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Meijer M, Oliveri F, van Oort MJH, Bingen BO, van der Kley F, Jukema JW, Al Amri I, Montero-Cabezas JM. Intravascular lithotripsy for the treatment of peri-stent calcific lesions in saphenous vein grafts: A case series report. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024:S1553-8389(24)00583-9. [PMID: 39054171 DOI: 10.1016/j.carrev.2024.07.004] [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: 04/04/2024] [Revised: 06/20/2024] [Accepted: 07/12/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND Coronary artery bypass grafting (CABG) is a cornerstone treatment for coronary artery disease, with the use of saphenous vein grafts (SVGs) being prevalent. However, SVGs are susceptible to high failure rates due to graft inflammation, intimal hyperplasia, and atherosclerosis, leading to a substantial number of patients requiring revascularization. Percutaneous coronary intervention (PCI) of SVGs poses unique challenges, including increased risk of distal embolization and perforation due to the grafts' structure and atherosclerotic nature. The role of intravascular lithotripsy (IVL) in calcific SVG lesions has not been elucidated. METHODS We retrospectively analyzed four cases of patients treated with IVL for SVG stenosis at Leiden University Medical Centre between May 2019 and December 2023. Quantitative coronary analysis and intravascular ultrasound were utilized to assess procedural success and mid- to long-term clinical outcomes were reported as well. RESULTS In all 4 cases, IVL was performed in stent (2 due to calcific in-stent neoatherosclerosis; 2 bail-out due to extrinsic stent calcification). No major adverse cardiovascular events (MACE) were reported during mid- to long-term follow-up. The procedure demonstrated effective calcium cracking, leading to optimal stent expansion and minimal residual stenosis with a low risk of procedural complications. CONCLUSIONS IVL represents a promising approach for managing calcified peri-stent SVG lesions, showing potential for safe and effective revascularization with minimal complications. These findings suggest that IVL could be incorporated into the treatment paradigm for calcified peri-stent SVG stenosis, warranting further investigation in larger, prospective studies to validate its efficacy and safety.
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Affiliation(s)
- Maura Meijer
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Federico Oliveri
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Martijn J H van Oort
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Brian O Bingen
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Frank van der Kley
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - J Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Ibtihal Al Amri
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - J M Montero-Cabezas
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands.
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2
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Wang W, Liu Y, Qi H, Liu Y, Jiang Y, Fan R, Shao J, Chen W, Su C, Chen X. Mid-term outcomes of endoscopic vein harvesting in coronary artery bypass grafting: a retrospective cohort study. J Cardiothorac Surg 2024; 19:389. [PMID: 38926738 PMCID: PMC11210013 DOI: 10.1186/s13019-024-02930-5] [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] [Received: 03/28/2024] [Accepted: 06/15/2024] [Indexed: 06/28/2024] Open
Abstract
OBJECTIVES Endoscopic vein harvesting (EVH) is an alternative technique to obtain the saphenous vein for coronary artery bypass grafting (CABG) surgery. We aimed to evaluate the early and mid-term outcomes of patients with EVH in CABG. METHODS This cohort study included consecutive isolated CABG patients in Nanjing First Hospital from July 2020 to December 2022 using propensity score matching methods. Patients were classified to EVH group and open vein harvesting (OVH) group according to the vein harvesting methods. The primary outcome was the all-cause death, and the secondary outcomes were major adverse cardiovascular events (MACEs) including cardiovascular death, heart failure, myocardial infarction and revascularization and asymptomatic survival in the follow-up. RESULTS Totally 1247 patients were included in the study with 849 in OVH group and 398 in EVH group. Patients with EVH were more female, diabetes, higher body mass index, more multi-vessel and left main diseases. 308 pairs were formed after the matching. There was no significant difference in the rates of in-hospital death (EVH vs. OVH, 2.3% vs. 1.3%, P = 0.543). During the 3 years follow-up, EVH grafts were considered not inferior to OVH grafts, no differences were found in all-cause death [8.5% vs. 5.0%, hazard ratio (HR) 1.565, 95% confidence interval (CI): 0.77-3.17, P = 0.21], MACEs (8.1% vs. 7.1%, HR 1.165, 95CI: 0.51-2.69, P = 0.71) and asymptomatic survival (66.7% vs. 72.5%, HR 1.117, 95%CI: 0.65-1.92, P = 0.68). CONCLUSIONS EVH grafts were considered comparable to OVH grafts in patients following CABG in the 3 years follow-up.
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Affiliation(s)
- Wuwei Wang
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Changle Road 68, Nanjing, China
| | - Yiming Liu
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Changle Road 68, Nanjing, China
| | - Haoyu Qi
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Changle Road 68, Nanjing, China
| | - Yafeng Liu
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Changle Road 68, Nanjing, China
| | - Yunfei Jiang
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Changle Road 68, Nanjing, China
| | - Rui Fan
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Changle Road 68, Nanjing, China
| | - Junjie Shao
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Changle Road 68, Nanjing, China
| | - Wen Chen
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Changle Road 68, Nanjing, China
| | - Cunhua Su
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Changle Road 68, Nanjing, China.
| | - Xin Chen
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Changle Road 68, Nanjing, China.
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Anderson D, Kiaii B, Catrip J. The Current Status of Minimally Invasive Conduit Harvesting for Coronary Artery Bypass Grafting. J Cardiovasc Dev Dis 2024; 11:188. [PMID: 39057610 PMCID: PMC11276993 DOI: 10.3390/jcdd11070188] [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: 05/18/2024] [Revised: 06/18/2024] [Accepted: 06/20/2024] [Indexed: 07/28/2024] Open
Abstract
The harvesting of conduits for coronary artery bypass surgery has evolved over the last decade to include endoscopic approaches to access the saphenous vein, radial artery, and internal mammary artery. These minimally invasive techniques reduce the morbidity associated with open procedures by decreasing pain and recovery time and increasing mobility post operatively. This review highlights the differences in morbidity, quality, and patency between the most common conduits that are harvested minimally invasively for coronary artery bypass grafting surgery.
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Affiliation(s)
- Devon Anderson
- Division of Cardiac Surgery, Department of Surgery, University of California Davis Medical Center, Sacramento, CA 95817, USA; (B.K.); (J.C.)
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Sampath HK, Lee TJH, Cher CE, Liang S, Cheong OO, Kofidis T, Vitaly S, Sazzad F. A Comprehensive Clinical Outcome Analysis of Endoscopic Vessel Harvesting for Coronary Artery Bypass Surgery. J Clin Med 2024; 13:3405. [PMID: 38929933 PMCID: PMC11204017 DOI: 10.3390/jcm13123405] [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: 05/14/2024] [Revised: 06/04/2024] [Accepted: 06/09/2024] [Indexed: 06/28/2024] Open
Abstract
Background: The long saphenous vein is routinely used for coronary bypass graft (CABG) surgery, and two primary techniques are commonly utilized: endoscopic vessel harvesting (EVH) and open vessel harvesting (OVH). The aim of this study was to compare the clinical outcomes of the EVH and OVH techniques used for CABG within the confines of a tertiary hospital. Methods: The clinical data of all patients subjected to either EVH or OVH for CABG surgery between 2014 and 2018 were retrospectively analyzed. Statistical analysis was performed to discern variations in the rates of postoperative complications between EVH and OVH. Results: A cohort of 1884 individuals were included in this study, 75.3% of whom underwent EVH. Notably, the incidence of postoperative leg wound complications was significantly different between the patients who underwent OVH and the patients who underwent EVH, with incidence rates of 18.6% and 32%, respectively (p < 0.001). Leg wound complications (p < 0.001; OR 1.946; 95% CI 1.528-2.477) and leg wound infections (p = 0.050, OR 1.517, 95% CI 0.999-2.303) were significantly associated with OVH. Moreover, leg wound hematoma (p = 0.039, OR = 0.402, 95% CI = 0.169-0.957) and EVH were strongly associated. Conclusions: The large sample of patients and the inclusion of a range of Asian ethnic groups provided notable insights into postoperative complications related to different modalities. EVH was associated with a lower incidence of postoperative leg wound complications, which suggests that EVH is a better modality for those undergoing CABG surgery.
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Affiliation(s)
- Hari Kumar Sampath
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore 119228, Singapore
| | - Terence Ji Hui Lee
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Chua E. Cher
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Shen Liang
- Biostatistics Unit (BSU), Department of Medicine, National University of Singapore, Singapore 117549, Singapore
| | - Ooi Oon Cheong
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore 119228, Singapore
| | - Theo Kofidis
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore 119228, Singapore
- Centre for Translational Medicine (MD6), National University of Singapore, 14 Medical Drive, Level-8 (South), Singapore 117599, Singapore
| | - Sorokin Vitaly
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore 119228, Singapore
- Centre for Translational Medicine (MD6), National University of Singapore, 14 Medical Drive, Level-8 (South), Singapore 117599, Singapore
| | - Faizus Sazzad
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore 119228, Singapore
- Centre for Translational Medicine (MD6), National University of Singapore, 14 Medical Drive, Level-8 (South), Singapore 117599, Singapore
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Mikami T, Dashwood MR, Kawaharada N, Furuhashi M. An Obligatory Role of Perivascular Adipose Tissue in Improved Saphenous Vein Graft Patency in Coronary Artery Bypass Grafting. Circ J 2024; 88:845-852. [PMID: 37914280 DOI: 10.1253/circj.cj-23-0581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
The gold standard graft for coronary artery bypass grafting (CABG) is the internal thoracic artery (ITA), and the second recommendation is the radial artery. However, complete revascularization with arterial grafts alone is often difficult, and the saphenous vein (SV) is the most commonly used autologous graft for CABG, because it is easier to use without restriction for the length of the graft. On the other hand, the patency of SV grafts (SVGs) is poor compared with that of arterial grafts. The SVG is conventionally harvested as a distended conduit with surrounding tissue removed, a procedure that may cause vascular damage. A no-touch technique of SVG harvesting has been reported to result in improved long-term patency in CABG comparable to that when using the ITA for grafting. Possible reasons for the excellent long-term patency of no-touch SVGs are the physical support provided by preserved surrounding perivascular adipose tissue, preservation of the vascular wall structure including the vasa vasorum, and production of adipocyte-derived factors. In this review, we discuss recent strategies aimed at improving the performance of SVGs, including no-touch harvesting, minimally invasive harvesting and mechanical support using external stents.
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Affiliation(s)
- Takuma Mikami
- Department of Cardiovascular Surgery, Sapporo Medical University
| | - Michael R Dashwood
- Surgical and Interventional Sciences, Royal Free Hospital Campus, University College London Medical School
| | | | - Masato Furuhashi
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University
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Gikandi A, Stock E, DeMatt E, Hirji S, Awtry J, Quin JA, Tolis G, Biswas K, Zenati MA. Performance of left internal thoracic artery-left anterior descending artery anastomosis by residents versus attendings and coronary artery bypass grafting outcomes. Eur J Cardiothorac Surg 2024; 65:ezae155. [PMID: 38598201 DOI: 10.1093/ejcts/ezae155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Revised: 03/06/2024] [Accepted: 04/08/2024] [Indexed: 04/11/2024] Open
Abstract
OBJECTIVES Performance of a technically sound left internal thoracic artery to left anterior descending artery (LITA-LAD) anastomosis during coronary artery bypass grafting (CABG) is critically important. We used prospectively collected data from the multicentre, randomized REGROUP (Randomized Endograft Vein Perspective) trial to investigate CABG outcomes based on whether a resident or an attending surgeon performed the LITA-LAD anastomosis. METHODS This was a post hoc subanalysis of the REGROUP trial, which randomized veterans undergoing isolated on-pump CABG to endoscopic versus open vein harvest from 2014 through 2017. The primary end point was major cardiac adverse events, defined as the composite of all-cause deaths, nonfatal myocardial infarctions or repeat revascularizations. RESULTS Among 1,084 patients, 344 (31.8%) LITA-LAD anastomoses were performed by residents and 740 (68.2%), by attending surgeons. Residents (compared to attendings) operated on fewer patients with high tercile SYNTAX scores (22.1% vs 37.4%, P < 0.001), performed fewer multiarterial CABGs (5.2% vs 14.6%, P < 0.001) and performed more anastomoses to distal targets with diameters > 2.0 mm (19.0% vs 10.9%, P < 0.001) and non-calcified landing zones (25.1% vs 21.6%, P < 0.001). During a median observation time of 4.7 years (interquartile range 3.84-5.45), major cardiac adverse events occurred in 77 patients (22.4%) in the group treated by residents and 169 patients (22.8%) in the group treated by attendings (unadjusted HR 1.00; 95% confidence interval, 0.76-1.33; P = 0.99). Outcomes persisted on adjusted analyses. CONCLUSIONS Based on this REGROUP trial subanalysis, under careful supervision and with appropriate patient selection, LITA-LAD anastomoses performed by the residents yielded clinical outcomes similar to those of the attendings.
