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Influence of Prior Coronary Stenting on the Immediate and Mid-term Outcome of Isolated Coronary Artery Bypass Surgery. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2019; 2:217-25. [DOI: 10.1097/imi.0b013e31815bdbc1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background There has been little emphasis on the possible consequences of prior stent placement on the outcome of coronary bypass surgery (CABG). We compared the results of isolated CABG patients who had prior stents with those who had not with respect to preoperative status, operative procedure, and postoperative immediate and long-term outcome. Methods Records of 1471 patients undergoing isolated CABG at our institution between January 1, 2000, and March 31, 2005, were reviewed. Patients were divided into three groups. Group I had no stents (n = 1317). Group II had one to three stents (n = 137). Group III had more than three stents (n = 17). Groups were compared with respect to preoperative risk factors, operative procedures, and postoperative results. Long-term survival data were obtained on 97.6% of patients with a mean follow-up, 4.1 ± 2.3 years. Results Stented patients were younger (66.1 ± 10.8 vs. 69.1 ± 10.8 years, P = 0.006), had more unstable angina (68.2% vs. 58.9%, P = 0.02), hypercholesterolemia (83.8% vs. 61.2%, P = 0.00), chronic obstructive pulmonary disease (13.6% vs. 8.4%, P = 0.03), peripheral vascular disease (15.2% vs. 8.4%, P = 0.00), and previous CABG (10.1% vs. 4.2%, P = 0.00), fewer low ejection fractions (1.3% vs. 5.2%, P = 0.02), left main disease (25.3% vs. 32.6%, P = 0.04), diabetes (31.2% vs. 40.8%, P = 0.01), or diffuse disease (19.5 ± 10.5 vs. 22.5 ± 10.9, P = 0.00), had more off pump procedures (53.2% vs. 45.3%, P = 0.03), fewer internal thoracic artery grafts (80.5% vs. 86.6%, P = 0.03), fewer grafts placed (>3: 52.6% vs. 61.8%, P = 0.02), more complications (76.5% vs. 42.6%, P = 0.005), atrial fibrillation (47.1% vs. 19.7%, P = 0.011), longer hospital stays (12.2 vs. 8.3 days, P = 0.019). Percentage survival for groups I, II, and III at 60 months was 82.1%, 84.7%, and 72.6%, respectively. Conclusions Stents placed before surgery in isolated CABG patients may be associated with higher preoperative risk, altered operative procedures, more postoperative complications, longer hospitalizations, and more readmissions. Overall, stented patients experienced more preoperative hospitalizations, catheterizations, and percutaneous coronary interventions (PCIs) than nonstented patients. Survival for those with more than three stents may be diminished.
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Razzouk L, Farkouh ME. Optimal approaches to diabetic patients with multivessel disease. Trends Cardiovasc Med 2015; 25:625-31. [PMID: 26398271 DOI: 10.1016/j.tcm.2015.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Revised: 02/10/2015] [Accepted: 02/11/2015] [Indexed: 11/15/2022]
Abstract
The pathophysiology of diabetes and systemic insulin resistance contributes to the nature of diffuse atherosclerosis and a high prevalence of multivessel coronary artery disease (CAD) in diabetic patients. The optimal approach to this patient population remains a subject of an ongoing discussion. In this review, we give an overview of the unique pathophysiology of CAD in patients with diabetes, summarize the current state of therapies available, and compare modalities of revascularization that have been investigated in recent clinical trials. We conclude by highlighting the importance of a comprehensive heart team approach to every patient while accommodating both patient preference and quality-of-life decisions.
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Affiliation(s)
- Louai Razzouk
- Department of Medicine, New York University Langone Medical Center, New York, NY
| | - Michael E Farkouh
- Peter Munk Cardiac Centre, University of Toronto, Toronto, Ontario, Canada; Heart and Stroke Richard Lewar Centre of Excellence in Cardiovascular Research, University of Toronto, Toronto, Ontario, Canada.
