Does use of aprotinin in coronary artery bypass graft surgery affect graft patency?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether use of aprotinin in coronary artery bypass graft surgery adversely affects graft patency. Altogether 45 papers were identified using the below mentioned search, of which 10 presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that aprotinin clearly reduces blood loss, requirement for blood transfusion, and the risk of reoperation for bleeding, but does increase the risk of saphenous vein graft occlusion.     

Radial artery in CABG: could the early results be comparable to internal mammary artery graft?

Background. The accidental detection of patency of radial artery grafts, by Acar, which had been labeled as blocked 18 years earlier, has led to its revival as a conduit in coronary artery bypass surgery. We used radial artery as one of the grafts in 287 patients from February 1996 to June 1998. Here we present our early clinical experience and the midterm angiographic follow up of the initial 62 patients.

Methods. A no touch, atraumatic harvesting technique coupled with gentle hydrostatic and pharmacological dilatation of the radial artery graft was employed. Radial artery was used to revascularize coronary vessels with >80% proximal stenosis. Postoperatively, the patients were administered a low dose nifedipine that was continued for 6 months thereafter. The patients were followed up clinically after discharge from the hospital and angiographic evaluation of the grafted radial artery by selective injection was done at a mean interval of 16.2 ± 5.1 months (3–24 months) postoperatively.

Results. There was no perioperative or late myocardial infarction or mortality. No significant complications related to the harvesting of radial artery were encountered. Angiographically, the radial artery grafts were found to be patent in 96.8% of patients (60/62). Mild distal anastomotic narrowing was seen in angiogram of one patient with good filling of the target vessel. Another patient showed diffuse spasm of radial artery graft. The patency of the pedicled left internal mammary grafts was also 98.2% (56/57). All the patients were asymptomatic.

Conclusions. Radial artery seems to be an excellent alternate arterial conduit for myocardial revascularization with early and midterm patency rates equivalent to that of pedicled internal mammary artery, and it should be used more often for myocardial revascularization as an adjunct to pedicled internal mammary artery graft.     

Does the radial artery provide better long-term patency than the saphenous vein?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether the radial artery provides better long-term patency than the saphenous vein. Altogether 379 papers were found using the reported search, of which 12 presented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We concluded that there is evidence that radial artery grafts have a higher rate of patency than saphenous vein grafts. Surgeons can confidently use the radial artery as a second arterial bypass graft, particularly in patients with severe native-vessel stenosis.     

Abnormal duplex findings at the proximal anastomosis of infrainguinal bypass grafts: Does revision enhance patency?

Using color duplex ultrasound (CDU) surveillance of autogenous infrainguinal bypasses, a peak systolic flow velocity (PSFV) ratio of greater than 3 to 1 within the graft relative to adjacent PSFV has been accepted as predicting significant stenosis mandating revision. At the proximal anastomosis, where significant vessel diameter differences and turbulent flow exist, the validity of these criteria is less clear. Our purpose was to review our experience with proximal anastomotic abnormalities in a CDU surveillance protocol. Routine CDU surveillance for all infrainguinal bypass gratis consisted of evaluation in an accredited vascular laboratory at 1 month postoperatively, every 3 months for the first year, every 6 months in the second year, and annually thereafter. Grafts with a PSFV ratio of > 3 at the proximal anastomosis on any CDU study were included in this review. From our results we conclude that currently accepted CDU criteria for graft-threatening stenosis may not be valid for abnormalities at the proximal anastomosis of infrainguinal grafts. Regression of these abnormalities is common. Better CDU criteria are needed for predicting not only severity of proximal anastomotic stenosis but also likelihood of graft thrombosis. Presented at the Twenty-fifth Annual Meeting of the Peripheral Vascular Surgery Society, Toronto, Ontario, Canada, June 10, 2000.     

Incidentally detected stenoses proximal to grafts originating below the common femoral artery: do they affect graft patency or warrant repair in asymptomatic patients?