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Affiliation(s)
- Ajami Gikandi
- Division of Cardiac Surgery, Veterans Affairs (VA) Boston Healthcare System and Harvard Medical School, Boston, MA, USA
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Eileen Stock
- VA Cooperative Studies Program Coordinating Center, Office of Research and Development, U.S. Department of Veterans Affairs, Perry Point, MD, USA
| | - Ellen DeMatt
- VA Cooperative Studies Program Coordinating Center, Office of Research and Development, U.S. Department of Veterans Affairs, Perry Point, MD, USA
| | - Sameer Hirji
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jake Awtry
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jacquelyn A Quin
- Division of Cardiac Surgery, Veterans Affairs (VA) Boston Healthcare System and Harvard Medical School, Boston, MA, USA
| | - George Tolis
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kousick Biswas
- VA Cooperative Studies Program Coordinating Center, Office of Research and Development, U.S. Department of Veterans Affairs, Perry Point, MD, USA
| | - Marco A Zenati
- Division of Cardiac Surgery, Veterans Affairs (VA) Boston Healthcare System and Harvard Medical School, Boston, MA, USA
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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7
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Gikandi A, Habertheuer A, Stock EM, Hirji S, Kinlay S, Tsao A, Butala N, Biswas K, Zenati MA. Anatomical SYNTAX score and major adverse cardiac events following CABG in the REGROUP trial. J Cardiol 2024; 83:348-350. [PMID: 37977259 DOI: 10.1016/j.jjcc.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 10/24/2023] [Accepted: 10/30/2023] [Indexed: 11/19/2023]
Affiliation(s)
- Ajami Gikandi
- Division of Cardiac Surgery, Veterans Affairs (VA) Boston Healthcare System and Harvard Medical School, Boston, MA, USA; Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Andreas Habertheuer
- Division of Cardiac Surgery, Veterans Affairs (VA) Boston Healthcare System and Harvard Medical School, Boston, MA, USA; Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Eileen M Stock
- VA Cooperative Studies Program Coordinating Center, Office of Research and Development, U.S. Department of Veterans Affairs, Perry Point, MD, USA
| | - Sameer Hirji
- Division of Cardiac Surgery, Veterans Affairs (VA) Boston Healthcare System and Harvard Medical School, Boston, MA, USA; Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Scott Kinlay
- Division of Cardiology, Veterans Affairs (VA) Boston Healthcare System and Harvard Medical School, Boston, MA, USA
| | - Allison Tsao
- Division of Cardiology, Veterans Affairs (VA) Boston Healthcare System and Harvard Medical School, Boston, MA, USA
| | - Neel Butala
- Division of Cardiology, Rocky Mountain Regional Veterans Affairs Medical Center and University of Colorado School of Medicine, Aurora, CO, USA
| | - Kousick Biswas
- VA Cooperative Studies Program Coordinating Center, Office of Research and Development, U.S. Department of Veterans Affairs, Perry Point, MD, USA
| | - Marco A Zenati
- Division of Cardiac Surgery, Veterans Affairs (VA) Boston Healthcare System and Harvard Medical School, Boston, MA, USA; Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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8
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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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Belyayev L, Stock EM, Hattler B, Bakaeen FG, Kinlay S, Quin JA, Haime M, Biswas K, Zenati MA. Complete Coronary Revascularization and Outcomes in Patients Who Underwent Coronary Artery Bypass Grafting: Insights from The REGROUP Trial. Am J Cardiol 2024; 217:127-135. [PMID: 38266796 DOI: 10.1016/j.amjcard.2024.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 12/19/2023] [Accepted: 01/15/2024] [Indexed: 01/26/2024]
Abstract
There is growing evidence in support of coronary complete revascularization (CR). Nonetheless, there is no universally accepted definition of CR in patients who undergo coronary bypass grafting surgery (CABG). We sought to investigate the outcomes of CR, defined as surgical revascularization of any territory supplied by a suitable coronary artery with ≥50% stenosis. We performed a preplanned subanalysis in the Randomized Trial of Endoscopic or Open Saphenous Vein Graft Harvesting (REGROUP) clinical trial cohort. Of 1,147 patients who underwent CABG, 810 (70.6%) received CR. The primary outcome was a composite of major adverse cardiac events (MACEs), including death from any cause, nonfatal myocardial infarction, or repeat revascularization over a median 4.7 years of follow-up. MACE occurred in 175 patients (21.6%) in the CR group and 86 patients (25.5%) in the incomplete revascularization (IR) group (hazard ratio [HR] 0.87, 95% confidence interval [CI] 0.67 to 1.13, p = 0.29). A total of 97 patients (12.0%) in the CR group and 48 patients (14.2%) in the IR group died (HR 0.93, 95% CI 0.65 to 1.32, p = 0.67); nonfatal myocardial infarction occurred in 49 patients (6.0%) in the CR group and 30 patients (8.9%) in the IR group (HR 0.76, 95% CI 0.48 to 1.2, p = 0.24), and repeat revascularization occurred in 62 patients (7.7%) in the CR group and 39 patients (11.6%) in the IR group (HR 0.64; 95% CI 0.42 to 0.95, p = 0.027). In conclusion, in patients with a great burden of co-morbidities who underwent CABG in the REGROUP trial over a median follow-up period of a median 4.7 years, CR was associated with similar MACE rates but a reduced risk of repeat revascularization. Longer-term follow-up is warranted.
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Affiliation(s)
- Leonid Belyayev
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
| | - Eileen M Stock
- Cooperative Studies Program Coordinating Center, Office of Research and Development, US Department of Veterans Affairs, Perry Point, Maryland
| | - Brack Hattler
- Division of Cardiology, Eastern Colorado Veterans Affairs Healthcare System and University of Colorado, Aurora, Colorado
| | - Faisal G Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Scott Kinlay
- Divisions of Cardiology, Veterans Affairs Boston Healthcare System, and Harvard Medical School, Boston, Massachusetts
| | - Jacqueline A Quin
- Cardiac Surgery, Veterans Affairs Boston Healthcare System, and Harvard Medical School, Boston, Massachusetts
| | - Miguel Haime
- Cardiac Surgery, Veterans Affairs Boston Healthcare System, and Harvard Medical School, Boston, Massachusetts
| | - Kousick Biswas
- Cooperative Studies Program Coordinating Center, Office of Research and Development, US Department of Veterans Affairs, Perry Point, Maryland
| | - Marco A Zenati
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Cardiac Surgery, Veterans Affairs Boston Healthcare System, and Harvard Medical School, Boston, Massachusetts
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Almassi GH, Quin JA, Stock EM, DeMatt EJ, Biswas K, Hattler B, Tseng E, Zenati MA. Impact of Oral Anticoagulation on Clinical Outcomes in Postoperative Atrial Fibrillation. J Surg Res 2024; 295:122-130. [PMID: 38007859 DOI: 10.1016/j.jss.2023.10.016] [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] [Received: 04/30/2023] [Revised: 09/14/2023] [Accepted: 10/28/2023] [Indexed: 11/28/2023]
Abstract
INTRODUCTION The impact of postoperative oral anticoagulation (OAC) with warfarin on postoperative atrial fibrillation (POAF) after coronary artery bypass grafting (CABG) was the focus of this examination of patients from the randomized endo-vein graft prospective (REGROUP) Trial. MATERIAL AND METHODS REGROUP was a prospective randomized Veterans Affairs cooperative study comparing endoscopic versus open vein harvest in elective CABG patients (March 2014-April 2017) at 16 Veterans Affairs facilities. This study compared new-onset POAF patients who were treated with warfarin versus no-warfarin. Outcomes included stroke during active follow-up and a major adverse cardiac event composite of mortality, acute myocardial infarction, and repeat revascularization during active and passive follow-up. RESULTS Of the 316/1103 (28.6%) of REGROUP patients who developed new-onset POAF, 45 patients were excluded - mainly for preoperative warfarin use. Of the remaining 269 patients, 85 received OAC with warfarin (OAC group); 184 did not (no-OAC group). Stroke rates during active follow-up (32 [IQR 24-38] mo) were 3.5% OAC group versus 5.4% no-OAC group (P = 0.76); major adverse cardiac eventrates were 20% OAC versus 11.4% no-OAC (P = 0.06). On longer follow-up of (median 4.61 [IQR 3.9-5.1] y), discharge OAC use was associated with all-cause mortality after adjusting for Society of Thoracic Surgeons mortality risk (20.0% versus 11.4% no-OAC use; HR = 2.00, 95% CI: 1.05-3.81, P = 0.035). CONCLUSIONS REGROUP patients with POAF treated with OAC had similar stroke and higher mortality rates versus no-OAC patients. Further investigation of the risk-benefit ratio of OAC in post-CABG patients and which POAF patient subgroups might derive the most benefit with anticoagulation appears warranted.
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Affiliation(s)
- G Hossein Almassi
- Division of Cardiothoracic Surgery, Zablocki Veterans Affairs (VA) Medical Center, Milwaukee, Wisconsin; Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Jacquelyn A Quin
- Department of Surgery, VA Boston Healthcare System, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Eileen M Stock
- Cooperative Studies Program, Perry Point/Baltimore Coordinating Center, Office of Research and Development, U.S. Department of Veterans Affairs, Perry Point, Maryland
| | - Ellen J DeMatt
- Cooperative Studies Program, Perry Point/Baltimore Coordinating Center, Office of Research and Development, U.S. Department of Veterans Affairs, Perry Point, Maryland
| | - Kousick Biswas
- Cooperative Studies Program, Perry Point/Baltimore Coordinating Center, Office of Research and Development, U.S. Department of Veterans Affairs, Perry Point, Maryland
| | - Brack Hattler
- Department of Medicine, Rocky Mountain Regional VA Medical Center, Aurora, Colorado; University of Colorado Anschutz School of Medicine, Aurora, Colorado
| | - Elaine Tseng
- Cardiothoracic Surgery, San Francisco Veterans Affairs Medical Center, San Francisco, California; Department of Surgery, University of California in San Francisco, San Francisco, California
| | - Marco A Zenati
- Department of Surgery, VA Boston Healthcare System, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
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11
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Emmert MY, Bonatti J, Caliskan E, Gaudino M, Grabenwöger M, Grapow MT, Heinisch PP, Kieser-Prieur T, Kim KB, Kiss A, Mouriquhe F, Mach M, Margariti A, Pepper J, Perrault LP, Podesser BK, Puskas J, Taggart DP, Yadava OP, Winkler B. Consensus statement-graft treatment in cardiovascular bypass graft surgery. Front Cardiovasc Med 2024; 11:1285685. [PMID: 38476377 PMCID: PMC10927966 DOI: 10.3389/fcvm.2024.1285685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 01/15/2024] [Indexed: 03/14/2024] Open
Abstract
Coronary artery bypass grafting (CABG) is and continues to be the preferred revascularization strategy in patients with multivessel disease. Graft selection has been shown to influence the outcomes following CABG. During the last almost 60 years saphenous vein grafts (SVG) together with the internal mammary artery have become the standard of care for patients undergoing CABG surgery. While there is little doubt about the benefits, the patency rates are constantly under debate. Despite its acknowledged limitations in terms of long-term patency due to intimal hyperplasia, the saphenous vein is still the most often used graft. Although reendothelialization occurs early postoperatively, the process of intimal hyperplasia remains irreversible. This is due in part to the persistence of high shear forces, the chronic localized inflammatory response, and the partial dysfunctionality of the regenerated endothelium. "No-Touch" harvesting techniques, specific storage solutions, pressure controlled graft flushing and external stenting are important and established methods aiming to overcome the process of intimal hyperplasia at different time levels. Still despite the known evidence these methods are not standard everywhere. The use of arterial grafts is another strategy to address the inferior SVG patency rates and to perform CABG with total arterial revascularization. Composite grafting, pharmacological agents as well as latest minimal invasive techniques aim in the same direction. To give guide and set standards all graft related topics for CABG are presented in this expert opinion document on graft treatment.
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Affiliation(s)
- Maximilian Y. Emmert
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charite (DHZC), Berlin, Germany
- Institute for Regenerative Medicine (IREM), University of Zurich, Zurich, Switzerland
| | - Johannes Bonatti
- Department of Cardiothoracic Surgery, UPMC Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, PA, United States
| | - Etem Caliskan
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charite (DHZC), Berlin, Germany
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, United States
| | - Martin Grabenwöger
- Sigmund Freud Private University, Vienna, Austria
- Department of Cardiovascular Surgery KFL, Vienna Health Network, Vienna, Austria
| | | | - Paul Phillip Heinisch
- German Heart Center Munich, Technical University of Munich, School of Medicine, Munich, Germany
| | - Teresa Kieser-Prieur
- LIBIN Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Ki-Bong Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Attila Kiss
- Ludwig Boltzmann Institute at the Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | | | - Markus Mach
- Department of Cardiac Surgery, Medical University Vienna, Vienna, Austria
| | - Adrianna Margariti
- The Wellcome-Wolfson Institute of Experimental Medicine, Belfast, United Kingdom
| | - John Pepper
- Cardiology and Aortic Centre, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | | | - Bruno K. Podesser
- Ludwig Boltzmann Institute at the Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - John Puskas
- Department of Cardiovascular Surgery, Mount Sinai Morningside, New York, NY, United States
| | - David P. Taggart
- Nuffield Dept Surgical Sciences, Oxford University, Oxford, United Kingdom
| | | | - Bernhard Winkler
- Department of Cardiovascular Surgery KFL, Vienna Health Network, Vienna, Austria
- Ludwig Boltzmann Institute at the Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
- Karld Landsteiner Institute for Cardiovascular Research Clinic Floridsdorf, Vienna, Austria
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12
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Gikandi A, Quin J, Stock EM, Dematt E, Hirji S, Haime M, Biswas K, Zenati MA. Impact of great saphenous vein quality on clinical outcomes after CABG in the REGROUP Trial. THE JOURNAL OF CARDIOVASCULAR SURGERY 2024; 65:79-81. [PMID: 38127303 DOI: 10.23736/s0021-9509.23.12916-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Affiliation(s)
- Ajami Gikandi
- Harvard Medical School, Division of Cardiac Surgery, Veterans Affairs (VA) Boston Healthcare System, Boston, MA, USA -
- Harvard Medical School, Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, MA, USA -
| | - Jacquelyn Quin
- Harvard Medical School, Division of Cardiac Surgery, Veterans Affairs (VA) Boston Healthcare System, Boston, MA, USA
| | - Eileen M Stock
- Office of Research and Development, USA Department of Veterans Affairs, VA Cooperative Studies Program Coordinating Center, Perry Point, MD, USA
| | - Ellen Dematt
- Office of Research and Development, USA Department of Veterans Affairs, VA Cooperative Studies Program Coordinating Center, Perry Point, MD, USA
| | - Sameer Hirji
- Harvard Medical School, Division of Cardiac Surgery, Veterans Affairs (VA) Boston Healthcare System, Boston, MA, USA
- Harvard Medical School, Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Miguel Haime
- Harvard Medical School, Division of Cardiac Surgery, Veterans Affairs (VA) Boston Healthcare System, Boston, MA, USA
| | - Kousick Biswas
- Office of Research and Development, USA Department of Veterans Affairs, VA Cooperative Studies Program Coordinating Center, Perry Point, MD, USA
| | - Marco A Zenati
- Harvard Medical School, Division of Cardiac Surgery, Veterans Affairs (VA) Boston Healthcare System, Boston, MA, USA
- Harvard Medical School, Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, MA, USA
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13
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Gemelli M, Addonizio M, Geatti V, Gallo M, Dixon LK, Slaughter MS, Gerosa G. Techniques and Technologies to Improve Vein Graft Patency in Coronary Surgery. Med Sci (Basel) 2024; 12:6. [PMID: 38249082 PMCID: PMC10801616 DOI: 10.3390/medsci12010006] [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] [Received: 11/14/2023] [Revised: 12/22/2023] [Accepted: 01/05/2024] [Indexed: 01/23/2024] Open
Abstract
Vein grafts are the most used conduits in coronary artery bypass grafting (CABG), even though many studies have suggested their lower patency compared to arterial alternatives. We have reviewed the techniques and technologies that have been investigated over the years with the aim of improving the quality of these conduits. We found that preoperative and postoperative optimal medical therapy and no-touch harvesting techniques have the strongest evidence for optimizing vein graft patency. On the other hand, the use of venous external support, endoscopic harvesting, vein preservation solution and anastomosis, and graft configuration need further investigation. We have also analyzed strategies to treat vein graft failure: when feasible, re-doing the CABG and native vessel primary coronary intervention (PCI) are the best options, followed by percutaneous procedures targeting the failed grafts.
