Re-do coronary artery bypass grafting with the descending branch of the lateral femoral circumflex artery in a patient with chronic hemodialysis

A 52-year-old man with hemodialysis had undergone coronary artery bypass grafting (CABG); left internal thoracic artery (LITA) to left anterior descending artery (LAD), right gastroepiploic artery (RGEA) to posterolateral branch (PL), saphenous vein graft (SVG) to diagonal artery (Dx) 5 years previously. After 3 years, angiography was performed due to recurrence of angina pectoris and revealed RGEA and SVG was totally occluded. Since repeated intervention was unsuccessful, reoperation was necessary. Therefore, we performed re-do CABG without cardiopulmonary bypass using lateral femoral circumflex artery (LFCA) as an arterial conduit for myocardial revascularization via the 6th left intercostal posterolateral thoracotomy. Postoperative angiography showed that the LFCA bypass graft was patent and supplied sufficient blood to anastomosed vessel. The patient has had no angina pectoris subsequently. We believe this procedure is useful for re-do myocardial revascularization, and LFCA deserves to be taken into account as an alternative graft in a patient with chronic hemodialysis.     

冠状动脉旁路移植术后长期随访

目的 总结１９８２年至１９９１年间３８例冠状动脉旁路移植术（ＣＡＢＧ）者的长期随访结果,以探讨术前危险因子对ＣＡＢＧ疗效的影响。方法 ３８例中男３６例,女２例。年龄４１－７３岁,平均５５．４岁,７３．７％病人年龄大于５０岁。有心肌梗死发作史者１５例,有心衰史者２例。ＰＴＣＡ失败后急症手术２例,３支,３支以上冠状动脉病变者１９例。心功能Ⅲ级及以上者３０例。应用Ｓｔａｔｉｓｔｉｃａ软件包中的Ｌｏｇｉｓ     

Limitations in the cardiac risk reduction provided by coronary revascularization prior to elective vascular surgery

OBJECTIVE: The objective of this study was to evaluate the proposed cardiac protective effect of previous coronary revascularization (coronary artery bypass grafting [CABG] or percutaneous transluminal coronary angioplasty [PTCA]) before elective major arterial surgery. METHOD: Preoperative cardiac risk stratification using American College of Cardiology/American Heart Association (ACC/AHA) guidelines was done on 425 consecutive patients undergoing 481 elective major vascular operations at an academic VA Medical Center. The algorithm assumed asymptomatic patients with prior coronary revascularization (CABG, <5 year; PTCA, <2 year) were low cardiac risk. Coronary angiography was done for recurrent symptoms with secondary intervention when appropriate. Outcomes (myocardial infarction, unstable angina, congestive heart failure, ventricular arrhythmia, cardiac death, and mortality) within 30 days of vascular surgery were compared between patients with and without previous CABG or PTCA by contingency table and logistic regression analyses. RESULTS: Coronary revascularization was classified as recent (CABG, <1 year; PTCA, <6 months) in 35 cases (7%), prior (1 year < or = CABG < 5 year, 6 months < or = PTCA < 2 year) in 45 cases (9%), and remote (CABG, > or = 5 year; PTCA, > or = 2 year) in 48 cases (10%). A larger fraction of patients with previous revascularization possessed pathologic cardiac risk variables and were stratified as high-risk preoperatively than their nonrevascularized counterparts. Outcomes in patients with previous PTCA were similar to those after CABG (P =.7). Significant differences in adverse cardiac events (P =.01) and mortality (P =.05) were found between patients with CABG done within 5 years or PTCA within 2 years (6.3%, 1.3%, respectively), individuals with remote revascularization (10.4%, 6.3%), and nonrevascularized patients stratified at high risk (13.3%, 3.3%) or intermediate/low (2.8%, 0.9%) risk. De novo or recurrent 3-vessel coronary disease by angiography, but not the presence or timing of previous revascularization, was an independent predictor of cardiac events after vascular operations, whereas remote revascularization was associated with fatal outcomes by multivariate analysis. CONCLUSIONS: Previous coronary revascularization (CABG, <5 years; PTCA, <2 years) may provide only modest protection against adverse cardiac events and mortality following major arterial reconstruction.     

