ultrasound and angiography. Major cardiac and cerebrovascular events (MACCE; including death, myocardial infarction, stroke, and revascularization) were recorded over a median follow-up of 3 years. RESULTS Worse lumen uniformity, greater stenosis, and worse graft perfusion were associated with higher IH values and an increased incidence of clinical events. Consistent with previous findings, we identified endoscopic vein harvesting, female sex, and transit time flow measurement of pulsatility index and flow as risk factors for SVG occlusion during the first year postsurgery. CONCLUSIONS In this secondary analysis of the VEST trial, we observed an association between intimal hyperplasia area and clinical measures of SVG disease at 1 year postsurgery. More severe SVG disease and larger areas of IH were associated with a higher incidence of 3-year MACCE. Ongoing follow-up to 5 years will further elucidate the impact of SVG disease on long-term clinical outcomes of CABG.
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Affiliation(s)
- Daniel J Goldstein
- Department of Cardiovascular and Thoracic Surgery, Montefiore Medical Center, Bronx, NY
| | - Helena L Chang
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Michael J Mack
- Cardiothoracic Surgery, Baylor Scott & White Health, Plano, Tex
| | - Pierre Voisine
- Department of Surgery, Institut de Cardiologie et Pneumologie de Québec, Québec City, Québec, Canada
| | - James S Gammie
- Johns Hopkins Heart and Vascular Institute, Johns Hopkins Health System, Baltimore, Md
| | - Mary E Marks
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alexander Iribarne
- Section of Cardiac Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Yuliya Vengrenyuk
- Division of Cardiology, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, NY
| | - Samantha Raymond
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Bradley S Taylor
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Md
| | - François Dagenais
- Department of Surgery, Institut de Cardiologie et Pneumologie de Québec, Québec City, Québec, Canada
| | - Gorav Ailawadi
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Michael W A Chu
- Division of Cardiac Surgery, Western University, London Health Sciences Centre, London, Ontario, Canada
| | | | - Jagat Narula
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ellen G Moquete
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Karen O'Sullivan
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | | | - Vincent Scavo
- Cardiovascular and Thoracic Surgery, Lutheran Medical Group, Fort Wayne, Ind
| | - John D Puskas
- Department of Cardiovascular Surgery, Mount Sinai Morningside, New York, NY
| | - Michael A Acker
- Division of Cardiovascular Surgery, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Annetine C Gelijns
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Patrick T O'Gara
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Mass
| | - Alan J Moskowitz
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - John H Alexander
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC
| | - Emilia Bagiella
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
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Thuan PQ, Chuong PTV, Nam NH, Dinh NH. Coronary Artery Bypass Surgery: Evidence-Based Practice. Cardiol Rev 2023:00045415-990000000-00183. [PMID: 38112423 DOI: 10.1097/crd.0000000000000621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
Coronary artery bypass graft (CABG) surgery remains a pivotal cornerstone, offering established symptomatic alleviation and prognostic advantages for patients grappling with complex multivessel and left main coronary artery diseases. Despite the lucid guidance laid out by contemporary guidelines regarding the choice between CABG and percutaneous coronary intervention (PCI), a notable hesitation persists among certain patients, characterized by psychological reservations, knowledge gaps, or individual beliefs that sway their inclination toward surgical intervention. This comprehensive review critically synthesizes the prevailing guidelines, modern practices, and outcomes pertaining to CABG surgery, delving into an array of techniques and advancements poised to enhance both short-term and enduring surgical outcomes. The exploration encompasses advances in on-pump and off-pump procedures, conduit selection strategies encompassing the bilateral utilization of internal mammary artery and radial artery conduits, meticulous graft evaluation methodologies, and the panorama of minimally invasive approaches, including those assisted by robotic technology. Furthermore, the review navigates the terrain of hybrid coronary revascularization, shedding light on the pivotal roles of shared decision-making and the heart team in shaping treatment pathways. As a comprehensive compendium, this review not only navigates the intricate landscape of CABG surgery but also aligns it with contemporary practices, envisioning its trajectory within the evolving currents of healthcare dynamics.