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Affiliation(s)
- Marco Gemelli
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35128 Padova, Italy; (M.A.); (V.G.); (G.G.)
| | - Mariangela Addonizio
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35128 Padova, Italy; (M.A.); (V.G.); (G.G.)
| | - Veronica Geatti
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35128 Padova, Italy; (M.A.); (V.G.); (G.G.)
| | - Michele Gallo
- Department of Cardiothoracic Surgery, University of Louisville, Louisville, KY 40292, USA; (M.G.); (M.S.S.)
| | - Lauren K. Dixon
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London WC2A 3PE, UK;
| | - Mark S. Slaughter
- Department of Cardiothoracic Surgery, University of Louisville, Louisville, KY 40292, USA; (M.G.); (M.S.S.)
| | - Gino Gerosa
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35128 Padova, Italy; (M.A.); (V.G.); (G.G.)
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14
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Gaudino M, Bakaeen FG, Sandner S, Aldea GS, Arai H, Chikwe J, Firestone S, Fremes SE, Gomes WJ, Bong-Kim K, Kisson K, Kurlansky P, Lawton J, Navia D, Puskas JD, Ruel M, Sabik JF, Schwann TA, Taggart DP, Tatoulis J, Wyler von Ballmoos M. Expert systematic review on the choice of conduits for coronary artery bypass grafting: endorsed by the European Association for Cardio-Thoracic Surgery (EACTS) and The Society of Thoracic Surgeons (STS). J Thorac Cardiovasc Surg 2023; 166:1099-1114. [PMID: 37542480 DOI: 10.1016/j.jtcvs.2023.06.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 03/10/2023] [Accepted: 04/20/2023] [Indexed: 08/07/2023]
Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY.
| | - Faisal G Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Sigrid Sandner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Gabriel S Aldea
- Division of Cardiothoracic Surgery, University of Washington School of Medicine, Seattle, Wash
| | - Hirokuni Arai
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Science, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Joanna Chikwe
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif
| | | | - Stephen E Fremes
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, and the Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Walter J Gomes
- Cardiology and Cardiovascular Surgery Disciplines, São Paulo Hospital, Escola Paulista de Medicina, Universidade Federal de São Paulo (Unifesp), São Paulo, Brazil
| | - Ki Bong-Kim
- Cardiovascular Center, Myong-ji Hospital, Gyeong-gi-do, Republic of Korea
| | | | - Paul Kurlansky
- Division of Cardiac Surgery, Department of Surgery, Columbia University, New York, NY
| | - Jennifer Lawton
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Md
| | - Daniel Navia
- Department of Cardiac Surgery, ICBA Instituto Cardiovascular, Buenos Aires, Argentina
| | - John D Puskas
- Department of Cardiovascular Surgery, Mount Sinai Saint Luke's, New York, NY
| | - Marc Ruel
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Joseph F Sabik
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | | | - David P Taggart
- Department of Cardiac Surgery, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - James Tatoulis
- Department of Cardiothoracic Surgery, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
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15
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Gaudino M, Bakaeen FG, Sandner S, Aldea GS, Arai H, Chikwe J, Firestone S, Fremes SE, Gomes WJ, Bong-Kim K, Kisson K, Kurlansky P, Lawton J, Navia D, Puskas JD, Ruel M, Sabik JF, Schwann TA, Taggart DP, Tatoulis J, Wyler von Ballmoos M. Expert Systematic Review on the Choice of Conduits for Coronary Artery Bypass Grafting: Endorsed by the European Association for Cardio-Thoracic Surgery (EACTS) and The Society of Thoracic Surgeons (STS). Ann Thorac Surg 2023; 116:659-674. [PMID: 37542509 DOI: 10.1016/j.athoracsur.2023.06.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/20/2023] [Indexed: 08/07/2023]
Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York.
| | - Faisal G Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Sigrid Sandner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Gabriel S Aldea
- Division of Cardiothoracic Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Hirokuni Arai
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Science, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Joanna Chikwe
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | | | - Stephen E Fremes
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, and the Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Walter J Gomes
- Cardiology and Cardiovascular Surgery Disciplines, São Paulo Hospital, Escola Paulista de Medicina, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil
| | - Ki Bong-Kim
- Cardiovascular Center, Myong-ji Hospital, Gyeong-gi-do, Republic of Korea
| | - Kalie Kisson
- The Society of Thoracic Surgeons, Chicago, Illinois
| | - Paul Kurlansky
- Division of Cardiac Surgery, Department of Surgery, Columbia University, New York, New York
| | - Jennifer Lawton
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Daniel Navia
- Department of Cardiac Surgery, ICBA Instituto Cardiovascular, Buenos Aires, Argentina
| | - John D Puskas
- Department of Cardiovascular Surgery, Mount Sinai Saint Luke's, New York, New York
| | - Marc Ruel
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Joseph F Sabik
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Thomas A Schwann
- Division of Cardiac Surgery, Baystate Health, Springfield, Massachusetts
| | - David P Taggart
- Department of Cardiac Surgery, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - James Tatoulis
- Department of Cardiothoracic Surgery, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
| | - Moritz Wyler von Ballmoos
- Division of Cardiothoracic Surgery, Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas
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16
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Lee JY, Pedula KL, Berkley TO, McNevin KP, Chen JC. Vein Morphology in Endoscopic Vein Harvesting: 15-Year Outcomes. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2023; 18:459-465. [PMID: 37830754 DOI: 10.1177/15569845231204363] [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: 10/14/2023]
Abstract
OBJECTIVE Long-term outcomes of vein morphologies in the endoscopic vein harvesting setting are lacking. We analyzed 15-year follow-up for endoscopic versus open vein harvesting and associated vein morphology outcomes in coronary artery bypass grafting at a single center. METHODS This single-center, prospectively collected, retrospective, observational study evaluated 15-year major adverse cardiovascular events (MACE) of endoscopic versus open vein harvesting and associated vein morphologies. RESULTS Among 729 patients, no differences were found between endoscopic and open vein harvesting in MACE hazard ratios despite increased risks with native Hawai'ian, Pacific Islander, and Filipino patients. Asian and Filipino patients had more thin-walled veins and Asian and multirace patients had more vasovasoral branches than White patients. Bifid veins were associated with increased risk of cardiac catheterization. Varicose veins were associated with myocardial infarction, congestive heart failure, and death. Thick-walled veins were associated with revascularization and dense adhesions with cardiac catheterization and revascularization. CONCLUSIONS Fifteen-year adjusted MACE was similar between endoscopic and open vein harvesting in small coronary targets despite increased risks with native Hawai'ian, Pacific Islander, and Filipino patients. Bifid, varicose, thick-walled veins, and dense adhesions had worse MACE.
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Affiliation(s)
- John Y Lee
- Department of Cardiothoracic Surgery, Kaiser Permanente Moanalua Medical Center, Honolulu, HI, USA
| | - Kathryn L Pedula
- Kaiser Permanente, Quality and Care Integration, Hawai'i Permanente Medical Group, Honolulu, HI, USA
| | - Timothy O Berkley
- Department of Cardiothoracic Surgery, Straub Medical Center, Honolulu, HI, USA
| | - Kamala P McNevin
- Department of Cardiothoracic Surgery, Kaiser Permanente Moanalua Medical Center, Honolulu, HI, USA
| | - John C Chen
- Cardiac Surgery, Keck Medicine of USC, Los Angeles, CA, USA
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17
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Gaudino M, Bakaeen FG, Sandner S, Aldea GS, Arai H, Chikwe J, Firestone S, Fremes SE, Gomes WJ, Bong-Kim K, Kisson K, Kurlansky P, Lawton J, Navia D, Puskas JD, Ruel M, Sabik JF, Schwann TA, Taggart DP, Tatoulis J, Wyler von Ballmoos M. Expert systematic review on the choice of conduits for coronary artery bypass grafting: endorsed by the European Association for Cardio-Thoracic Surgery (EACTS) and The Society of Thoracic Surgeons (STS). Eur J Cardiothorac Surg 2023; 64:ezad163. [PMID: 37535847 DOI: 10.1093/ejcts/ezad163] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 03/10/2023] [Accepted: 04/20/2023] [Indexed: 08/05/2023] Open
Abstract
PREAMBLE The finalized document was endorsed by the EACTS Council and STS Executive Committee before being simultaneously published in the European Journal of Cardio-thoracic Surgery (EJCTS) and The Annals of Thoracic Surgery (The Annals) and the Journal of Thoracic and Cardiovascular Surgery (JTCVS).
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Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY, USA
| | - Faisal G Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Sigrid Sandner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Gabriel S Aldea
- Division of Cardiothoracic Surgery, University of Washington School of Medicine, Seattle, WA, USA
| | - Hirokuni Arai
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Science, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Joanna Chikwe
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | - Stephen E Fremes
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, and the Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Walter J Gomes
- Cardiology and Cardiovascular Surgery Disciplines, São Paulo Hospital, Escola Paulista de Medicina, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil
| | - Ki Bong-Kim
- Cardiovascular Center, Myong-ji Hospital, Gyeong-gi-do, Republic of Korea
| | - Kalie Kisson
- The Society of Thoracic Surgeons, Chicago, IL, USA
| | - Paul Kurlansky
- Division of Cardiac Surgery, Department of Surgery, Columbia University, New York, NY, USA
| | - Jennifer Lawton
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Daniel Navia
- Department of Cardiac Surgery, ICBA Instituto Cardiovascular, Buenos Aires, Argentina
| | - John D Puskas
- Department of Cardiovascular Surgery, Mount Sinai Saint Luke's, New York, NY, USA
| | - Marc Ruel
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Joseph F Sabik
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Thomas A Schwann
- Division of Cardiac Surgery, Baystate Health, Springfield, MA, USA
| | - David P Taggart
- Department of Cardiac Surgery, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - James Tatoulis
- Department of Cardiothoracic Surgery, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
| | - Moritz Wyler von Ballmoos
- Division of Cardiothoracic Surgery, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA
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18
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Biroš E, Staffa R, Novotný T, Krejčí M, Velecký L, Skotáková M. Long-Term Comparison of Endoscopic Versus Open Saphenous Vein Harvest for Femoral-to-Popliteal Artery Bypass. Indian J Surg 2023. [DOI: 10.1007/s12262-023-03745-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023] Open
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19
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Xie X, Shirasu T, Li J, Guo LW, Kent KC. miR579-3p is an inhibitory modulator of neointimal hyperplasia and transcription factors c-MYB and KLF4. Cell Death Discov 2023; 9:73. [PMID: 36813774 PMCID: PMC9946956 DOI: 10.1038/s41420-023-01364-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 01/28/2023] [Accepted: 02/07/2023] [Indexed: 02/24/2023] Open
Abstract
Neointimal hyperplasia (IH) is a common vascular pathology that typically manifests in in-stent restenosis and bypass vein graft failure. Smooth muscle cell (SMC) phenotypic switching is central to IH, both regulated by some microRNAs, yet the role of miR579-3p, a scarcely studied microRNA, is not known. Unbiased bioinformatic analysis suggested that miR579-3p was repressed in human primary SMCs treated with different pro-IH cytokines. Moreover, miR579-3p was software-predicted to target both c-MYB and KLF4 - two master transcription factors known to promote SMC phenotypic switching. Interestingly, treating injured rat carotid arteries via local infusion of miR579-3p-expressing lentivirus reduced IH 14 days after injury. In cultured human SMCs, transfection with miR579-3p inhibited SMC phenotypic switching, as indicated by decreased proliferation/migration and increased SMC contractile proteins. miR579-3p transfection downregulated c-MYB and KLF4, and luciferase assays indicated miR579-3p's targeting of the 3'UTRs of the c-MYB and KLF4 mRNAs. In vivo, immunohistochemistry showed that treatment of injured rat arteries with the miR579-3p lentivirus reduced c-MYB and KLF4 and increased SMC contractile proteins. Thus, this study identifies miR579-3p as a previously unrecognized small-RNA inhibitor of IH and SMC phenotypic switch involving its targeting of c-MYB and KLF4. Further studies on miR579-3p may provide an opportunity for translation to develop IH-mitigating new therapeutics.
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Affiliation(s)
- Xiujie Xie
- Department of Surgery, School of Medicine, University of Virginia, Charlottesville, VA, 22908, USA.
| | - Takuro Shirasu
- grid.27755.320000 0000 9136 933XDepartment of Surgery, School of Medicine, University of Virginia, Charlottesville, VA 22908 USA
| | - Jing Li
- grid.27755.320000 0000 9136 933XDepartment of Surgery, School of Medicine, University of Virginia, Charlottesville, VA 22908 USA
| | - Lian-Wang Guo
- Department of Surgery, School of Medicine, University of Virginia, Charlottesville, VA, 22908, USA. .,Department of Molecular Physiology and Biological Physics, University of Virginia, Charlottesville, VA, 22908, USA. .,Robert M. Berne Cardiovascular Research Center, University of Virginia, Charlottesville, VA, 22908, USA.
| | - K. Craig Kent
- grid.27755.320000 0000 9136 933XDepartment of Surgery, School of Medicine, University of Virginia, Charlottesville, VA 22908 USA
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Zivkovic I, Krasic S, Stankovic M, Milacic P, Milutinovic A, Zdravkovic D, Tabakovic Z, Peric M, Krstic M, Bojic M, Milic D, Micovic S. Influence of Three Different Surgical Techniques on Microscopic Damage of Saphenous Vein Grafts-A Randomized Study. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020217. [PMID: 36837419 PMCID: PMC9962261 DOI: 10.3390/medicina59020217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 12/27/2022] [Indexed: 01/25/2023]
Abstract
Background and Objectives: The saphenous vein is one of the most common used grafts (SVG) for surgical revascularization. The mechanism of the SVGs occlusion is still unknown. Surgical preparation techniques have an important role in the early and late graft occlusion. Our study analyzed the influence of the three different surgical techniques on the histological and immunohistochemical characteristics of the vein grafts. Methods: Between June 2019 and December 2020, 83 patients who underwent surgical revascularization were prospectively randomly assigned to one of the three groups, according to saphenous vein graft harvesting (conventional (CVH), no-touch (NT) and endoscopic (EVH)) technique. The vein graft samples were sent on the histological (hematoxylin-eosin staining) and immunohistochemical (CD31, Factor VIII, Caveolin and eNOS) examinations. Results: The CVH, NT, and EVH groups included 27 patients (mean age 67.66 ± 5.6), 31 patients (mean age 66.5 ± 7.4) and 25 patients (mean age 66 ± 5.5), respectively. Hematoxylin-eosin staining revealed a lower grade of microstructural vein damage in the NT group (2, IQR 1-2) in comparison with CVH and EVH (3, IQR 2-4), (4, IQR 2-4) respectively (p < 0.001). Immunohistochemical examination revealed a high grade of staining in the NT group compared to the CVH and EVH group (CD 31 antibody p = 0.02, FVIII, p < 0.001, Caveolin, p = 0.001, and eNOS, p = 0.003). Conclusion: The best preservation of the structural vein integrity was in the NT group, while the lowest rate of leg wound complication was in the EVH group. These facts increase the interest in developing and implementing the endoscopic no-touch technique.