Early angiographic results of multivessel off-pump coronary artery bypass grafting.

OBJECTIVES: Recently off-pump coronary artery bypass grafting (CABG) is being widely used for coronary revascularization. However, there is some evidence that off-pump surgery increases the risk of recurrent angina and the need for reintervention, suggesting poor graft quality or incomplete revascularization. We describe our experience to demonstrate the feasibility of multiple coronary revascularization in off-pump CABG (OPCAB). PATIENTS AND METHODS: From January 2002 to March 2003, 168 patients underwent OPCAB at our institute. In 16 of them, 6 to 9 vessels were revascularized in each patient. There were 14 males and 2 females with a mean age of 66 years (47 to 74 years). All patients had triple-vessel disease. Ten patients received in situ arterial grafts only which were harvested with the skeletonization technique using an ultrasonic scalpel. We used the Starfish heart positioner to expose lateral, posterior, and inferior walls of the heart with minimal hemodynamic compromise. RESULTS: All patients were discharged from the hospital without any serious complications. Postoperative angiography was performed in 87.5% within 1 month after operation. The patency rate was 96.6%. CONCLUSION: These results indicate that complete revascularization can be achieved in OPCAB in patients with diffuse coronary arterial disease. Complete revascularization with in situ arterial conduits only is technically feasible and yields a high early graft patency, even in the off-pump situation.     

Effect of age in the Bypass Angioplasty Revascularization Investigation (BARI) randomized trial

BACKGROUND: The influence of age on the relative success of either percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG) in patients requiring myocardial revascularization continues to be controversial. METHODS: In the Bypass Angioplasty Revascularization Investigation (BARI) trial, 1,829 patients with symptomatic multivessel coronary artery disease requiring revascularization were randomly assigned to undergo either CABG or PTCA. RESULTS: Seven hundred nine patients (39%) were 65 to 80 years old at baseline; the other 1,120 were younger than 65 years. The in-hospital 30-day mortality rate for PTCA and CABG in the younger patients was 0.7% and 1.1%, respectively, and that for patients 65 years or older was 1.7% and 1.7%, respectively. In older compared with younger patients, stroke was more common after CABG (1.7% versus 0.2%, p = 0.015) and heart failure or pulmonary edema was more common after PTCA (4.0 versus 1.3%, p = 0.011). In both age groups, CABG resulted in greater relief of angina and fewer repeat procedures. The 5-year survival rate in patients younger than 65 years was 91.5% for CABG and 89.5% for PTCA. In patients 65 years or older, the 5-year survival rate was 85.7% for CABG and 81.4% for PTCA. Cardiac mortality at 5 years was greater in patients assigned to the PTCA group than in those assigned to the CABG group. However, no significant treatment differences were noted in cardiac mortality when only nondiabetic patients were examined. CONCLUSIONS: Within the context of the Bypass Angioplasty Revascularization Investigation trial, older patients with multivessel coronary disease do well with either PTCA or CABG. Compared with younger patients, older patients had less recurrent angina and were less likely to undergo repeat procedures, particularly among those assigned to undergo CABG. Cardiac mortality was greater in patients 65 years or older assigned to undergo PTCA; however, this difference was not noted when treated diabetic patients were excluded from analysis.     

Left anterior descending coronary artery: long-term angiographic results of CABG with endarterectomy