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Affiliation(s)
- Phan Quang Thuan
- From the Department of Adult Cardiovascular Surgery, University Medical Center, Ho Chi Minh City, Vietnam
| | - Pham Tran Viet Chuong
- From the Department of Adult Cardiovascular Surgery, University Medical Center, Ho Chi Minh City, Vietnam
| | - Nguyen Hoai Nam
- Department of Cardiovascular and Thoracic Surgery, Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Vietnam
| | - Nguyen Hoang Dinh
- From the Department of Adult Cardiovascular Surgery, University Medical Center, Ho Chi Minh City, Vietnam
- Department of Cardiovascular and Thoracic Surgery, Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Vietnam
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Ramponi F, Seco M, Vallely MP. Defining the Role of Anaortic Coronary Artery Bypass Grafting. J Clin Med 2023; 12:4697. [PMID: 37510812 PMCID: PMC10380961 DOI: 10.3390/jcm12144697] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/30/2023] [Accepted: 07/04/2023] [Indexed: 07/30/2023] Open
Abstract
As the population ages and co-morbidities become more prevalent, the complexity of patients presenting for coronary artery bypass surgery is increasing. Cardiopulmonary bypass and aortic cross-clamping in these patients carry increased risk and, indeed, in some patients, with ascending aortic disease, the risks are prohibitive. Total-arterial anaortic coronary artery surgery is a technique that provides complete surgical coronary artery revascularization without cardiopulmonary bypass and without manipulating the ascending aorta. The technique essentially eliminates the risk of cerebral embolization of aortic atheroma and aortic injury. Anaortic techniques are an essential skillset for coronary artery surgery centers treating higher-risk patients.
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Affiliation(s)
- Fabio Ramponi
- Department of Cardiovascular Surgery, Mount Sinai Morningside, New York, NY 10025, USA
| | - Michael Seco
- Department of Cardiothoracic Surgery, Royal North Shore Hospital, Sydney 2065, Australia
| | - Michael P Vallely
- Department of Cardiothoracic Surgery, Monash Health, The Victorian Heart Hospital, Melbourne 3168, Australia
- Department of Surgery, Monash University, Melbourne 3168, Australia
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Mavioglu I. Minimally Invasive Off-Pump Anaortic Complete Arterial Coronary Artery Bypass: How to Do It? INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2023; 18:376-379. [PMID: 37464774 DOI: 10.1177/15569845231185333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
Minimally invasive direct coronary artery bypass has empowered coronary artery bypass grafting to compete with the appeal of percutaneous coronary procedures. Successful results of off-pump coronary artery bypass surgery and without touching the aorta have facilitated the development and use of minimally invasive methods. Multivessel coronary bypass surgery performed using a minimally invasive method through a small thoracotomy in the left chest with off-pump, anaortic, and all-arterial grafts is described step by step. Technical considerations, description of operation stages, and tips and pitfalls will be examined. A 64-year-old male patient with no known comorbidities except smoking revealed 3 vessels and a side vessel disease, and the heart team decided on surgical revascularization with a low-risk procedure. Experienced surgeons may perform this operation successfully, and the development of efficient simulation systems will increase its use.