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Affiliation(s)
- Igor Zivkovic
- Cardiac Surgery Department, Dedinje Cardiovascular Institute, 11000 Belgrade, Serbia
- School of Medicine, University of Belgrade, 11000 Belgrade, Serbia
- Correspondence: ; Tel.: +381-6-2100-9619
| | - Stasa Krasic
- Cardiology Department, Mother and Child Health Care Institute, 11000 Belgrade, Serbia
| | - Milica Stankovic
- Center for Pathology and Pathological Anatomy, Clinical Center of Niš, 18000 Niš, Serbia
| | - Petar Milacic
- Cardiac Surgery Department, Dedinje Cardiovascular Institute, 11000 Belgrade, Serbia
- School of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | | | - Djordje Zdravkovic
- Cardiac Surgery Department, Dedinje Cardiovascular Institute, 11000 Belgrade, Serbia
| | - Zoran Tabakovic
- Cardiac Surgery Department, Dedinje Cardiovascular Institute, 11000 Belgrade, Serbia
| | - Miodrag Peric
- Cardiac Surgery Department, Dedinje Cardiovascular Institute, 11000 Belgrade, Serbia
- School of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Miljan Krstic
- Center for Pathology and Pathological Anatomy, Clinical Center of Niš, 18000 Niš, Serbia
- Faculty of Medicine, University of Niš, 18000 Niš, Serbia
| | - Milovan Bojic
- Cardiac Surgery Department, Dedinje Cardiovascular Institute, 11000 Belgrade, Serbia
- School of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Dragan Milic
- Faculty of Medicine, University of Niš, 18000 Niš, Serbia
- Cardiac Surgery Department, Clinical Center of Niš, 18000 Niš, Serbia
| | - Slobodan Micovic
- Cardiac Surgery Department, Dedinje Cardiovascular Institute, 11000 Belgrade, Serbia
- School of Medicine, University of Belgrade, 11000 Belgrade, Serbia
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21
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Rustenbach CJ, Djordjevic I, Eghbalzadeh K, Baumbach H, Wendt S, Radwan M, Marinos SL, Mustafi M, Lescan M, Berger R, Salewski C, Sandoval Boburg R, Steger V, Nemeth A, Reichert S, Wahlers T, Schlensak C. Treatment of Complex Two-Vessel Coronary Heart Disease with Single Left Internal Mammary Artery as T-Graft with Itself—A Retrospective Double Center Analysis of Short-Term Outcomes. Medicina (B Aires) 2022; 58:medicina58101415. [PMID: 36295575 PMCID: PMC9610783 DOI: 10.3390/medicina58101415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/23/2022] [Accepted: 09/27/2022] [Indexed: 11/16/2022] Open
Abstract
Background and Objectives: The strategy of revascularization may be constrained in patients with insufficient bypass grafts and with increased risk of wound healing disorders. Among those with complex left-sided double-vessel disease in whom a percutaneous coronary intervention (PCI), as well as the surgical procedure of minimally invasive coronary artery bypass grafting via left minithoracotomy (MICS CABG), is not a treatment option, CABG using the left internal mammary artery as a T-graft with itself may be an effective treatment strategy. Materials and Methods: We reviewed the data from patients treated in Cologne and Tuebingen from 2019 to 2022. We included 40 patients who received left internal mammary artery (LIMA) grafting, and additional T-graft with the LIMA itself. The objective was focused on intraoperative and short-term outcomes. Results: A total of 40 patients were treated with the LIMA-LIMA T-graft procedure with a Fowler score calculated at 20.1 ± 3.0. A total of 37.5% of all patients had lacking venous graft material due to prior vein stripping, and 21 patients presented severe vein varicosis. An overall of 2.6 ± 0.5 distal anastomoses (target vessels were left anterior descending, diagonal, intermediate branch, and/or left marginal ramus) were performed, partly sequentially. Mean flow of LIMA-Left anterior descending (LAD) anastomosis was 59.31 ± 11.04 mL/min with a mean PI of 1.21 ± 0.18. Mean flow of subsequent T-Graft accounted for 51.31 ± 3.81 mL/min with a mean PI of 1.39 ± 0.47. Median hospital stay was 6.2 (5.0; 7.5) days. No incidence of postoperative wound healing disorders was observed, and all patients were discharged. There was one 30-day readmission with a diagnosis of pericardial effusion (2.5%). There was no 30-day mortality within the cohort. Conclusions: Patients requiring surgical myocardial revascularization due to complex two-vessel coronary artery disease (CAD) can be easily managed with LIMA alone, despite an elevated Fowler score and a promising outcome. A prospective study needs to be conducted, as well as longer term surveillance, to substantiate and benchmark the long-term results, as well as the patency rates.
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Affiliation(s)
- Christian Jörg Rustenbach
- Department of Thoracic and Cardiovascular Surgery, German Cardiac Competence Center, University of Tuebingen, 72076 Tübingen, Germany
| | - Ilija Djordjevic
- Department of Cardiothoracic Surgery, Heart Center, University of Cologne, 50937 Cologne, Germany
| | - Kaveh Eghbalzadeh
- Department of Cardiothoracic Surgery, Heart Center, University of Cologne, 50937 Cologne, Germany
| | | | - Stefanie Wendt
- Department of Cardiothoracic Surgery, Heart Center, University of Cologne, 50937 Cologne, Germany
| | - Medhat Radwan
- Department of Thoracic and Cardiovascular Surgery, German Cardiac Competence Center, University of Tuebingen, 72076 Tübingen, Germany
- Correspondence: ; Tel.: +49-7071-29-68492
| | - Spiro Lukas Marinos
- Department of Thoracic and Cardiovascular Surgery, German Cardiac Competence Center, University of Tuebingen, 72076 Tübingen, Germany
| | - Migdat Mustafi
- Department of Thoracic and Cardiovascular Surgery, German Cardiac Competence Center, University of Tuebingen, 72076 Tübingen, Germany
| | - Mario Lescan
- Department of Thoracic and Cardiovascular Surgery, German Cardiac Competence Center, University of Tuebingen, 72076 Tübingen, Germany
| | - Rafal Berger
- Department of Thoracic and Cardiovascular Surgery, German Cardiac Competence Center, University of Tuebingen, 72076 Tübingen, Germany
| | - Christoph Salewski
- Department of Thoracic and Cardiovascular Surgery, German Cardiac Competence Center, University of Tuebingen, 72076 Tübingen, Germany
| | - Rodrigo Sandoval Boburg
- Department of Thoracic and Cardiovascular Surgery, German Cardiac Competence Center, University of Tuebingen, 72076 Tübingen, Germany
| | - Volker Steger
- Department of Thoracic and Cardiovascular Surgery, German Cardiac Competence Center, University of Tuebingen, 72076 Tübingen, Germany
| | - Attila Nemeth
- Department of Thoracic and Cardiovascular Surgery, German Cardiac Competence Center, University of Tuebingen, 72076 Tübingen, Germany
| | - Stefan Reichert
- Department of Thoracic and Cardiovascular Surgery, German Cardiac Competence Center, University of Tuebingen, 72076 Tübingen, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, Heart Center, University of Cologne, 50937 Cologne, Germany
| | - Christian Schlensak
- Department of Thoracic and Cardiovascular Surgery, German Cardiac Competence Center, University of Tuebingen, 72076 Tübingen, Germany
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22
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Siddiqui S, Whooley J, Miceli A, Bartolozzi F, Soo A. Endoscopic vein harvesting: a guide for approaching difficult cases and assessing patients preoperatively. Interact Cardiovasc Thorac Surg 2022; 35:6595113. [PMID: 35640590 PMCID: PMC9486924 DOI: 10.1093/icvts/ivac142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 04/25/2022] [Accepted: 05/24/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
Coronary artery bypass grafting remains the most commonly performed cardiac surgical procedure worldwide. The long saphenous vein still presides as the first choice conduit as a second graft in multivessel coronary artery bypass grafting surgery. Traditionally, the long saphenous vein has been harvested with an open approach which can potentially result in significant wound complications in certain circumstances. Endoscopic vein harvesting is a minimally invasive vein harvesting technique, which requires a single 2–3 cm incision and is associated with a quicker return to normal daily activities, decreased wound complications and better quality of life in the longer term. There is a learning curve associated with endoscopic vein harvesting adoption and there are certain patient factors that can prove to be challenging when adopting an endoscopic approach. This commentary aims to provide a concise guide of certain challenging patient factors that operators may encounter during endoscopic vein harvesting, and how to approach these patients in both the preoperative and intraoperative settings. We suggest that with appropriate planning and awareness of the challenging patient factors and problematic venous anatomy that exists, the operator can consistently formulate a strategy for ensuring a successful endoscopic harvest.
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Affiliation(s)
- Sadiq Siddiqui
- Department of Cardiothoracic Surgery, University Hospital Galway , Galway, Ireland
| | - Jack Whooley
- Department of Cardiothoracic Surgery, University Hospital Galway , Galway, Ireland
| | - Antonio Miceli
- Department of Cardiothoracic Surgery, University Hospital Galway , Galway, Ireland
- Instituto Clinico Sant’Ambrogio, Gruppo Ospedaliero San Donato , Milan, Italy
| | - Fabio Bartolozzi
- Department of Cardiothoracic Surgery, University Hospital Galway , Galway, Ireland
| | - Alan Soo
- Department of Cardiothoracic Surgery, University Hospital Galway , Galway, Ireland
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23
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Rosati F, Pervez MB, Palacios CM, Tomasi C, Mastroiacovo G, Pirola S, Bonomi A, Polvani G, Bisleri G. Cost Analysis of Endoscopic Conduit Harvesting Technique Using a Non-Sealed System for Coronary Artery Bypass Surgery. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2022; 17:310-316. [PMID: 35997682 DOI: 10.1177/15569845221115149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective: Endoscopic vessel harvest (EVH) is evolving as the standard of care for coronary artery bypass grafting. However, the increase in upfront equipment-related costs has resulted in reluctance of uptake globally. We investigated the costs involving a non-sealed technique for EVH versus open vessel harvesting techniques (OVH) for both the greater saphenous vein and radial artery with a 6-month follow-up. Methods: From September 2016 to December 2018, 226 patients underwent OVH while 251 patients underwent EVH using a reusable non-sealed system and a single-use radiofrequency sealing system. Cumulative costs for OVH versus EVH were calculated as a summation of total operative and in-hospital stay costs. Costs related to harvest site complication management were also analyzed for up to 6 months. Results: Total operative costs were greater in the EVH group (Can$2,283.70 [Can$1,377.60 to $4,183.50] vs Can$1,742.40 [Can$998.50 to $3,628.10], P < 0.001). Total length of stay was significantly shorter for the EVH group (5.9 [4 to 43] days vs 6.8 [4 to 55] days, P = 0.018). Cumulative costs were comparable at the end of the hospitalization period (EVH, Can$6,534.70 [Can$2,076.50 to $33,087.70] vs OVH, Can$6,112.50 [Can$3,322.30 to $45,503.50], P = 0.06). After discharge, harvest site-related complications occurred more frequently in the OVH group (27% vs 4.4%, P < 0.001), resulting in increased use of antibiotics (2.2% vs 0.8%, P = 0.02) as well as more frequent requirement for home nursing assistance in the OVH group (5.7% vs 0.8%, P = 0.002) at 6 months of follow-up. Conclusions: Cumulative costs did not show a statistical difference between OVH and EVH, with higher intraoperative costs for EVH being offset by higher harvest site management costs in the OVH group.
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Affiliation(s)
- Fabrizio Rosati
- Division of Cardiac Surgery, Spedali Civili di Brescia, 9297University of Brescia, Italy
| | - Mohammad Bin Pervez
- Division of Cardiac Surgery, 10071St Michael's Hospital, University of Toronto, ON, Canada
| | | | - Cesare Tomasi
- Division of Cardiac Surgery, Spedali Civili di Brescia, 9297University of Brescia, Italy
| | | | - Sergio Pirola
- Department of Cardiac Surgery, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Alice Bonomi
- Unit of Biostatistic, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Gianluca Polvani
- Department of Cardiac Surgery, Centro Cardiologico Monzino, IRCCS, Milan, Italy.,Department of Biomedical, Surgical, and Dental Sciences, University of Milan, Italy
| | - Gianluigi Bisleri
- Division of Cardiac Surgery, 10071St Michael's Hospital, University of Toronto, ON, Canada
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24
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Sandner SE, Donovan TJ, Edelstein S, Puskas JD, Angleitner P, Krasopoulos G, Channon K, Gehrig T, Rajakaruna C, Ladyshenskij L, De Silva R, Bonaros N, Bolotin G, Jacobs S, Thielmann M, Choi YH, Ohri S, Lipey A, Friedrich I, Taggart DP. Effects of the harvesting technique and external stenting on progression of vein graft disease 2 years after coronary artery bypass. Eur J Cardiothorac Surg 2022; 62:ezac045. [PMID: 35312782 DOI: 10.1093/ejcts/ezac045] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 01/16/2022] [Accepted: 01/25/2022] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVES In a post hoc analysis of the VEST III trial, we investigated the effect of the harvesting technique on saphenous vein graft (SVG) patency and disease progression after coronary artery bypass grafting. METHODS Angiographic outcomes were assessed in 183 patients undergoing open (126 patients, 252 SVG) or endoscopic harvesting (57 patients, 114 SVG). Overall SVG patency was assessed by computed tomography angiography at 6 months and by coronary angiography at 2 years. Fitzgibbon patency (FP I, II and III) and intimal hyperplasia (IH) in a patient subset were assessed by coronary angiography and intravascular ultrasound, respectively, at 2 years. RESULTS Baseline characteristics were similar between patients who underwent open and those who underwent endoscopic harvesting. Open compared with endoscopic harvesting was associated with higher overall SVG patency rates at 6 months (92.9% vs 80.4%, P = 0.04) and 2 years (90.8% vs 73.9%, P = 0.01), improved FP I, II and III rates (65.2% vs 49.2%; 25.3% vs 45.9%, and 9.5% vs 4.9%, respectively; odds ratio 2.81, P = 0.09) and reduced IH area (-31.8%; P = 0.04) and thickness (-28.9%; P = 0.04). External stenting was associated with improved FP I, II and III rates (odds ratio 2.84, P = 0.01), reduced IH area (-19.5%; P < 0.001) and thickness (-25.0%; P < 0.001) in the open-harvest group and reduced IH area (-12.7%; P = 0.01) and thickness (-9.5%; P = 0.21) in the endoscopic-harvest group. CONCLUSIONS A post-hoc analysis of the VEST III trial showed that open harvesting is associated with improved overall SVG patency and reduced IH. External stenting reduces SVG disease progression, particularly with open harvesting.