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Drug-eluting stents in multivessel coronary artery disease: cost effectiveness and clinical outcomes. Adv Pharmacol Sci 2013; 2012:679013. [PMID: 23346105 PMCID: PMC3533590 DOI: 10.1155/2012/679013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Revised: 11/07/2012] [Accepted: 11/25/2012] [Indexed: 11/29/2022] Open
Abstract
Multivessel coronary artery disease is more often treated either with coronary artery bypass surgery (CABG) or percutaneous coronary intervention (PCI) with stenting. The advent of drug-eluting stent (DES) has changed the revascularization strategy, and caused an increase in the use of DES in multivessel disease (MVD), with reduced rate of repeat revascularization compared to conventional bare metal stent. The comparative studies of DES-PCI over CABG have shown comparable safety; however, the rate of major adverse cerebrovascular and cardiac events and repeat revascularization was significantly higher with DES-PCI at long term. In diabetic patients with MVD, concern of repeat revascularization with DES-PCI is persistent. More recent, one-year economic outcomes have reported that the CABG is favored among patients with high angiographic complexity. The higher rate of repeat revascularization with DES-PCI in MVD would lead to increased economic burden on patient at long term besides bearing high cost of DES. In diabetic MVD patients, CABG is associated with having better clinical outcomes and being more cost-effective approach when compared to DES-PCI at long term.
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Menasché P. Revascularisation myocardique 30 ans après : la chirurgie toujours d’actualité. Presse Med 2008; 37:1569-74. [DOI: 10.1016/j.lpm.2008.01.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2007] [Accepted: 01/02/2008] [Indexed: 11/29/2022] Open
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Lapanashvili LV, Buziashvili YI, Matskeplishvili ST, Lobjanidze TG, Yoshina VI, Kamardinov DK, Tugeeva EF, Bockeria LA. Therapeutic value of muscular counterpulsation after coronary bypass grafting operation. J Card Surg 2008; 24:134-40. [PMID: 18793232 DOI: 10.1111/j.1540-8191.2008.00725.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Coronary artery bypass grafting continues to be the operation of choice in patients with severe multiple coronary artery disease. However, there are several unresolved issues such as treatment of postoperative heart failure following bypass surgery. There is worldwide interest in evaluating new treatment methods for this condition. The objective is to determine the effect of a new external, bioassisted circulation-muscular counterpulsation (MCP) method in patients with ischemic heart disease (IHD) undergoing coronary artery bypass grafting (CABG). METHODS Fifty patients (age 54 +/- 8) undergoing CABG were included in the present analysis. Patients were randomized into two groups: A control group (n = 20) receiving standard postoperative treatment without counterpulsation and a treatment group (n = 30) undergoing MCP with a cardio-synchronized pulse generator using stimulation electrodes on the lower extremities. Treatment was 30 minutes daily for the eight initial postoperative days in addition to standard therapy. In all patients, a resting electrocardiogram (ECG), two-dimensional echocardiography, and impedance plethysmography of the forearm were carried out pre-CABG and on the eighth postoperative day. RESULTS Follow-up was completed in 94% of the patients. Two patients of the control and one of the treatment group refused follow-up examination. MCP treatment resulted in a 36% decrease of systemic vascular resistance (p < 0.001) compared to a 16% decrease (p = 0.011) in the control group. Postoperative complications occurred in one (3%) patient of the treatment group and in seven (39%) patients of the control group. Compared to the control group, patients in the treatment group had a 28% shorter postoperative hospital stay (12.0 +/- 4.6 days) than in the control group (16.8 +/- 4.4 days) (p < 0.001). CONCLUSIONS MCP represents a new, noninvasive, ECG-triggered circulation support system, which is effective for achieving hemodynamic improvement via afterload reduction. The use of MCP decreases postoperative complications and significantly shortens the hospital stay.