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Affiliation(s)
- Ilhan Mavioglu
- Cardiovascular Surgery, Cardiac Surgical Clinic of Private Cardiac Surgeons (CSCPCS), Istanbul, Turkey
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Vervoort D, Elbatarny M, Rocha R, Fremes SE. Reconstruction Technique Options for Achieving Total Arterial Revascularization and Multiple Arterial Grafting. J Clin Med 2023; 12:jcm12062275. [PMID: 36983276 PMCID: PMC10056232 DOI: 10.3390/jcm12062275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/11/2023] [Accepted: 03/14/2023] [Indexed: 03/17/2023] Open
Abstract
Ischemic heart disease is the leading cause of morbidity and mortality worldwide and may require coronary revascularization when more severe or symptomatic. Coronary artery bypass grafting (CABG) is the most common cardiac surgical procedure and can be performed with different bypass conduits and anastomotic techniques. Saphenous vein grafts (SVGs) are the most frequently used conduits for CABG, in addition to the left internal thoracic artery. Outcomes with a single internal thoracic artery and SVGs are favorable, and the long-term patency of SVGs may be improved through novel harvesting techniques, preservation methods, and optimal medical therapy. However, increasing evidence points towards the superiority of arterial grafts, especially in the form of multiple arterial grafting (MAG). Nevertheless, the uptake of MAG remains limited and variable, both as a result of technical complexity and a scarcity of conclusive randomized controlled trial evidence. Here, we present an overview of CABG techniques, harvesting methods, and anastomosis types to achieve total arterial revascularization and adopt MAG. We further narratively summarize the available evidence for MAG versus single arterial grafting to date and highlight remaining gaps and questions that require further study to elucidate the role of MAG in CABG.
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Affiliation(s)
- Dominique Vervoort
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5S 1A1, Canada
- Division of Cardiac Surgery, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Malak Elbatarny
- Division of Cardiac Surgery, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Rodolfo Rocha
- Division of Cardiac Surgery, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Stephen E. Fremes
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5S 1A1, Canada
- Division of Cardiac Surgery, University of Toronto, Toronto, ON M5S 1A1, Canada
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
- Correspondence: ; Tel.: +1-416-480-6073
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Hardisky D, Vijayakumar A, Whitson BA, Lilly SM, Boudoulas KD, Vallely MP. Concomitant anaortic OPCAB and transfemoral TAVR for high-risk patients: A case series. J Card Surg 2022; 37:3935-3942. [PMID: 36098378 DOI: 10.1111/jocs.16838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 07/28/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Combined on-pump coronary artery bypass (ONCAB) and surgical aortic valve replacement (SAVR) is the treatment of choice for concomitant severe aortic stenosis and coronary artery disease not amenable to percutaneous coronary intervention. Extensive aortic calcification and atheromatous disease may prohibit cardiopulmonary bypass and aortic cross-clamping. In these cases, anaortic off-pump coronary artery bypass (OPCAB) is a Class I (EACTS 2018) and Class IIA (AHA 2021) indication for surgical coronary revascularization. Transcatheter aortic valve replacement (TAVR) has similar benefits when compared with SAVR for this population (Partner 2 & 3). Herewith we describe a case series of concomitant Anaortic OPCAB and TAVR via the transfemoral approach for patients with coronary artery and valve disease considered too high risk for traditional coronary artery bypass grafting and SAVR due to severe aortic disease. METHODS/RESULTS Eight patients underwent anaortic OPCAB and transfemoral TAVR during the same anesthetic in a hybrid operating room. Seven patients with multivessel disease had anaortic OPCAB via a sternotomy using composite grafts, one patient with LAD disease had anaortic OPCAB using a Da Vinci-assisted MIDCAB approach. All patients then had an Edwards Sapien 3 TAVR placed percutaneously via the common femoral artery. There was no 30 mortality or CVA in the series and all patients were discharged to home or a rehabilitation facility on Day 4-13. CONCLUSIONS Combined anaortic OPCAB and transfemoral TAVR is a safe and feasible approach to treating concomitant extensive coronary artery disease and severe aortic stenosis. The aortic no-touch technique provides benefits in the elderly high-risk patients by reducing the risk of postoperative myocardial infarction and cerebrovascular stroke.
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Affiliation(s)
- Dariya Hardisky
- College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Ammu Vijayakumar
- Division of Cardiothoracic Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Bryan A Whitson
- Division of Cardiothoracic Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Scott M Lilly
- Division of Cardiology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - K Dean Boudoulas
- Division of Cardiology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Michael P Vallely
- Division of Cardiothoracic Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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