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Affiliation(s)
- Sigrid E Sandner
- Department of Cardiac Surgery, Medical University of Vienna, Austria
| | | | | | - John D Puskas
- Department of Cardiovascular Surgery, Mount Sinai Morningside, New York, USA
| | | | - George Krasopoulos
- Department of Cardiac Surgery, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Keith Channon
- Department of Cardiovascular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Thomas Gehrig
- Herzzentrum Trier, Krankenhaus der Barmherzigen Bruder, Trier, Germany
| | - Cha Rajakaruna
- Department of Cardiothoracic Surgery, University Hospitals Bristol, UK
| | - Leonid Ladyshenskij
- Department of Cardiothoracic Surgery, Immanuel Klinikum Bernau, Herzzentrum Brandenburg, Germany
| | - Ravi De Silva
- Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, UK
| | - Nikolaos Bonaros
- Department of Cardiac Surgery, Medical University of Innsbruck, Austria
| | - Gil Bolotin
- Department of Cardiothoracic Surgery, Rambam Medical Center, Israel
| | - Stephan Jacobs
- Department of Cardiothoracic Surgery, German Heart Centre Berlin, Germany
| | - Matthias Thielmann
- Department of Cardiothoracic Surgery, West-German Heart and Vascular Center Essen, University Hospital Essen, Germany
| | - Yeong-Hoon Choi
- Kerkhoff-Klinik Bad Nauheim, Campus Kerkhoff, Justus-Liebig-University Gießen, Bad Nauheim, Germany
| | - Sunil Ohri
- Department of Cardiothoracic Surgery, University Hospital Southampton, UK
| | - Alexander Lipey
- Department of Cardiothoracic Surgery, Sheba Medical Center, Israel
| | - Ivar Friedrich
- Herzzentrum Trier, Krankenhaus der Barmherzigen Bruder, Trier, Germany
| | - David P Taggart
- Department of Cardiac Surgery, University of Oxford, John Radcliffe Hospital, Oxford, UK
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25
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Tang CY, Samsudin SS, Raja Mokhtar RA. Uniportal Endoscopic Vein Harvest Using the Three-Step Haemostatic Technique-A Modified Approach. Heart Lung Circ 2022; 31:e123-e125. [PMID: 35690563 DOI: 10.1016/j.hlc.2022.05.038] [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: 04/22/2022] [Revised: 05/06/2022] [Accepted: 05/11/2022] [Indexed: 10/18/2022]
Abstract
Endoscopic venous harvest (EVH) has become widely adopted in routine elective coronary artery bypass graft operations given it reduces surgical-site infections and improves wound cosmesis. The conventional EVH involves a 'stab and grab' incision at the inguinal crease, which is a hard-to-reach area for routine wound care. This paper describes the steps of the uniportal EVH, which transects the venous conduit, omitting the need for a stab incision at the groin.
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Affiliation(s)
- Chu-Yik Tang
- The Division of Cardiovascular and Thoracic Surgery, Department of Surgery, University of Malaya Medical Centre, Kuala Lumpur, Malaysia.
| | - Siti Shuhaida Samsudin
- Department of Infection Control, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Raja Amin Raja Mokhtar
- The Division of Cardiovascular and Thoracic Surgery, Department of Surgery, University of Malaya Medical Centre, Kuala Lumpur, Malaysia; Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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26
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Wagner TH, Hattler B, Stock EM, Biswas K, Bhatt DL, Bakaeen FG, Gujral K, Zenati MA. Costs of Endoscopic vs Open Vein Harvesting for Coronary Artery Bypass Grafting: A Secondary Analysis of the REGROUP Trial. JAMA Netw Open 2022; 5:e2217686. [PMID: 35727582 PMCID: PMC9214587 DOI: 10.1001/jamanetworkopen.2022.17686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
IMPORTANCE Value-based purchasing creates pressure to examine whether newer technologies and care processes, including new surgical techniques, yield any economic advantage. OBJECTIVE To compare health care costs and utilization between participants randomized to receive endoscopic vein harvesting (EVH) or open vein harvesting (OVH) during a coronary artery bypass grafting (CABG) procedure. DESIGN, SETTING, AND PARTICIPANTS This secondary economic analysis was conducted alongside the 16-site Randomized Endo-Vein Graft Prospective (REGROUP) clinical trial funded by the Department of Veterans Affairs (VA) Cooperative Studies Program. Adults scheduled for urgent or elective bypass involving a vein graft were eligible. The first participant was enrolled in September 2013, with most sites completing enrollment by March 2014. The last participant was enrolled in April 2017. A total of 1150 participants were randomized, with 574 participants receiving OVH and 576 receiving EVH. For this secondary analysis, cost and utilization data were extracted through September 30, 2020. Participants were linked to administrative data in the VA Corporate Data Warehouse and activity-based cost data starting with the index procedure. INTERVENTIONS EVH vs OVH, with comparisons based on intention to treat. MAIN OUTCOMES AND MEASURES Discharge costs for the index procedure as well as follow-up costs (including intended and unintended events; mean [SD] follow-up time, 33.0 [19.9] months) were analyzed, with results from different statistical models compared to test for robustness (ie, lack of variation across models). All costs represented care provided or paid by the VA, standardized to 2020 US dollars. RESULTS Among 1150 participants, the mean (SD) age was 66.4 (6.9) years; most participants (1144 [99.5%] were male. With regard to race and ethnicity, 6 participants (0.5%) self-reported as American Indian or Alaska Native, 10 (0.9%) as Asian or Pacific Islander, 91 (7.9%) as Black, 62 (5.4%) as Hispanic, 974 (84.7%) as non-Hispanic White, and 6 (0.5%) as other race and/or ethnicity; data were missing for 1 participant (0.1%). The unadjusted mean (SD) costs for the index CABG procedure were $76 607 ($43 883) among patients who received EVH and $75 368 ($45 900) among those who received OVH, including facility costs, insurance costs, and physician-related costs (commonly referred to as provider costs in Centers for Medicare and Medicaid and insurance data). No significant differences were found in follow-up costs; per 90-day follow-up period, EVH was associated with a mean (SE) added cost of $302 ($225) per patient. The results were highly robust to the statistical model. CONCLUSIONS AND RELEVANCE In this study, EVH was not associated with a reduction in costs for the index CABG procedure or follow-up care. Therefore, the choice to provide EVH may be based on surgeon and patient preferences. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01850082.
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Affiliation(s)
- Todd H. Wagner
- Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
- Department of Surgery, Stanford University, Stanford, California
| | - Brack Hattler
- Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado
- Division of Cardiology, University of Colorado, Denver
| | - Eileen M. Stock
- Office of Research and Development, VA Cooperative Studies Program Coordinating Center, Perry Point, Maryland
| | - Kousick Biswas
- Office of Research and Development, VA Cooperative Studies Program Coordinating Center, Perry Point, Maryland
| | - Deepak L. Bhatt
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Faisal G. Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Kritee Gujral
- Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
| | - Marco A. Zenati
- Division of Cardiac Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Veterans Affairs Boston Healthcare System, Boston, Massachusetts
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27
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D’Alessio A, Akoumianakis I, Kelion A, Terentes-Printzios D, Lucking A, Thomas S, Verdichizzo D, Keiralla A, Antoniades C, Krasopoulos G. Graft flow assessment and early coronary artery bypass graft failure: a computed tomography analysis. Interact Cardiovasc Thorac Surg 2022; 34:974-981. [PMID: 34718571 PMCID: PMC9159422 DOI: 10.1093/icvts/ivab298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 08/08/2021] [Accepted: 09/20/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES We evaluated graft patency by computed tomography and explored the determinants of intraoperative mean graft flow (MGF) and its contribution to predict early graft occlusion. METHODS One hundred and forty-eight patients under a single surgeon were prospectively enrolled. Arterial and endoscopically harvested venous conduits were used. Intraoperative graft characteristics and flows were collected. Graft patency was blindly evaluated by a follow-up computed tomography at 11.4 weeks (median). RESULTS Graft occlusion rate was 5.2% (n = 22 of 422; 8% venous and 3% arterial). Thirteen were performed on non-significant proximal stenosis while 9 on occluded or >70% stenosed arteries. Arterial and venous graft MGF were lower in females (Parterial = 0.010, Pvenous = 0.009), with median differences of 10 and 13.5 ml/min, respectively. Arterial and venous MGF were associated positively with target vessel diameter ≥1.75 mm (Parterial = 0.025; Pvenous = 0.002) and negatively with pulsatility index (Parterial < 0.001; Pvenous < 0.001). MGF was an independent predictor of graft occlusion, adjusting for EuroSCORE-II, pulsatility index, graft size and graft type (arterial/venous). An MGF cut-off of 26.5 ml/min for arterial (sensitivity 83.3%, specificity 80%) and 36.5 ml/min for venous grafts (sensitivity 75%, specificity 62%) performed well in predicting early graft occlusion. CONCLUSIONS We demonstrate that MGF absolute values are influenced by coronary size, gender and graft type. Intraoperative MGF of >26.5 ml/min for arterial and >36.5 ml/min for venous grafts is the most reliable independent predictor of early graft patency. Modern-era coronary artery bypass graft is associated with low early graft failure rates when transit time flow measurement is used to provide effective intraoperative quality assurance.
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Affiliation(s)
- Andrea D’Alessio
- Department of Cardiothoracic Surgery, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | | | - Andrew Kelion
- Department of Cardiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Andrew Lucking
- Department of Cardiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Sheena Thomas
- Cardiovascular Medicine Division, University of Oxford, Oxford, UK
| | - Danilo Verdichizzo
- Department of Cardiothoracic Surgery, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Amar Keiralla
- Department of Cardiac Anesthesia, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Charalambos Antoniades
- Cardiovascular Medicine Division, University of Oxford, Oxford, UK
- Department of Cardiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - George Krasopoulos
- Department of Cardiothoracic Surgery, Oxford University Hospital NHS Foundation Trust, Oxford, UK
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Pirondini L, Gregson J, Owen R, Collier T, Pocock S. Covariate Adjustment in Cardiovascular Randomized Controlled Trials: Its Value, Current Practice, and Need for Improvement. JACC. HEART FAILURE 2022; 10:297-305. [PMID: 35483791 DOI: 10.1016/j.jchf.2022.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 01/31/2022] [Accepted: 02/03/2022] [Indexed: 11/17/2022]
Abstract
In randomized controlled trials, patient characteristics are expected to be well balanced between treatment groups; however, adjustment for characteristics that are prognostic can still be beneficial with a modest gain in statistical power. Nevertheless, previous reviews show that many trials use unadjusted analyses. In this article, we review current practice regarding covariate adjustment in cardiovascular trials among all 84 randomized controlled trials relating to cardiovascular disease published in the New England Journal of Medicine, The Lancet, and the Journal of the American Medical Association during 2019. We identify trials in which use of covariate adjustment led to a change in the trial conclusions. By using these trials as case studies, along with data from the CHARM trial and simulation studies, we demonstrate some of the potential benefits and pitfalls of covariate adjustment. We discuss some of the complexities of using covariate adjustment, including how many covariates to choose, how covariates should be modeled, how to handle missing data for baseline covariates, and how adjusted analyses are viewed by regulators. We conclude that contemporary cardiovascular trials do not make best use of covariate adjustment and that more frequent use could lead to improvements in the efficiency of future trials.
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Affiliation(s)
- Leah Pirondini
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - John Gregson
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Ruth Owen
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Tim Collier
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom.
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29
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Djouani A, Smith A, Choi J, Lall K, Ambekar S. Cardiac surgery in the morbidly obese. J Card Surg 2022; 37:2060-2071. [PMID: 35470870 DOI: 10.1111/jocs.16537] [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: 01/04/2022] [Revised: 02/28/2022] [Accepted: 04/01/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Obesity rates globally continue to rise and in turn the body mass index (BMI) of patients undergoing cardiac surgery is set to mirror this. Patients who are Class III obese (BMI ≥ 40) pose significant challenges to the surgical teams responsible for their care and are also at high risk of complications from surgery and even death. To improve outcomes in this population, interventions carried out in the preoperative, operative, and postoperative periods have shown promise. Despite this, there are no defined best practice national guidelines for perioperative management of obese patients undergoing cardiac surgery. AIM This review is aimed at clinicians and researchers in the field of cardiac surgery and aims to form a basis for the future development of clinical guidelines for the management of obese cardiac surgery patients. METHODS The PubMed database was utilized to identify relevant literature and strategies employed at various stages of the surgical journey were analyzed. CONCLUSIONS Data presented identified the benefits of preoperative respiratory muscle training, off-pump coronary artery bypass grafting where possible, and early extubation. Further randomized controlled trials are required to identify optimal operative and perioperative management strategies before the introduction of such guidance into clinical practice.