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Pliam MB, Zapolanski A, Anastassiou P, Ryan CJ, Manila LL, Shaw RE, Pira BK. Influence of Prior Coronary Stenting on the Immediate and Mid-term Outcome of Isolated Coronary Artery Bypass Surgery. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2007. [DOI: 10.1177/155698450700200501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Michael B. Pliam
- Department of Cardiovascular Surgery, San Francisco Heart and Vascular Institute, Seton Medical Center, Daly City, California
| | | | - Peter Anastassiou
- Department of Cardiovascular Surgery, San Francisco Heart and Vascular Institute, Seton Medical Center, Daly City, California
| | - Colman J. Ryan
- Department of Cardiovascular Surgery, San Francisco Heart and Vascular Institute, Seton Medical Center, Daly City, California
| | - Louis L. Manila
- Clinical Research and Operations, San Francisco Heart and Vascular Institute, Seton Medical Center, Daly City, California
| | - Richard E. Shaw
- Sutter Pacific Heart Centers, California Pacific Medical Center, San Francisco, California
| | - Bob-Kenneth Pira
- Clinical Database Analysis, San Francisco Heart and Vascular Institute, Seton Medical Center, Daly City, California
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Woollard KV, Newman MAJ. How should stable coronary artery disease be managed in the modern era? Med J Aust 2007; 187:140-1. [PMID: 17680737 DOI: 10.5694/j.1326-5377.2007.tb01169.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2007] [Accepted: 06/20/2007] [Indexed: 11/17/2022]
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Percutaneous Coronary Intervention and Stable Angina. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Smith PK, Califf RM, Tuttle RH, Shaw LK, Lee KL, Delong ER, Lilly RE, Sketch MH, Peterson ED, Jones RH. Selection of Surgical or Percutaneous Coronary Intervention Provides Differential Longevity Benefit. Ann Thorac Surg 2006; 82:1420-8; discussion 1428-9. [PMID: 16996946 DOI: 10.1016/j.athoracsur.2006.04.044] [Citation(s) in RCA: 132] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2006] [Revised: 04/07/2006] [Accepted: 04/13/2006] [Indexed: 11/30/2022]
Abstract
BACKGROUND Treatment of coronary artery disease (CAD) is evolving with better medications, improvements in percutaneous coronary intervention (PCI), and enhanced techniques for coronary artery bypass grafting (CABG). METHODS In this study, 18,481 patients with significant (>75% stenosis) CAD treated at a single center between 1986 and 2000 were assigned to one of three groups based on initial treatment strategy: medical therapy (MED) (n = 6862), PCI (n = 6292), or CABG (n = 5327). Each group was categorized into 3 groups according to baseline severity of CAD: low-severity (predominantly 1-vessel), intermediate-severity (predominantly 2-vessel), and high-severity (all 3-vessel), and prospectively evaluated in Cox models for all-cause mortality adjusted for cardiac risk, comorbidity, and propensity for selection of a specific treatment. Treatments were compared for the entire period and three eras (1: 1986 to 1990; 2: 1991 to 1995; 3: 1996 to 2000), the last encompassing widespread availability of PCI with stenting. RESULTS Survival significantly improved in all groups for all degrees of CAD, despite increasing severity of illness. Revascularization strategies provided significant survival over MED with 8.1, 10.6, and 23.6 additional months per 15 years of follow-up for low-severity, intermediate-severity, and high-severity CAD, respectively. Therapeutic improvements led to increased survival of 5.3 additional months per 7 years of follow-up (95% confidence interval, 0.2 to 10.2; p = 0.039) in era 3 for CABG compared with PCI for high-severity CAD. CONCLUSIONS Initial revascularization strategies result in significant survival advantage over MED for all CAD levels. Patients with high-severity CAD have reduced survival with PCI compared with those initially treated with CABG.
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Affiliation(s)
- Peter K Smith
- Division of Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina 27710, USA.
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Abstract
With the wider use of imaging and interventional techniques that require the use of iodinated contrast media in seriously ill patients, many clinical situations occur where patients may be at increased risk for contrast-induced nephropathy (CIN). There is little guidance for clinicians in these areas. The aim of this review is to assess the available literature. Acute renal failure is a common complication following coronary artery bypass surgery, and exposure to contrast medium may increase the risk for this condition, although there is insufficient evidence to make a definitive statement. Evidence is also limited for patients with liver disease: in those undergoing transarterial chemoembolization, cirrhosis may be a risk factor for renal failure. There is some evidence that periprocedural hypotension may be a risk factor for CIN after percutaneous coronary intervention, but no published information was identified on the significance of shock or hypotension in other groups of patients. The published evidence on the risk of CIN in renal transplant recipients is inconsistent. In emergency situations, the course of action is usually dictated by clinical circumstances; the renal status of a patient is likely to be unknown and it is important to ensure adequate volume expansion, especially after the procedure. In all clinical situations that are potentially associated with a high risk for CIN, the decision to administer contrast medium is a matter for clinical judgment, based on the clinical status of the patient and the expected benefits of the investigation or procedure.