AIM: The procedure of coronary bypass grafting (CABG) with coronary endarterectomy (CE) is controversial. However, in the setting of severely calcified coronary arteries CE may enable complete revascularization. Complete revascularization, especially of the left anterior descending artery (LAD), is important for long-term outcome. In this study we assessed long-term LAD graft patency and anterior wall function after CABG with CE of the LAD. METHODS: Between 1984 and 1992, 283 patients underwent CABG with CE of the LAD. In 50 patients (47 men), aged 59+/-7.6 (40-77), clinical reassessment and surveillance angiography were performed. In all patients complete revascularization had been achieved with 3.5+/-1 (1-5) grafts/patient with 1-3 CE/patient. The LAD was grafted either with a saphenous vein segment (N=38) or with left intern thoracic artery (N=12). A graft obstructed less than 50% in diameter was defined as patent. RESULTS: At follow-up 39 patients (78%) were in CCS class I/II and had improved significantly (P<0.000). Control angiography after 7.6+/-2.5 (3.5-11.7) years after CABG revealed a patent LAD graft in 30/50 patients (60%). Actuarial graft patency was 100%, 96%, and 56% after 2, 5, and 10 years and was lower in patients with diabetes (P=0.001). Deterioration of anterior wall motion was observed in 17 patients (34%) and was more frequent if anterior wall motion was preoperatively normal (P=0.002), irrespective of LAD graft patency. CONCLUSION: Clinical status and long-term graft patency of grafts on endarterectomized LAD is considerable. However, patients with preoperatively normal anterior wall function are at increased risk for myocardial damage in the long-term.     

Clinical experience of bovine internal mammary artery graft (BIOFLOW) for coronary artery bypass surgery

Bovine internal mammary artery graft (BIOFLOW: BIOVASCULAR INC. Netherlands) has been used for coronary artery bypass grafting (CABG) in 8 patients since May 1988 at Osaka Medical College Hospital. There were 4 males and 4 females. Mean age was 66.9 year-old ranged from 62 to 72. Two were emergency CABG and other six had inadequate saphenous veins. The internal mammary artery and/or the saphenous vein were concomitantly used in all patients. Number of grafts was 2 to 6 with the mean of 2.9 and BIOFLOW (phi 3 mm) was anastomosed to 2 left anterior descending arteries and 6 right coronary arteries, the mean graft flow of BIOFLOW was 72.5 ml/min ranged from 52 to 120 ml/min. One patient died of ventricular arrhythmia on 5 postoperative day. There was no new Q wave infarction. Postoperative angiogram within 2 months showed 4 of 5 BIOFLOW grafts were patent, and no stenosis was found in those patent grafts. All survivors returned to home with a freedom from angina. From our experience, although the number was small and the follow-up period was short, BIOFLOW can be expected as an conduit of choice for CABG when the saphenous vein was not available and the internal mammary artery and the gastroepiploic artery were not enough to accomplish the complete revascularization.     

From Vineberg to bypass: a "second-hand" internal mammary artery.

A patient operated upon 20 years ago for myocardial revascularization with two Vineberg procedures and one coronary artery bypass graft (CABG) on the right coronary artery had a recurrence of unstable angina due to the thrombosis of the left internal mammary artery (IMA) and the right CABG. The right IMA was patent but stenosed distally. Reoperation was performed with a direct end to side anastomosis of the patent right IMA onto the left anterior descending artery and a saphenous vein graft as a CABG on the marginal branch. We comment on the choice of this "second hand" IMA graft and the pathological appearances of the patent IMA.     

Indication for coronary revascularization in aortic surgery

In order to know how to treat the coronary artery disease in scheduled aortic surgery for aortic aneurysms, a prospective study started about ten years ago using routine coronary angiography (CAG). Thoracic aortic aneurysm (TAA): CAG was performed in 73 among 143 patients and 18 had significant coronary artery stenoses (CAD), 3 of whom had angina. Concomitant CABG was performed in 2 of 4 patients requiring coronary revascularization (CR) to prevent intraoperative myocardial ischemia. Complications due to CAD were experienced in the 2 patients without CR despite of angina, while patients without angina or with CR had no complication. Abdominal aortic aneurysm (AAA): Seventy six among 150 patients had CAG, and CAD was found in 38. CR was indicated to 5 of 7 patients with angina. Complications occurred in 2 patients who had not CR in spite of angina. Patients without angina had no complication. Conclusion: 1) Patients who had angina are at high risk for complications due to CAD. 2) Patients with angina and necessity of cardiac arrest during aneurysmectomy should have coronary revascularization prior to aneurysmectomy. 3) Patients without angina are at low risk for myocardial ischemia in the perioperative period of aortic surgery.     