OBJECTIVE: Stenoses in infrageniculate arteries proximal to a lower extremity vein graft may reduce flow velocity through the bypass graft and are thought to predispose to graft occlusion. Repair of these lesions has been recommended to preserve graft function. This study was undertaken to better define the natural history of grafts below inflow lesions and to evaluate the necessity of repair to preserve graft patency. METHODS: From 1994 through 1999, patients undergoing lower extremity vein grafts by a single surgeon at a university hospital and an affiliated teaching hospital were placed in a prospective protocol for proximal infrageniculate native artery and graft surveillance through use of duplex scanning. The records of those patients with grafts originating distal to the common femoral artery were evaluated; they form the basis for this report. Arteriograms were obtained before bypass grafting, and no patient had a stenosis greater than 50% diameter reduction proximal to the graft origin. Follow-up scans were obtained from the common femoral artery through the graft and outflow artery. The peak systolic velocity and velocity ratio in an infrageniculate native artery proximal to the graft origin were recorded, as were the location and the time interval since the bypass graft. Repair of these proximal lesions was not performed during the course of this study. Revision of the bypass graft or its anastomoses was undertaken according to preestablished duplex scan criteria. RESULTS: During this time, 288 autogenous infrainguinal bypass grafts were performed, of which 159 originated below the common femoral artery; of these, 74 were from the superficial femoral artery, 29 from the profunda femoris artery, 49 from the popliteal artery, and 7 from a tibial artery. The maximum peak systolic velocity proximal to the graft origin was more than 250 in 38 arteries (25%) and more than 300 in 26 arteries (16%). The velocity ratio was 3.0 or more in 32 arteries at the same location as the peak systolic velocity and 3.5 or more in 23 arteries (15%), confirming hemodynamically significant stenoses at these sites. The location of peak systolic velocity was the common femoral artery in 81 patients (51%), the superficial femoral artery in 50 (31%), the popliteal artery in 22 (14%), and a tibial artery in 6 (4%). Follow-up ranged from 8 to 60 months (mean, 35 months). During follow-up, 19 patients died, 18 with patent grafts. Overall, nine grafts occluded. One of the occluded grafts had a velocity ratio greater than 3.0; this may have contributed to graft thrombosis. The other occlusions resulted from an unrepaired graft lesion in 2 patients, graft infection in 2 patients, and graft ligation necessitated by below-knee amputation in 2 patients. No cause for the occlusion could be identified in two of the grafts (neither had evidence of proximal arterial stenosis). Assisted primary patency rates were 95% and 91% at 3 and 5 years, respectively. CONCLUSIONS: For grafts originating distal to the common femoral artery, stenoses proximal to the graft do not affect bypass graft patency and do not require repair to prevent graft occlusion. Surveillance of these lesions may therefore be unnecessary, inasmuch as the repair of proximal lesions should not be undertaken to preserve graft function.     

Does obesity affect the results of lumbar decompressive spinal surgery in the elderly?

The prevalence of obesity among the population is increasing, including in many elderly people. The purpose of this study was to evaluate whether lumbar spinal surgery in elderly patients with different body mass indices influences pain, satisfaction rate, and activities of daily living. Two hundred ninety-eight elderly patients (older than 65 years), 153 women and 145 men, who had decompressive laminectomy, discectomy, or combinations of these procedures during 1990 to 2000 were followed up. Indications for surgery included limitation in doing activities of daily living, severe pain, or both. The patients were classified into one of four categories in terms of their body mass index. The operative parameters, pain reduction, satisfaction rate, and activities of daily living using the Barthel index were assessed. The more obese patients were younger, tended to be female, and were more symptomatic. All four groups of patients had reduction in pain, improvement in activities of daily living, and were satisfied with the operation. Our data suggest that it is reasonable to operate on patients who are elderly and obese and who have lumbar symptoms, with the appropriate indications.     

Does detrusor underactivity affect the results of transurethral resection of prostate?

International Urology and Nephrology - We aimed to evaluate the outcome of transurethral resection of the prostate (TURP) in patients with benign prostatic hyperplasia (BPH) and diagnosed to have...     

Use of the radial artery graft after transradial catheterization: is it suitable as a bypass conduit?

BACKGROUND: The suitability of the radial artery after transradial catheterization as a bypass conduit has been of great concern to surgeons. METHODS: A total of 67 patients underwent isolated coronary artery bypass grafting using the radial artery: 22 patients received preoperative transradial catheterization (group 1) and 45 patients did not receive transradial catheterization (group 2). Those patients were retrospectively reviewed. RESULTS: Patient characteristics, operative procedures, and early clinical outcome were not different between groups. The stenosis-free graft patency rates in groups 1 and 2 were 88% (16 of 18 patients) and 90% (38 of 42 patients) in the left internal thoracic artery (p = 0.87); 77% (17 of 22 patients) and 98% (48 of 49 patients) in the radial artery (p = 0.017); and 87% (13 of 15 patients) and 84% (21 of 25 patients) in the saphenous vein (p = 0.42), respectively. Intimal hyperplasia of the radial artery was observed in 68% (11 of 16 patients) in group 1 and in 39% (14 of 34 patients) in group 2 (p = 0.046). CONCLUSIONS: Transradial catheterization reduced early graft patency and caused intimal hyperplasia, although it did not affect early clinical outcomes. We suggest that the use of the radial artery as a bypass conduit after transradial catheterization should be undertaken cautiously.     

Does the duration of surgery affect outcomes in patients undergoing coronary artery bypass grafting?

Background

Numerous predictors of coronary artery bypass grafting (CABG) outcomes have been identified. We aimed to determine whether the duration of surgery independently predicts outcome in patients undergoing CABG.