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Affiliation(s)
- Christoph R Becker
- Department of Clinical Radiology, University Hospital Grosshadern, Munich, Germany.
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Affiliation(s)
- Jonathan Abrams
- Division of Cardiology, Department of Internal Medicine, University of New Mexico, Albuquerque, NM 87131, USA.
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Kovacic JC, Roy PR, Baron DW, Muller DWM. Staged carotid artery stenting and coronary artery bypass graft surgery: Initial results from a single center. Catheter Cardiovasc Interv 2005; 67:142-8. [PMID: 16342270 DOI: 10.1002/ccd.20487] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The objective of this study was to assess the clinical course of patients undergoing planned percutaneous carotid stenting followed by staged coronary artery bypass grafting (CABG). Coexisting carotid and coronary atherosclerotic disease is relatively common. A combined or staged surgical approach has a composite stroke, myocardial infarction, or death rate of > 10%. We performed a retrospective search of our single-institution database to identify all patients scheduled to undergo staged carotid stenting followed by CABG. Twenty-three such patients (17 males, 6 females) were identified, with 3/23 (13%) requiring bilateral carotid stenting. Most carotid lesions were asymptomatic (18/26; 69.2%) and severe (mean stenosis, 82.9% 6+/- 8.6%). Stents were successfully placed in 26/26 carotid arteries (100%). One stent procedure (1/26; 3.8%) resulted in a minor stroke, but full recovery occurred within 1 week. There were no other peri-stenting complications. Three patents (3/23; 13%), none of whom suffered an adverse event at carotid stenting, elected not to undergo CABG. The mean interval from last carotid stent to CABG was 69.6 6 +/- 39.6 days (range, 8-157 days). Antiplatelet therapy was ceased > 3 days prior to CABG in 10/20 patients (50%), but continued until surgery in the remainder. There were no peri-CABG bleeding or neurological complications, but one myocardial infarction occurred (1/20; 5%). Therefore, of the 20 patients who underwent planned carotid stenting followed by CABG, our overall rate of death, stroke, or myocardial infarction was 10%. However, our rate of death, persistent stroke or myocardial infarction was 5%. Planned carotid stenting followed by staged CABG is a viable method of treatment for patients with coexistent carotid and coronary atherosclerosis.
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Affiliation(s)
- Jason C Kovacic
- Cardiology Department, St. Vincent's Hospital, Sydney, Australia
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Abstract
PURPOSE OF REVIEW Despite numerous advances in coronary interventional techniques, the frequent occurrence of restenosis continues to plague interventional cardiology. With the widespread use of drug-eluting stents, there is a need to reexamine critically the roles of the various interventional techniques currently available. RECENT FINDINGS Drug-eluting stents have dramatically reduced the rates of restenosis and target vessel revascularization in a wide spectrum of patients with varying lesion morphologies. However, when restenosis does occur, it still tends to be dependent on the same factors that predict restenosis with bare metal stenting. The routine use of drug-eluting stents entails high initial costs to the health care system. Debulking as a means to improve outcomes after angioplasty has not lived up to expectations. Gene therapy is rapidly evolving into a viable means to reduce neointimal proliferation after angioplasty. SUMMARY Careful patient selection and attention to the procedure of stent deployment optimize the results of angioplasty with drug-eluting stents. Because of cost considerations, drug-eluting stents should be used in patients who are expected to have the greatest absolute benefit. In this context, when judiciously used, conventional balloon angioplasty and bare metal stenting still have a definite role in the management of patients with obstructive coronary artery disease.
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Affiliation(s)
- Ganesan Karthikeyan
- Department of Cardiology, Cardiothoracic Sciences Center, All India Institute of Medical Sciences, New Delhi, India
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