Long-term follow-up of total arterial myocardial revascularization using exclusively pedicle bilateral internal thoracic artery and right gastroepiploic artery

Objective: In order to reduce remote cardiac events associated with graft occlusions, arterial conduits are being increasingly utilized in coronary artery bypass grafting (CABG). While the internal thoracic artery (ITA) is the graft of choice for CABG, it is sometimes difficult or impossible to obtain a complete arterial revascularization only with ITAs in three-vessel diseases. We present our experience with total arterial myocardial revascularization with bilateral internal thoracic artery (BITA) and right gastroepiploic artery (rGEA). Methods: From April 1994 to January 2004, 174 patients (165 male, mean age 55.9±7.4) underwent coronary artery bypass procedure with exclusive use of BITA and rGEA. Left ventricular ejection fraction ranged from 20 to 68% (mean 55.9±6.8%). Seven patients (4%) had poor ejection fraction (<0.30), 23 (13, 2%) had acute myocardial infarction, 14 (8%) had left main disease. The mean CPB time was 96.9±15.7 min and the mean cross clamping time was 70±14.2 min. The mean number of distal anastomoses was 3.3±0.5 per patient. Results: Early mortality was 1.7%. The patients were followed for up to 9 years (mean follow-up time 6.3±2.6 years). Actuarial freedom from cardiac death (including hospital death) was 97.6%, at 9 years after the operation. Actuarial freedom from angina and cardiac events at 9 years was 79, 5% and 77, 6%, respectively. No perioperative myocardial infarction occurred. None of the patients needed a redo-CABG after leaving the hospital. Conclusions: This study indicates that the myocardial revascularization in young patients with three-vessel disease using exclusively pedicle BITA and rGEA provides excellent 9-year patient survival and improvement in terms of freedom from return of angina pectoris and freedom from any cardiac-related event. These results encourage the more extensive use of BITA and rGEA in selected patients with three-vessel coronary disease.     

Guidelines for the clinical use of transmyocardial laser revascularization

Patients with chronic, severe angina refractory to medical therapy who cannot be completely revascularized with either percutaneous catheter intervention or coronary artery bypass graft surgery (CABG) are clinically challenging. Transmyocardial laser revascularization (TMR), as sole therapy or as an adjunct to CABG, may be appropriate therapy for these patients. The recommendations are based on a review of the available evidence including expert consensus opinions. The author follows the format of the American Heart Association and the American College of Cardiology guidelines for diagnostic and therapeutic procedures. There are class I indications for sole therapy TMR and class IIA indications for TMR as an adjunct to CABG. TMR is indicated for selected patients: as sole therapy for a subset of patients with refractory angina. It also may be effective as an adjunct to CABG for a subset of patients with angina who cannot be completely revascularized surgically.     

Optimal timing of abdominal aortic aneurysm repair after coronary artery revascularization.

OBJECTIVE: The authors ascertained the optimal timing of repair of an abdominal aortic aneurysm (AAA) after coronary artery revascularization. SUMMARY BACKGROUND DATA: Cardiac events are the most common cause of death after elective repair of AAA. Preoperative coronary revascularization has significantly reduced postoperative cardiac complications after elective AAA repair. Currently, most patients undergo repair of asymptomatic AAA within 6 months after the coronary revascularization. METHODS: The authors performed a retrospective review of patients who underwent repair or scheduled repair of an asymptomatic AAA within 6 months after coronary artery bypass graft (CABG) between March 1988 and October 1993. RESULTS: There was no mortality in the group of patients (n = 14) who underwent repair of AAA simultaneously or within 14 days of coronary revascularization. In contrast, there was a significantly increased mortality rate of 3 of 9 (33%) in patients scheduled to undergo repair of the AAA more than 2 weeks after coronary revascularization (p < 0.05). All nonsurvivors died between 16 and 29 days after CABG, and died as a result of ruptured AAA. CONCLUSION: Elective AAA repair should be undertaken simultaneously or within 2 weeks of coronary artery revascularization because of an increased risk of postoperative AAA rupture seen after this time period. In addition, simultaneous or early postoperative AAA repair does not increase the overall operative risk.     