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Affiliation(s)
- Adam Djouani
- The Department of Cardiac Surgery, St Bartholomew's Hospital, London, UK
| | - Alexander Smith
- The Department of Cardiac Surgery, St Bartholomew's Hospital, London, UK
| | - Jeesoo Choi
- The Department of Cardiac Surgery, St Bartholomew's Hospital, London, UK
| | - Kulvinder Lall
- The Department of Cardiac Surgery, St Bartholomew's Hospital, London, UK
| | - Shirish Ambekar
- The Department of Cardiac Surgery, St Bartholomew's Hospital, London, UK
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30
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Cancelli G, Audisio K, Perezgrovas-Olaria R, Soletti GJ, Chadow D, Rahouma M, Robinson NB, Gaudino M. Representation of racial minorities in cardiac surgery randomized clinical trials. J Card Surg 2022; 37:1311-1316. [PMID: 35238064 DOI: 10.1111/jocs.16371] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 12/26/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Racial minorities account for 39.9% of the population in the United States, but are often underrepresented in clinical research. Results from studies predominantly enrolling White patients may not apply to racial minorities. The aim of this analysis is to assess the representation of racial minorities in cardiac surgery randomized clinical trials (RCTs). METHODS A systematic search of the literature was performed. All RCTs published from 2000 to 2020 including at least 100 patients and comparing two or more adult cardiac surgery procedures were included. Meta-analytic estimates were calculated. RESULTS Among 51 cardiac surgery RCTs published between 2000 and 2020, only 9 (17.6%) reported the race of patients and were included in the final analysis. All of them were multicentric, with a mean of 33 centers included. Six RCTs enrolled patients undergoing coronary artery bypass grafting (66.7%), while the remaining three were on valve surgery (33.3%). Overall, 9193 patients were included; of them, 8034 (87.4%) were White and 1026 (11.2%) nonWhite (386 [4.2%] Black, 191 [2.1%] Hispanic, 274 [3.0%] from other races, and 175 [1.9%] nonWhite patients of unspecified race). The proportion of nonWhite patients did not change over time. CONCLUSIONS Only 9 (17.6%) of the 51 cardiac surgery RCTs published between 2000 and 2020 reported the race of the patients enrolled and only 11.2% of them were nonWhite patients. Given the association between race and clinical outcomes, future RCTs should either guarantee a balanced inclusion of racial minorities or be designed to specifically enroll them.
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Affiliation(s)
- Gianmarco Cancelli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Katia Audisio
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | | | - Giovanni J Soletti
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - David Chadow
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Mohamed Rahouma
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - N B Robinson
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
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31
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Vuong NL, Elfaituri MK, Eldoadoa M, Karimzadeh S, Mokhtar MA, Eid PS, Nam NH, Mostafa MR, Radwan I, Zaki MMM, Al Khudari R, Kassem M, Huy NT. Saphenous vein harvesting techniques for coronary artery bypass grafting: a systematic review and meta-analysis. Coron Artery Dis 2022; 33:128-136. [PMID: 34010184 DOI: 10.1097/mca.0000000000001048] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The great saphenous vein (GSV) graft remains a frequently used conduit for coronary artery bypass graft (CABG) surgery. The optimal technique for GSV harvesting has been the subject of on-going controversy. We therefore sought to conduct a systematic review and meta-analysis of all available GSV harvesting techniques in CABG. A systematic search of 12 electronic databases was performed to identify all randomized controlled trials (RCTs) of any GSV harvesting technique, including conventional vein harvesting (CVH), no-touch, standard bridging technique (SBT) and endoscopic vein harvesting (EVH) techniques. We investigated safety and long-term efficacy outcomes. All outcomes were analyzed using the frequentist network meta-analysis. A total of 6480 patients from 34 RCTs were included. For safety outcomes, EVH reduced 91% and 77% risk of wound infection compared to no-touch and CVH, respectively. EVH and SBT also significantly reduced the risk of sensibility disorder and postoperative pain. The techniques were not significantly different regarding long-term efficacy outcomes, including mortality, myocardial infarction and graft patency. For GSV harvesting for CABG, EVH techniques are the most favorable, but in case of using an open technique, no-touch is more recommended than CVH. More effective and safer procedures should be investigated for GSV harvesting in CABG.
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Affiliation(s)
- Nguyen Lam Vuong
- Department of Cardiovascular and Thoracic Surgery, Faculty of Medicine
- Department of Medical Statistics and Informatics, Faculty of Public Health, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Muhammed Khaled Elfaituri
- Online Research Club ( http://www.onlineresearchclub.org ), School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
- Faculty of Medicine - University of Tripoli, Tripoli, Libya
| | - Mohammed Eldoadoa
- Online Research Club ( http://www.onlineresearchclub.org ), School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
- Milton Keynes University Hospital, Milton Keynes, UK
| | - Sedighe Karimzadeh
- Online Research Club ( http://www.onlineresearchclub.org ), School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
- School of Medicine, Sabzevar University of Medical Sciences, Sabzevar, Iran
| | - Mohamed Ashraf Mokhtar
- Online Research Club ( http://www.onlineresearchclub.org ), School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
- Faculty of Medicine, Sohag University, Sohag
| | - Peter Samuel Eid
- Online Research Club ( http://www.onlineresearchclub.org ), School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Nguyen Hai Nam
- Online Research Club ( http://www.onlineresearchclub.org ), School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Mostafa Reda Mostafa
- Online Research Club ( http://www.onlineresearchclub.org ), School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
- School of Medicine, Tanta University, Tanta
| | - Ibrahim Radwan
- Online Research Club ( http://www.onlineresearchclub.org ), School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Marwa Mostafa Mohamed Zaki
- Online Research Club ( http://www.onlineresearchclub.org ), School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
- Faculty of Clinical Pharmacy, Fayoum university, Fayoum, Egypt
| | - Rawan Al Khudari
- Online Research Club ( http://www.onlineresearchclub.org ), School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
- Pediatric Department, Children's University Hospital, Damascus University, Damascus, Syria
| | - Mahmoud Kassem
- Online Research Club ( http://www.onlineresearchclub.org ), School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
- Department of Medical Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Nguyen Tien Huy
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
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32
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Beerkens FJ, Claessen BE, Mahan M, Gaudino MFL, Tam DY, Henriques JPS, Mehran R, Dangas GD. Contemporary coronary artery bypass graft surgery and subsequent percutaneous revascularization. Nat Rev Cardiol 2022; 19:195-208. [PMID: 34611327 DOI: 10.1038/s41569-021-00612-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/15/2021] [Indexed: 11/09/2022]
Abstract
Patients who have undergone coronary artery bypass graft (CABG) surgery are susceptible to bypass graft failure and progression of native coronary artery disease. Although the saphenous vein graft (SVG) was traditionally the most-used conduit, arterial grafts (including the left and right internal thoracic arteries and the radial artery) have improved patency rates. However, the need for secondary revascularization remains common, and percutaneous coronary intervention (PCI) has become the most common modality of secondary revascularization after CABG surgery. Procedural characteristics and clinical outcomes differ considerably from those associated with PCI in patients without previous CABG surgery, owing to altered coronary anatomy and differences in conduit pathophysiology. In particular, SVG PCI carries an increased risk of complications, and operators are shifting their focus towards embolic protection strategies and complex native-vessel interventions, increasingly using SVGs as conduits to facilitate native-vessel PCI rather than pursuing SVG PCI. In this Review, we discuss the differences in conduit pathophysiology, changes in CABG surgery techniques, and the latest evidence in terms of PCI in patients with previous CABG surgery, with a particular emphasis on safety and long-term efficacy. We explore the subject of contemporary CABG surgery and subsequent percutaneous revascularization in this complex patient population.
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Affiliation(s)
- Frans J Beerkens
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bimmer E Claessen
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Cardiology, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Marielle Mahan
- Department of Ophthalmology, MedStar Georgetown University/Washington Hospital Center, Washington, DC, USA
| | - Mario F L Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Derrick Y Tam
- Division of Cardiac Surgery, University of Toronto, Toronto, ON, Canada
| | - José P S Henriques
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Roxana Mehran
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - George D Dangas
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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33
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Vervoort D, Malik A, Fremes SE. The evolving evidence base for coronary artery bypass grafting and arterial grafting in 2021: How to improve vein graft patency. JTCVS Tech 2022; 10:102-109. [PMID: 34977712 PMCID: PMC8691822 DOI: 10.1016/j.xjtc.2021.09.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 09/20/2021] [Indexed: 11/03/2022] Open
Affiliation(s)
- Dominique Vervoort
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Abdullah Malik
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada.,Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Stephen E Fremes
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Cardiac Surgery, Department of Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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34
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O'Fee K, Deych E, Ciani O, Brown DL. Assessment of Nonfatal Myocardial Infarction as a Surrogate for All-Cause and Cardiovascular Mortality in Treatment or Prevention of Coronary Artery Disease: A Meta-analysis of Randomized Clinical Trials. JAMA Intern Med 2021; 181:1575-1587. [PMID: 34694318 PMCID: PMC8546625 DOI: 10.1001/jamainternmed.2021.5726] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE Although nonfatal myocardial infarction (MI) is associated with an increased risk of mortality, evidence validating nonfatal MI as a surrogate end point for all-cause or cardiovascular (CV) mortality is lacking. OBJECTIVE To examine whether nonfatal MI may be a surrogate for all-cause or CV mortality in patients with or at risk for coronary artery disease. DATA SOURCES In this meta-analysis, PubMed was searched from inception until December 31, 2020, for randomized clinical trials of interventions to treat or prevent coronary artery disease reporting mortality and nonfatal MI published in 3 leading journals. STUDY SELECTION Randomized clinical trials including at least 1000 patients with 24 months of follow-up. DATA EXTRACTION AND SYNTHESIS Trial-level correlations between nonfatal MI and all-cause or CV mortality were assessed for surrogacy using the coefficient of determination (R2). The criterion for surrogacy was set at 0.8. Subgroup analyses based on study subject (primary prevention, secondary prevention, mixed primary and secondary prevention, and revascularization), era of trial (before 2000, 2000-2009, and 2010 and after), and follow-up duration (2.0-3.9, 4.0-5.9, and ≥6.0 years) were performed. MAIN OUTCOMES AND MEASURES All-cause or CV mortality and nonfatal MI. RESULTS A total of 144 articles randomizing 1 211 897 patients met the criteria for inclusion. Nonfatal MI did not meet the threshold for surrogacy for all-cause (R2 = 0.02; 95% CI, 0.00-0.08) or CV (R2 = 0.11; 95% CI, 0.02-0.27) mortality. Nonfatal MI was not a surrogate for all-cause mortality in primary (R2 = 0.01; 95% CI, 0.001-0.26), secondary (R2 = 0.03; 95% CI, 0.00-0.20), mixed primary and secondary prevention (R2 = 0.001; 95% CI, 0.00-0.08), or revascularization trials (R2 = 0.21; 95% CI, 0.002-0.50). For trials enrolling patients before 2000 (R2 = 0.22; 95% CI, 0.08-0.36), between 2000 and 2009 (R2 = 0.02; 95% CI, 0.00-0.17), and from 2010 and after (R2 = 0.01; 95% CI, 0.00-0.09), nonfatal MI was not a surrogate for all-cause mortality. Nonfatal MI was not a surrogate for all-cause mortality in randomized clinical trials with 2.0 to 3.9 (R2 = 0.004; 95% CI, 0.00-0.08), 4.0 to 5.9 (R2 = 0.06; 95% CI, 0.001-0.16), or 6.0 or more years of follow-up (R2 = 0.30; 95% CI, 0.01-0.55). CONCLUSIONS AND RELEVANCE The findings of this meta-analysis do not appear to establish nonfatal MI as a surrogate for all-cause or CV mortality in randomized clinical trials of interventions to treat or prevent coronary artery disease.
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Affiliation(s)
- Kevin O'Fee
- Department of Medicine, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Elena Deych
- Department of Medicine, Washington University School of Medicine in St Louis, St Louis, Missouri.,Cardiovascular Division, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Oriana Ciani
- Center for Research in Health and Social Care Management, SDA Bocconi, Milan, Italy.,University of Exeter College of Medicine and Health, Exeter, United Kingdom
| | - David L Brown
- Department of Medicine, Washington University School of Medicine in St Louis, St Louis, Missouri.,Cardiovascular Division, Washington University School of Medicine in St Louis, St Louis, Missouri
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35
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Audisio K, Halbreiner MS, Chadow D, Gaudino M. Radial artery or saphenous vein for Coronary artery bypass grafitng. Trends Cardiovasc Med 2021; 32:479-484. [PMID: 34562573 DOI: 10.1016/j.tcm.2021.09.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 09/15/2021] [Accepted: 09/18/2021] [Indexed: 11/16/2022]
Abstract
Coronary artery disease (CAD) is the most common cardiovascular disease worldwide, affecting over 18 million American adults. Coronary artery bypass grafting (CABG) is the standard of care for patients with left main or triple vessel CAD. Historically, the saphenous vein (SV) has been utilized to bypass the majority of the coronary vessels in patients undergoing CABG, but more recent data suggest that the use of the radial artery (RA), rather than the SV, is associated with improved cardiac outcomes and better survival. The aim of this review is to summarize the current literature on the use of RA and SV for CABG in patients with multivessel CAD.
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Affiliation(s)
- Katia Audisio
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - M Scott Halbreiner
- Department of Thoracic and Cardiovascular Surgery, Allegheny General Hospital, Pittsburgh, PA, USA
| | - David Chadow
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA.
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36
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Rustenbach CJ, Djordjevic I, Gerfer S, Ivanov B, Gaisendrees C, Eghbalzadeh K, Wahlers T. Multiple Grafting with Single Left Internal Mammary Artery as T-Graft with Itself. Thorac Cardiovasc Surg 2021; 70:532-536. [PMID: 34521140 DOI: 10.1055/s-0041-1731758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Revascularization strategies might be limited in patients with lack of sufficient bypass graft material and increased risk of wound healing disturbances. In this regard, we present first results of patients treated with left internal mammary artery (LIMA) as T-graft with itself due to left-sided double-vessel disease, elevated risk of wound healing infection, and lack of graft material. METHODS Eighteen patients were retrospectively analyzed in this study. All patients received LIMA grafting, and additional T-graft with itself during off-pump coronary artery bypass surgery. The investigation was focused on intraoperative and postoperative outcomes. RESULTS LIMA-LIMA T-graft was performed in a total of 18 patients. Mean Fowler score accounted for 18.2 ± 2.9. Severe vein varicosis was present in 9 patients, and 38.9% of patients had lacking venous graft material due to prior vein stripping. A total of 2.5 ± 0.5 distal anastomoses were performed. Mean flow of LIMA-left anterior descending anastomosis was 41.72 ± 12.11 mL/min with a mean pulsatility index (PI) of 1.01 ± 0.21. Mean flow of subsequent T-graft accounted for 26.31 ± 4.22 mL/min with a mean PI of 1.59 ± 0.47. Median hospital stay was 7(6.75;8) days. No incidence of postoperative wound healing disorders was observed and all patients were discharged off hospital. CONCLUSIONS LIMA as T-graft with itself to treat left-sided double-vessel disease is feasible and safe in patients with missing bypass graft material and increased risk of deep sternal wound infection. Further prospective studies are necessary to confirm our results.