Methods

We retrospectively reviewed data from 337 patients (mean age 62 ± 7 years) who underwent CABG consecutively at our institution between January 2005 and December 2006.

Results

Duration of surgery correlated positively with length of both surgical intensive care unit (SICU) stay (r = .147, P = .004) and ventilator support (r = .097, P = .038) in univariate analysis, but only with length of SICU stay (P = .01) in a multivariate logistic regression after confounding factors were controlled for in the model. The regression coefficient was .006; every additional 30 minutes of surgery time was associated with 4.32 more hours of SICU stay. Duration of surgery was not associated with survival (P > .05).

Conclusions

Although duration of surgery did not affect short-term survival after CABG, surgical duration independently predicted length of SICU stays. Efforts to reduce the length of operations may promote more efficient use of hospital resources.     

Does the right internal thoracic artery or saphenous vein graft offer superior revascularization of the right coronary artery?

A best evidence topic was written according to a structured protocol. The question addressed was whether the right internal thoracic artery (RITA) provides a superior outcome for revascularization of the right coronary artery (RCA) compared with the saphenous vein graft (SVG). Using a designated search strategy, 226 articles were found, of which five represented the best available evidence. The authors, journal, date, country of publication, study type, patient group studied, relevant outcomes and results were tabulated. Of these five studies, one offered level I evidence (data from a randomized trial) and four were level II studies (reports of observational data). The outcome measures varied considerably, but most included graft patency at varying levels of the follow-up. The randomized data showed strong evidence favouring the SVG, mainly in terms of mid-term patency. With the exception of a large cohort study that demonstrated the superior patency of the RITA compared with the SVG in the right coronary territory, the observational studies showed better results for SVG in graft patency, reintervention and cardiovascular complication rate. Overall, and in view of the methodological limitations and the different weight of evidence among studies, it appears that the SVG may offer a superior outcome for revascularization of the RCA when compared with the RITA.     

Does intensive perioperative dialysis improve the results of coronary artery bypass grafting in haemodialysed patients?

BACKGROUND: Between January 1996 and April 1998, 17 chronic haemodialysed patients underwent coronary artery bypass grafting (CABG). Two of them simultaneously had valve replacement. METHODS: Except for two cases in which CABG was performed in an emergency, 15 patients (CRF group) received 3 consecutive days of haemodialysis in the preoperative period, intraoperative haemodialysis connected to cardiac pulmonary bypass (CPB) and continuous hemodiafiltration in the early postoperative period. The perioperative clinical parameters of the CRF group were compared with those of 17 age-matched patients with normal renal function undergoing CABG as the control (NRF group). RESULTS: When the perioperative variables were compared, no significant differences were seen in total operation time and CPB time, but we noted significant increases in the mean volume of transfused blood in the 6 perioperative days, postoperative intubation time, postoperative fasting time, and time spent in the intensive care unit. Levels of central venous pressure, systolic blood pressure, respiratory index (PaO2/FiO2) and daily fluid balance of the CRF group were the same as the control group in the early postoperative period. In addition, the levels of serum creatinine, urea nitrogen, potassium and hematocrit of CRF group remained almost constant in the early postoperative period. After all, the hospital morbidity of the CRF group was not more serious than that of the NRF group, and hospital mortality of the CRF and NRF groups was 0%. CONCLUSIONS: Our intensive perioperative dialysis programme could successfully manage the perioperative clinical course of haemodialysed patients undergoing CABG.     

Is the mid-term outcome of free right internal thoracic artery with a proximal anastomosis modification inferior to in situ right internal thoracic artery?

Background

We investigated the mid-term results of free right internal thoracic artery (RITA) grafts used in an aorto-coronary fashion with a modified proximal anastomosis.

Methods

The subjects were 214 patients who underwent coronary artery bypass grafting with anastomosis to the left circumflex arteries using the RITA as a free graft (Group A: 158 patients) or an in situ graft (Group B: 56 patients). In Group A, the proximal end of the free RITA was anastomosed onto the ascending aorta interposing free graft tissue or to part of its own tissue as a cuff.

Results

The number of RITA anastomoses was 1.38?±?0.50 in Group A and 1.04?±?0.19 in Group B (P?P?=?0.159), however, the number of cardiac events was decreased in Group A (Hazard Ratio 2.55, 95?% CI 1.03?C6.33, P?=?0.043). The graft patency was evaluated in 187 of 214 patients, and at 1, 3 and 5?years was 97.0, 97.0 and 97.0?% in Group A, and 97.9, 92.5 and 80.5?% in Group B (P?=?0.378), respectively.

Conclusion

By modifying the proximal anastomosis of the free RITA, cardiac events may be decreased, while survival and graft patency comparable with in situ RITA can be obtained, and a significantly larger number of targets can be revascularized.