Reoperation for coronary artery disease in the young: early and mid-term results

Background As the incidence of coronary artery disease (CAD) at young age is high in Asian countries, the number of coronary reoperations in this group of patients is increasing. The aim of this study was to define the incidence, risk factors and to discuss the methods of re-revascularization and early to mid-term outcomes in these patients. Methods This study is a retrospective analysis of the data of patients who underwent primary coronary artery bypass surgery (CABG) before the age of 45 years and underwent reoperation for recurrence of angina due to progression of native coronary artery disease and, or, graft occlusion. The data was also analyzed with regards to the risk factors contributing to the recurrence of the disease and the short to mid-term outcomes. During a six year period from January 1998 to October 2004, a total of 68 patients had reoperation for recurrence of angina. The mean interval of presentation following primary CABG was 12.48±3.11 years (ranged from 8 months to 16 years). Reoperation was performed under cardiopulmonary bypass (CPB) in 63 patients and in the remaining five patients on beating heart without using CPB. Results Reoperation accounted for 4.6% of 2478 patients who underwent CABG between January 1998 through October 2004 at our institute. Among these 114 patients, 68 patients underwent primary CABG before the age of 45 years. These 68 patients received a total of 214 grafts (3.14 grafts per patient) of which 169 grafts were re-anastamosed to previously grafted target arteries. Left internal mammary artery was used in 61 patients (89.7%) who required graft to left anterior descending coronary artery at reoperation. The early mortality was 4.4% (3 out of 68). Two patients (2.94%) had perioperative myocardial infarction and two more patients were re-explored for mediastinal bleeding. Freedom from recurrence of symptom of angina at 2 and 4 years was 98.01%, 94.5% respectively. Conclusions Redo CABG is associated with higher morbidity and mortality when compared to first-time CABG. Perioperative myocardial infarction and left ventricular dysfunction contribute significantly to the increased risk of redo CABG.     

Does technical failure of revascularization during coronary artery bypass grafting predict severity of poststernotomy mediastinitis?

BACKGROUND AND AIMS: To assess the impact of unsuccessful revascularization in relation to poststernotomy mediastinitis (PSM), which affects long-term outcome after coronary artery bypass grafting (CABG). MATERIAL AND METHODS: An active approach for the follow-up of PSM involved a step by step treatment protocol of conventional surgery and plastic reconstructive surgery. 47 patients treated for PSM after CABG were identified and further evaluated. Complete revascularization was considered unsuccessful when technical hazards were reported during CABG. When PSM subsided after thorough debridement and sternal refixation without plastic reconstructive surgery, such as omentoplasty or muscle transposition, PSM was categorized as mild PSM. If treatment required plastic reconstructive surgery, PSM was categorized as severe PSM. Preoperative coronary artery angiographic status and success of revascularization were compared to postoperative outcome in relation to mild and severe PSM. RESULTS: 36 patients suffered from mild PSM and 11 patients from severe PSM. Preoperative clinical status did not differ among patients. Two patients (4.3 %) died during hospitalization. The need for plastic reconstructive surgery was significant (p < 0.05) among patients with unsuccessful revascularization. 35 out of 41 patients (85 %) without problems of graft anastomosis during CABG (successful revascularization) were associated with mild PSM, whereas only 6 out of 41 patients (15 %) with successful revascularization during CABG required plastic reconstructive surgery (p < 0.05). Technical failure of graft anastomosis (3 cases) or poor outflow of internal thoracic artery (2 cases) were statistically associated with severe PSM. CONCLUSION: Technical failures of revascularization during CABG may delay recovery from PSM.     

The return of clinically evident ischemia after coronary artery bypass grafting.