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Affiliation(s)
| | - Ilija Djordjevic
- Department of Cardiothoracic Surgery, Heart Center, University of Cologne, Cologne, Germany
| | - Stephen Gerfer
- Department of Cardiothoracic Surgery, Heart Center, University of Cologne, Cologne, Germany
| | - Borko Ivanov
- Department of Cardiothoracic Surgery, Heart Center, University of Cologne, Cologne, Germany
| | | | - Kaveh Eghbalzadeh
- Department of Cardiothoracic Surgery, Heart Center, University of Cologne, Cologne, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, Heart Center, University of Cologne, Cologne, Germany
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37
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Hibino M, Dhingra NK, Verma S. Increased patency with comparable mortality and revascularization risk: Is the case for no-touch vein harvesting open and shut? J Card Surg 2021; 36:4376-4377. [PMID: 34477262 DOI: 10.1111/jocs.15973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 08/26/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Makoto Hibino
- Division of Cardiac Surgery, The Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Nitish K Dhingra
- Division of Cardiac Surgery, The Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Subodh Verma
- Division of Cardiac Surgery, The Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, Canada
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38
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Yokoyama Y, Shimamura J, Takagi H, Kuno T. Harvesting techniques of the saphenous vein graft for coronary artery bypass: Insights from a network meta-analysis. J Card Surg 2021; 36:4369-4375. [PMID: 34472140 DOI: 10.1111/jocs.15974] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 07/19/2021] [Accepted: 08/08/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The optimal harvesting technique of saphenous vein (SVG) in coronary artery bypass grafting (CABG) is still to be elucidated. The present study aimed to compare the methods of SVG harvesting technique, which were open vein harvesting (OVH), endoscopic vein harvesting (EVH), and no-touch vein harvesting (NT), using a network meta-analysis of randomized controlled trials (RCTs), and propensity-score matched (PSM) studies. METHODS MEDLINE and EMBASE were searched through April 2021 to identify RCTs and PSM studies that investigated the outcomes in patients who underwent CABG with the SVG using one of three methods; OVH, EVH, and NT. The outcomes of interest were all-cause mortality, the rates of revascularization, and graft failure. Risk ratios (RRs) were extracted for the rates of graft failure, and hazard ratios (HRs) were extracted for all-cause mortality and the rates of revascularization. RESULTS Eligible seven RCT and five PSM studies were identified which enrolled a total of 8111 patients. All-cause mortality was significantly lower in patients with EVH compared with OVH (HR [95% confidence interval (CI)] =0.77 [0.65-0.92], p = .0032). The rates of revascularization were similar among the groups. The rate of graft failures was significantly lower in patients with NT compared with OVH (HR [95% CI] =0.54 [0.32-0.90], p = .019) and with EVH (HR [95% CI] =0.39 [0.17-0.86], p = .023). CONCLUSION NT vein harvesting is favorable for graft patency, and OVH showed higher all-cause mortality than EVH. Further well-powered RCTs are needed to confirm our findings.
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Affiliation(s)
- Yujiro Yokoyama
- Department of Surgery, St. Luke's University Health Network, Pennsylvania, USA
| | - Junichi Shimamura
- Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Centre, Ontario, Canada
| | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Toshiki Kuno
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, USA.,Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, USA
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Burnaska DR, Huang GD, O'Leary TJ. Clinical trials proposed for the VA Cooperative Studies Program: Success rates and factors impacting approval. Contemp Clin Trials Commun 2021; 23:100811. [PMID: 34307958 PMCID: PMC8287148 DOI: 10.1016/j.conctc.2021.100811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 04/26/2021] [Accepted: 06/21/2021] [Indexed: 11/29/2022] Open
Abstract
The process by which funding organizations select among the myriad number of proposals they receive is a matter of significant concern for researchers and the public alike. Despite an extensive literature on the topic of peer review and publications on criteria by which clinical investigations are reviewed, publications analyzing peer review and other processes leading to government funding decisions on large multi-site clinical trials proposals are sparse. To partially address this gap, we reviewed the outcomes of scientific and programmatic evaluation for all letters of intent (LOIs) received by the Department of Veterans Affairs (VA) Cooperative Studies Program (CSP) between July 4, 2008, and November 28, 2016. If accepted, these LOIs represented initial steps towards later full proposals that also underwent scientific peer review. Twenty-two of 87 LOIs were ultimately funded and executed as CSP projects, for an overall success rate of 25%. Most proposals which received a negative decision did so prior to submission of a full proposal. Common reasons for negative scientific review of LOIs included investigator inexperience, perceived lack of major scientific impact, lack of preliminary data and flawed or confused experimental design, while the most common reasons for negative reviews of final proposals included questions of scientific impact and issues of study design, including outcome measures, randomization, and stratification. Completed projects have been published in high impact clinical journals. Findings highlight several factors leading to successfully obtaining funding support for clinical trials. While our analysis is restricted to trials proposed for CSP, the similarities in review processes with those employed by the National Institutes of Health and the Patient Centered Outcomes Research Institute suggest the possibility that they may also be important in a broader context.
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Affiliation(s)
- David R. Burnaska
- Cooperative Studies Program, Office of Research and Development, Veterans Health Administration, Washington DC, 20420, USA
| | - Grant D. Huang
- Cooperative Studies Program, Office of Research and Development, Veterans Health Administration, Washington DC, 20420, USA
| | - Timothy J. O'Leary
- Cooperative Studies Program, Office of Research and Development, Veterans Health Administration, Washington DC, 20420, USA
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA
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Xenogiannis I, Zenati M, Bhatt DL, Rao SV, Rodés-Cabau J, Goldman S, Shunk KA, Mavromatis K, Banerjee S, Alaswad K, Nikolakopoulos I, Vemmou E, Karacsonyi J, Alexopoulos D, Burke MN, Bapat VN, Brilakis ES. Saphenous Vein Graft Failure: From Pathophysiology to Prevention and Treatment Strategies. Circulation 2021; 144:728-745. [PMID: 34460327 DOI: 10.1161/circulationaha.120.052163] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Saphenous vein grafts (SVGs) remain the most frequently used conduits in coronary artery bypass graft surgery (CABG). Despite advances in surgical techniques and pharmacotherapy, SVG failure rates remain high, often leading to repeat coronary revascularization. The no-touch SVG harvesting technique (minimal graft manipulation with preservation of vasa vasorum and nerves) reduces the risk of SVG failure, whereas the effect of the off-pump technique on SVG patency remains unclear. Use of buffered storage solutions, intraoperative graft flow measurement, careful selection of the target vessels, and physiological assessment of the native coronary circulation before CABG may also reduce the incidence of SVG failure. Perioperative aspirin and high-intensity statin administration are the cornerstones of secondary prevention after CABG. Dual antiplatelet therapy is recommended for off-pump CABG and in patients with a recent acute coronary syndrome. Intermediate (30%-60%) SVG stenoses often progress rapidly. Stenting of intermediate SVG stenoses failed to improve outcomes; hence, treatment focuses on strict control of coronary artery disease risk factors. Redo CABG is associated with higher perioperative mortality compared with percutaneous coronary intervention (PCI); hence, the latter is preferred for most patients requiring repeat revascularization after CABG. SVG PCI is limited by high rates of no-reflow and a high incidence of restenosis during follow-up. Drug-eluting and bare metal stents provide similar long-term outcomes in SVG PCI. Embolic protection devices reduce no-reflow and should be used when feasible. PCI of the corresponding native coronary artery is associated with better short- and long-term outcomes and is preferred over SVG PCI, if technically feasible.
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Affiliation(s)
- Iosif Xenogiannis
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern, MN (I.X., I.N., E.V., J.K., M.N.B., V.N.B., E.S.B.).,Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Greece (I.X., D.A.)
| | - Marco Zenati
- Division of Cardiac Surgery, Veterans Affairs Boston Healthcare System and Harvard Medical School, Boston, MA (M.A.Z.)
| | - Deepak L Bhatt
- Heart and Vascular Center, Brigham and Women's Hospital, Harvard Medical School, MA (D.L.B.)
| | - Sunil V Rao
- Durham VA Medical Center, Duke University, NC (S.R.)
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (J.R.-C.).,Hospital Clinic of Barcelona, Barcelona, Spain (J.R.-C.)
| | - Steven Goldman
- Sarver Heart Center, University of Arizona, Tucson (S.G.)
| | - Kendrick A Shunk
- San Francisco VA Medical Center, University of California, San Francisco (K.S.)
| | | | - Subhash Banerjee
- VA North Texas Health Care System, University of Texas Southwestern Medical School, Dallas (S.B.)
| | | | - Ilias Nikolakopoulos
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern, MN (I.X., I.N., E.V., J.K., M.N.B., V.N.B., E.S.B.).,Yale School of Medicine, Yale New Haven Hospital (I.N., E.V.)
| | - Evangelia Vemmou
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern, MN (I.X., I.N., E.V., J.K., M.N.B., V.N.B., E.S.B.).,Yale School of Medicine, Yale New Haven Hospital (I.N., E.V.)
| | - Judit Karacsonyi
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern, MN (I.X., I.N., E.V., J.K., M.N.B., V.N.B., E.S.B.)
| | - Dimitrios Alexopoulos
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Greece (I.X., D.A.)
| | - M Nicholas Burke
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern, MN (I.X., I.N., E.V., J.K., M.N.B., V.N.B., E.S.B.)
| | - Vinayak N Bapat
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern, MN (I.X., I.N., E.V., J.K., M.N.B., V.N.B., E.S.B.)
| | - Emmanouil S Brilakis
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern, MN (I.X., I.N., E.V., J.K., M.N.B., V.N.B., E.S.B.)
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41
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Gaudino M, Di Mauro M, Fremes SE, Di Franco A. Representation of Women in Randomized Trials in Cardiac Surgery: A Meta-Analysis. J Am Heart Assoc 2021; 10:e020513. [PMID: 34350777 PMCID: PMC8475035 DOI: 10.1161/jaha.120.020513] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Women have traditionally been underrepresented in randomized clinical trials (RCTs). We performed a systematic evaluation of the inclusion of women in cardiac surgery RCTs published in the past 2 decades. Methods and Results MEDLINE, EMBASE, and the Cochrane Library were searched (2000 to July 2020) for RCTs written in English, comparing ≥2 adult cardiac surgical procedures. The percentage of women enrolled and its association with year of publication, sample size, mean age, funding source, geographic location, number of sites involved, and interventions tested were analyzed using a meta‐analytic approach. Fifty‐one trials were included. Of 25 425 total patients, 5029 were women (20.8%; 95% CI, 17.6–24.4; range, 0.5%–57.9%). The proportion of women dropped significantly during the study period (29.6% in 2000 versus 13.1% in 2019, P<0.001). Women were significantly more represented in European trials (26.2%; 95% CI, 21.2–31.9), and less represented in trials of coronary bypass surgery versus other interventions (16.8%; 95% CI, 12.3–22.7 versus 33.6%; 95% CI, 27.4–40.5; P=0.0002) and in trials enrolling younger patients (P=0.009); the percentage of women was higher in industry‐sponsored versus non‐industry sponsored trials (31.7%; 95% CI, 27.2–36.6 versus 15.5%; 95% CI, 10.0–23.2; P=0.0004) and was not associated with trial sample size (P=0.52) or study design (multicenter versus monocenter: P=0.22). After exclusion of trials conducted at Veteran Affairs centers, women representation was 24.4% (95% CI, 21.1–28.0; range, 10.4%–57.9%), with no significant changes during the study period. Conclusions The proportion of women in cardiac surgery trials is low and likely inadequate to provide meaningful estimates of the treatment effect.
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Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery Weill Cornell Medicine New York City NY
| | - Michele Di Mauro
- Cardio-Thoracic Surgery Unit, Heart and Vascular Centre Maastricht University Medical CentreCardiovascular Research Institute Maastricht Maastricht The Netherlands
| | - Stephen E Fremes
- Schulich Heart Centre Division of Cardiac Surgery Department of Surgery Sunnybrook Health Sciences Centre University of Toronto Toronto Ontario Canada
| | - Antonino Di Franco
- Department of Cardiothoracic Surgery Weill Cornell Medicine New York City NY
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Krishnamoorthy B, Zacharias J, Critchley WR, Rochon M, Stalpinskaya I, Rajai A, Venkateswaran RV, Raja SG, Bahrami T. A multicentre review comparing long term outcomes of endoscopic vein harvesting versus open vein harvesting for coronary artery bypass surgery. NIHR OPEN RESEARCH 2021; 1:11. [PMID: 35098131 PMCID: PMC7612280 DOI: 10.3310/nihropenres.13215.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 06/24/2021] [Indexed: 11/22/2022]
Abstract
Background Utilisation of the Endoscopic Vein Harvesting (EVH) technique has been increasing for coronary artery bypass grafting (CABG) for the last two decades. Some surgeons remain concerned about the long-term patency of the long saphenous vein harvested endoscopically compared to traditional Open Vein Harvesting (OVH). The aim of this study was to perform a retrospective analysis of the outcomes between EVH and OVH from three UK centres with 10 years follow-up. Methods 27,024 patients underwent CABG with long saphenous vein harvested by EVH (n=13,794) or OVH (n=13,230) in three UK centres between 2007 and 2019. Propensity modelling was used to calculate the Inverse Probability of Treatment Weights (IPTW). The primary endpoint was mortality from all causes and secondary endpoints were length of hospital stay, postoperative complications, and incidence of repeat coronary re-vascularisation for symptomatic patients. IPTW was used to balance the two intervention groups for baseline and preoperative co-morbidities. Results Median follow-up time was 4.54 years for EVH and 6.00 years for OVH. Death from any cause occurred in 13.8% of the EVH group versus 20.8% in the OVH group over the follow-up period. The hazard ratio of death (EVH to OVH) was 0.823 (95% CI: 0.767, 0.884). Length of hospital stay was similar between the groups (p=0.86). Post-operative pulmonary complications were more common in EVH vs OVH (14.7% vs. 12.8%, p<0.001), but repeat coronary re-vascularisation was similar between the groups. Conclusions This large retrospective multicentre analysis indicates that EVH has a lower risk of mortality compared with OVH during the follow-up period of the study. The observed benefits of EVH may outweigh the risks but should be considered on a case-by-case basis. We hope this review gives confidence to other cardiac centres that offering an EVH approach to conduit harvesting does not affect long term patient outcomes.