Although survival after coronary artery bypass grafting (CABG) is the most serious outcome information, the quality of life in living patients is largely determined by the freedom from ischemic events. The return of angina, acute myocardial infarct and sudden death were studied in a large (n = 5880) population of patients undergoing CABG between 1971 and 1987. The freedom from angina pectoris was 95%, 83% and 63% at 1, 5 and 10 years, respectively, after surgery. Early return of angina was related to both procedure incremental risk factors (incomplete revascularization and non-use of the internal mammary (thoracic) artery (IMA) as a conduit) and patient incremental risk factors (aggressiveness of the atherosclerotic process and severity of preCABG symptoms). Late angina return was related to patient risk factors including coexisting factors (hyperlipidemia and hypertension), preCABG symptom severity and gender (female). The freedom from an acute fatal or non-fatal postCABG myocardial infarct was 99%, 96% and 85% at 1, 5 and 10 years after surgery. The incremental risk factors for early infarction were related to incomplete revascularization, but late infarction was related to lipid levels, coexisting diseases (diabetes, positive family history) and non-use of IMA to LAD. The freedom from sudden death was 99.8%, 99% and 97% at 1, 5 and 10 years, respectively, after surgery. The incremental risk factors were dominated by the severity of the left ventricular dysfunction. The freedom from any ischemic event (any of the previous three) was 93%, 79% and 54% at 1, 5 and 10 years, respectively, after surgery. The incremental risk factors included all those cited above for the specific components. Patient-specific predictions validate the influences of these risk factors. They demonstrate that unlike the profound influence of the use of the IMA on survival, there is little benefit of the use of the IMA on return of ischemic events over and above the effect of revascularization per se. The study demonstrates that most patients will experience return of ischemic symptoms within a period of 15-20 years after surgery, but that this is most likely to be return of angina and rarely sudden death.     

Immediate and long-term results of coronary artery bypass operation in hemodialysis patients

This study evaluated the early and late results of coronary artery bypass grafting (CABG) in patients on long-term maintenance hemodialysis (chronic HD) at Teikyo University Ichihara Hospital between January 1996 and June 2000. Thirty-six patients on chronic HD underwent CABG. There were 26 males (72%) and 10 females (28%) ranging from 41 to 81 years (mean +/- SD, 61.8 +/- 9.2 years) of age. Twenty-one patients (58%) had unstable angina, 14 (39%) stable angina, and 1 acute myocardial infarction. Eleven patients (31%) had urgent or emergency CABG. The average graft number was 2.5 +/- 0.8 (arterial graft 1.3 +/- 0.7/patient). Six patients had concomitant cardiac operations. Three patients underwent re- or a second re-CABG. Five patients underwent off-pump CABG. Principally, HD was performed during cardiopulmonary bypass and was followed by continuous hemodiafiltration in the early postoperative period. The early mortality was 11%; 25% in emergency and urgent CABG and 4% in elective CABG. In the follow-up period between 1 and 53 months (mean +/- SD 21.9 +/- 15.1 months), 4 patients died, and 9 patients developed recurrence of angina pectoris (6, occlusion of saphenous vein graft and 3, native coronary progression). Six patients had coronary intervention. The postoperative angiogram showed that all arterial grafts were patent, but the patency of the vein grafts was only 61.5%. The early results of CABG in patients on chronic HD was satisfactory. The late recurrence of angina pectoris mostly was caused by occlusion of the saphenous vein graft. In conclusion, the aggressive use of arterial grafts is crucial in CABG for patients on chronic HD.     

Reinterventions for recurrent ischemic heart disease following a successful first re-do myocardial revascularization: predictors, indications and results.

Predictors for a reintervention following a successful first re-do surgical revascularization (CABG) were examined. Success and limitations of the reintervention procedures were evaluated. Between 3/88 and 3/95, 16.81% (302/1796) patients who had undergone a first re-do CABG surgery in the authors' center, required a reintervention. Graft angioplasty was performed in 158 (52.32%) patients and a second re-do CABG in 47.68% (n = 144). Graft angioplasty was preferred over surgery in patients aged 70 years or older (43% versus 24.3%, P<0.001) and in patients with unstable angina (55.6% versus 33.3%, NS) or a Left Ventricular Ejection Fraction (LVEF) <30% (34.8% versus 20%, P<0.05). Re-do CABG was preferred over graft angioplasty for multivessel revascularization (3+/-0.3 versus 1+/-0.6, P<0.001), proximal occlusive disease (P<0.001) and for graft disease of a longer duration (7.18+/-1.7 years versus 3+/-0.6 years, P<0.01). The independent predictors of a reintervention were (i) lack of arterial revascularization and (ii) inability to achieve a complete revascularization in a previous operation. The predictors of a failed graft angioplasty were diameter stenosis >70%, long occlusive lesions (multivariate), angulation, calcification and asymmetrical lesions (univariate). Failed graft angioplasty required a re-do CABG (n = 48: early 21, late 27), repeat graft angioplasty (n = 34: early 8, late 26) or transplant (n = 1). Recurrent symptoms following a second re-do CABG required a graft angioplasty (n = 6: early 2, late 4), a subsequent re-do CABG (n = 32) or a transplant (n = 4). Cumulative incidence of cardiac events at 1 month, and 1 and 8 years were: 20, 40.45 and 66.44% following graft angioplasty and 5.5, 10 and 56.55% following a second re-do CABG, respectively (P<0.05). Actuarial survival at 1 month and 6 years following graft angioplasty were 97.15 and 77.22%, and 94.7 and 83.26% after a second re-do CABG, respectively (NS). Re-do CABG was more effective and durable. Graft angioplasty provided a good palliation in suitable cases and also postponed the need for a high-risk surgical intervention for more favorable conditions.     

Percutaneous transluminal angioplasty of a constricting coronary artery bypass graft: a case report

A case with percutaneous transluminal coronary angioplasty (PTCA) for the stenosis of saphenous vein bypass graft was reported. A 68-year-old woman developed repeated effort angina two months after emergency triple CABG. Coronary angiographic study revealed 90% stenotic lesion in a sequential vein graft which was located between proximal and distal OM. PTCA was successful to dilate the stenotic lesion from 90% to 25% narrowing. She has been free from angina after the CABG and PTCA.     

Die Bedeutung der SYNTAX-Studie für die moderne Koronarchirurgie

Coronary artery bypass graft surgery (CABG) is still considered to be the standard of care for patients with a prognostically relevant pattern of coronary artery disease. New stent designs, including drug-eluting stents (DES) and improvements in percutaneous coronary intervention (PCI) technologies during recent years, challenge CABG in the treatment of coronary three-vessel disease and/or left main stem stenosis. To date, randomized trials have demonstrated significantly higher repeat revascularization rates in PCI patients but comparable results regarding procedural and mid-term survival as well as adverse events like myocardial infarction. In contrast, real world registry data demonstrated a survival benefit of CABG over PCI as the primary treatment option. Recently, 2-year results of the largest comparative randomized trial to date, the SYNTAX trial, were made available. These data demonstrated the superiority of CABG over PCI regarding the combined endpoint of death and major adverse cardiac and cerebrovascular events, including repeat revascularization. There were comparable results in patients with less complex coronary artery disease between PCI and CABG, while patients with more complex coronary pathologies had significantly better results after surgical intervention. These results have led to controversies in all major medical societies and have resulted in intensive and ongoing guideline discussions.     

The morbidity and mortality of reoperation for coronary artery disease and analysis of late results with use of actuarial estimate of event-free interval

To determine late survival and functional status after second revascularization procedures for coronary artery disease, we studied 106 consecutive patients operated on between June, 1969, and December, 1980. The mean age of the 96 men and 10 women was 49 +/- 8 years (range 22 to 65 years). Before reoperation, 101 patients (95%) were judged to be in New York Heart Association Class III or IV with angina, and 81 patients (76%) had three-vessel involvement. Angina recurrence was most commonly caused by bypass graft occlusion alone and in combination with progressive disease of the native arteries (60 patients, 57%). Three patients (2.8%) died within 30 days of reoperation; each death resulted from myocardial infarction. An average of 2.2 coronary arteries were bypassed in each patient. Complete follow-up data (mean 43 months) were available for 105 patients. Actuarial survival of patients dismissed alive is 94% at 5 years and 89% at 7 years. All late cardiac-related deaths occurred in patients with three-vessel disease. When recurrence of any angina, need for a third operation, and myocardial infarction are included with cardiac-related deaths, event-free survival is 28% at 5 years and 26% at 7 years. Late survival and functional status could not be predicted by the cause of recurrent angina or the presence of risk factors. Repeat myocardial revascularization can apparently be undertaken with low risk and with prospects for excellent long-term survival. After reoperation, recurrence of mild angina is not uncommon, but freedom from serious cardiac events and relief of severe symptoms were noted in more than 60% of patients 5 years later.