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Affiliation(s)
- Bhuvaneswari Krishnamoorthy
- Department of Cardiovascular Sciences, Faculty of Health, Biology and Medicine, The University of Manchester, Manchester, UK
- Department of Allied Health Professions, Faculty of Health and Social Service, Edge hill University, Ormskirk, UK
- Department of Cardiothoracic surgery, Manchester Foundation Trust, Wythenshawe Hospital, Manchester, UK
| | - Joesph Zacharias
- Department of Cardiothoracic surgery, Blackpool Victoria NHS trust, Blackpool, UK
| | - William R. Critchley
- Endothelial Cell Biology, School of Molecular Medicine, University of Leeds, Leeds, England, UK
| | - Melissa Rochon
- Department of Cardiothoracic surgery, Royal Brompton & Harefield NHS Trust, London, UK
| | - Iryna Stalpinskaya
- Department of Cardiothoracic surgery, Blackpool Victoria NHS trust, Blackpool, UK
| | - Azita Rajai
- Centre for Biostatitics, Division of Population Health, University of Manchester, Manchester, UK
| | - Rajamiyer V. Venkateswaran
- Department of Allied Health Professions, Faculty of Health and Social Service, Edge hill University, Ormskirk, UK
| | - Shahzad G. Raja
- Department of Cardiothoracic surgery, Royal Brompton & Harefield NHS Trust, London, UK
| | - Toufan Bahrami
- Department of Cardiothoracic surgery, Royal Brompton & Harefield NHS Trust, London, UK
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43
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Myocardial Revascularization Surgery: JACC Historical Breakthroughs in Perspective. J Am Coll Cardiol 2021; 78:365-383. [PMID: 34294272 DOI: 10.1016/j.jacc.2021.04.099] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 04/01/2021] [Accepted: 04/08/2021] [Indexed: 11/20/2022]
Abstract
Coronary artery bypass grafting (CABG) was introduced in the 1960s as the first procedure for direct coronary artery revascularization and rapidly became one of the most common surgical procedures worldwide, with an overall total of more than 20 million operations performed. CABG continues to be the most common cardiac surgical procedure performed and has been one of the most carefully studied therapies. Best CABG techniques, optimal bypass conduits, and appropriate patient selection have been rigorously tested in landmark clinical trials, some of which have resolved controversy and most of which have stoked further debate and trials. The evolution of CABG cannot be properly portrayed without presenting it in the context of the parallel development of percutaneous coronary intervention. In this Historical Perspective, we a provide a broad overview of the history of coronary revascularization with a focus on the foundations, evolution, best evidence, and future directions of CABG.
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44
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Stapleton CJ, Hussein AE, Behbahani M, Alaraj A, Amin-Hanjani S, Charbel FT. Comparative efficacy of autologous versus cadaveric saphenous vein grafts in cerebral revascularization surgery. J Neurosurg 2021; 134:1562-1568. [DOI: 10.3171/2020.3.jns192546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 03/30/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Cerebral bypasses are performed for the purpose of either flow augmentation for ischemic cerebrovascular disease or flow replacement for vessel sacrifice during complex aneurysm or tumor surgery. Saphenous vein grafts (SVGs) are commonly used interposition grafts. The authors of this study sought to compare the efficacy of autologous versus cadaveric SVGs in a large series of cerebral bypasses using interposition vein grafts with long-term angiographic follow-up.
METHODS
All intracranial bypass procedures performed between 2001 and 2018 were reviewed. Demographic, clinical, angiographic, and operative data were recorded and then analyzed according to SVG type.
RESULTS
A total of 308 consecutive intracranial bypasses were performed during the study period, 53 (17.2%) of which were bypasses with an interposition SVG (38 autologous, 15 cadaveric). At a median follow-up of 2.2 months (IQR 0.2–29.1), 39 (73.6%) bypasses were patent (26 [68.4%] autologous, 13 [86.7%] cadaveric, p = 0.30). Comparing autologous and cadaveric SVG recipients, there were no statistically significant differences in age (p = 0.50), sex (p > 0.99), history of smoking (p = 0.75), hypertension (p > 0.99), diabetes mellitus (p = 0.13), indication for bypass (p = 0.27), or SVG diameter (p = 0.65). While there were higher intraoperative (autologous, 100.0 ml/min, IQR 84.3–147.5; cadaveric, 80.0 ml/min, IQR 47.3–107.8; p = 0.11) and postoperative (autologous, 142.2 ml/min, IQR 76.8–160.8; cadaveric, 92.0 ml/min, IQR 69.2–132.2; p = 0.42) volumetric flow rates in the autologous SVGs compared to those in the cadaveric SVGs, the difference between the two groups did not reach statistical significance. In addition, the blood flow index, or ratio of postoperative to intraoperative blood flow, for each bypass was similar between the groups (autologous, 1.3, IQR 0.9–1.6; cadaveric, 1.5, IQR 1.0–2.3; p = 0.37). Kaplan-Meier estimates showed no difference in bypass patency rates over time between autologous and cadaveric SVGs (p = 0.58).
CONCLUSIONS
Cadaveric SVGs are a reasonable interposition graft option in cerebral revascularization surgery when autologous grafts are not available.
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Conduits' Biology Regulates the Outcomes of Coronary Artery Bypass Grafting. JACC Basic Transl Sci 2021; 6:388-396. [PMID: 33997524 PMCID: PMC8093468 DOI: 10.1016/j.jacbts.2020.11.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 11/30/2020] [Accepted: 11/30/2020] [Indexed: 01/22/2023]
Abstract
Accelerated atherosclerosis is common when SVGs, but not arterial grafts, are used for myocardial revascularization during CABG. This review will provide an overview of the available data on the most commonly used conduits in CABG, highlighting the differences in their cellular biology, mechanical, biochemical, and vasoconstrictive properties. Clinical and scientific evidence support the use of arterial grafts over venous conduits at the time of CABG. These arterial conduits seem to be more protected toward the development of atherosclerosis. Exploring the molecular and cellular mechanisms, of the various cell populations within these conduits, will help unveil the pathways responsible for these protective effects.
Coronary artery bypass graft (CABG) is the gold standard for coronary surgical revascularization. Retrospective, prospective, and meta-analysis studies looking into long-term outcomes of using different conduits have pointed to the superiority of arterial grafts over veins and have placed the internal mammary artery as the standard conduit of choice for CABG. The superiority of the internal mammary artery over other conduits could be attributable to its intrinsic characteristics; however, little is known regarding the features that render some conduits atherosclerosis-prone and others atherosclerosis-resistant. Here, an overview is provided of the available data on the most commonly used conduits in CABG (internal mammary artery, saphenous vein, radial artery, gastroepiploic artery), highlighting the differences in their cellular biology, mechanical, biochemical, and vasoconstrictive properties. This information should help in furthering our understanding of the clinical outcomes observed for each of these conduits.
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46
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Commentary: A device solution for the saphenous vein graft's infamous foible? J Thorac Cardiovasc Surg 2021; 164:1543-1545. [PMID: 33985808 DOI: 10.1016/j.jtcvs.2021.04.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 04/13/2021] [Accepted: 04/15/2021] [Indexed: 11/20/2022]
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47
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Lipshy KA, Itani K, Chu D, Bahadursingh A, Spector S, Raman K, Dardik A, Tzeng E, Ballantyne GH, John PR, Cmolik B, Maloney J, Kozol R, Longo WE. Sentinel Contributions of US Department of Veterans Affairs Surgeons in Shaping the Face of Health Care. JAMA Surg 2021; 156:380-386. [PMID: 33471058 DOI: 10.1001/jamasurg.2020.6372] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
The vast accomplishments of the US Department of Veterans Affairs (VA) during the past century have contributed to the advancement of medicine and benefited patients worldwide. This article highlights some of those accomplishments and the advantages in the VA system that promulgated those successes. Through its affiliation with medical schools, its formation of a structured research and development program, its Cooperative Studies Program, and its National Surgical Quality Improvement Program, the VA has led the world in the progress of health care. The exigencies of war led not only to the organization of VA health care but also to groundbreaking, landmark developments in colon surgery; surgical treatments for vascular disease, including vascular grafts, carotid surgery, and arteriovenous dialysis fistulas; cardiac surgery, including implantable cardiac pacemaker and coronary artery bypass surgery; and the surgical management of many conditions, such as hernias. The birth of successful liver transplantation was also seen within the VA, and countless other achievements have benefited patients around the globe. These successes have created an environment where residents and medical students are able to obtain superb education and postgraduate training and where faculty are able to develop their clinical and academic careers.
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Affiliation(s)
- Kenneth A Lipshy
- Department of Surgery, W. G. (Bill) Hefner Veterans Affairs (VA) Health Care System, Salisbury, North Carolina.,Department of Surgery, Wake Forest University, Winston-Salem, North Carolina.,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Kamal Itani
- Department of Surgery, VA Boston Health Care System, Boston, Massachusetts.,Department of Surgery, Boston University, Boston, Massachusetts.,Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Danny Chu
- Department of Surgery, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Anil Bahadursingh
- Department of Surgery, Kansas Veterans Affairs Medical Center (VAMC), Kansas City, Missouri.,Department of Surgery, University of Missouri, Kansas City
| | - Seth Spector
- Department of Surgery, Miami VAMC, Miami, Florida.,Department of Surgery, University of Miami School of Medicine, Miami, Florida
| | - Kathleen Raman
- Department of Surgery, University of Rochester School of Medicine, Rochester, New York
| | - Alan Dardik
- Department of Surgery, West Haven VAMC, West Haven, Connecticut.,Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Edith Tzeng
- Department of Surgery, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | | | - Preeti R John
- VA Maryland Health Care System, Baltimore.,Department of Surgery, University of Maryland School of Medicine, Baltimore
| | - Brian Cmolik
- Department of Surgery, Cleveland VAMC, Cleveland, Ohio
| | - James Maloney
- Department of Surgery, Madison VAMC, Madison, Wisconsin.,Department of Surgery, University of Wisconsin, Madison
| | | | - Walter E Longo
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
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Kosmopoulos A, Verma S, Meglis G, Bhatt DL, Verma R, Mazer CD, Voisine P. Generalizability of Reduction of Cardiovascular Events with Icosapent Ethyl-Intervention Trial in patients with a history of coronary artery bypass graft surgery. Curr Opin Cardiol 2021; 36:172-178. [PMID: 32925191 DOI: 10.1097/hco.0000000000000800] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Following coronary artery bypass grafting (CABG), there remains persistent risk of ischemic events despite secondary prevention strategies, including low-density lipoprotein cholesterol lowering. Although REDUCE-IT recently demonstrated the benefits of icosapent ethyl (IPE) on reducing ischemic events in a broad population of primary and secondary prevention patients, its generalizability to a contemporary CABG population is not known. This article aims to ascertain the proportion of patients with a history of CABG that would be eligible for IPE treatment. RECENT FINDINGS A review of recent literature highlights the presence of residual ischemic following CABG. Using the Québec Heart Database, a repository of contemporary Canadian cardiac patient information, was searched between 1 January 2006 and 31 December 2016, to ascertain generalizability of IPE. SUMMARY In a large (N = 12 641), contemporary, Canadian cohort of patients with a history of CABG and currently on statin therapy, 21.9, 33.6 and 26.4% would be eligible for IPE, according to REDUCE-IT, Health Canada, and Food and Drug Administration criteria, respectively. These analyses would support IPE as an adjunct to secondary prevention therapies post-CABG.
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Affiliation(s)
- Andrew Kosmopoulos
- Department of Pharmacology and Toxicology, University of Toronto
- Division of Cardiac Surgery, St. Michael's Hospital
- North York Diagnostic and Cardiac Centre, Toronto, Ontario, Canada
| | - Subodh Verma
- Division of Cardiac Surgery, St. Michael's Hospital
- Department of Surgery, University of Toronto
| | - Gus Meglis
- North York Diagnostic and Cardiac Centre, Toronto, Ontario, Canada
| | - Deepak L Bhatt
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Raj Verma
- North York Diagnostic and Cardiac Centre, Toronto, Ontario, Canada
| | - C David Mazer
- Departments of Anesthesia, St Michael's Hospital
- Departments of Anesthesia and Physiology, University of Toronto, Toronto
| | - Pierre Voisine
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (IUCPQ), Québec City, Québec, Canada
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49
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Zenati MA, Bhatt DL, Stock EM, Hattler B, Wagner TH, Bakaeen FG, Biswas K. Intermediate-Term Outcomes of Endoscopic or Open Vein Harvesting for Coronary Artery Bypass Grafting: The REGROUP Randomized Clinical Trial. JAMA Netw Open 2021; 4:e211439. [PMID: 33720367 PMCID: PMC7961312 DOI: 10.1001/jamanetworkopen.2021.1439] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
This randomized clinical trial examines intermediate-term outcomes of endoscopic vs open vein harvesting for coronary artery bypass grafting as part of the Randomized Endo-Vein Graft Perspective (REGROUP) trial.
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Affiliation(s)
- Marco A. Zenati
- Division of Cardiac Surgery, Department of Surgery, Veterans Affairs Boston Healthcare System, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Deepak L. Bhatt
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Eileen M. Stock
- Cooperative Studies Program, Perry Point/Baltimore Coordinating Center, Office of Research and Development, US Department of Veterans Affairs, Perry Point, Maryland
| | | | - Todd H. Wagner
- VA Health Economics Resource Center, Department of Surgery, Stanford University, Palo Alto, California
| | | | - Kousick Biswas
- Perry Point Cooperative Studies Program Coordinating Center, Office of Research and Development, US Department of Veterans Affairs, Perry Point, Maryland
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
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50
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Abstract
Coronary artery bypass grafting is the most common cardiac surgical procedure performed worldwide and the long saphenous vein the most common conduit for this. When performed as an open vein harvest (OVH), the incision on each leg can be up to 85cm long, making it the longest incision of any routine procedure. This confers a high degree of morbidity to the procedure. Endoscopic vein harvest (EVH) methods were popularised over two decades ago, demonstrating significant benefits over OVH in terms of leg wound complications including surgical site infections. They also appeared to hasten return to usual activities and wound healing and became popular particularly in North America. Subgroup analyses of two trials designed for other purposes created a period of uncertainty between 2009–2013 while the impact of endoscopic vein harvesting on vein graft patency and major adverse cardiac events was scrutinised. Large observational studies debunked the findings of increased mortality in the short-term, allowing practitioners and governing bodies to regain some confidence in the procedure. A well designed, adequately powered, randomised controlled trial published in 2019 also definitively demonstrated that there was no increase in death, myocardial infarction or repeat revascularisation with endoscopic vein harvest. Endoscopic vein harvest is a Class IIa indication in European Association of Cardio-Thoracic Surgery (EACTS) and a Class I indication in International Society of Minimally Invasive Cardiac Surgery (ISMICS) guidelines.
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Affiliation(s)
- Enoch Akowuah
- Department of Cardiac Surgery, James Cook University Hospital, South Tees NHS, Foundation Trust, Middlesbrough, UK
| | - Daniel Burns
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Joseph Zacharias
- Department of Cardiothoracic Surgery, Blackpool Victoria Hospital, Blackpool, UK
| | - Bilal H Kirmani
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
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