Myocardial revascularization in patients with end-stage renal disease: Comparison of percutaneous transluminal coronary angioplasty and coronary artery bypass grafting

Background: Ischemic heart disease is the major cause of death inpatients with end-stage renal disease. The high prevalence of coronary artery disease results in a rising number of dialysis patients requiring myocardial revascularisation. Objective: The objective of this study was to compare the outcomes of recurrent angina, myocardial infarction, rate of reinterventions and cardiovascular death following percutaneous coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG) inpatients with end-stage renal disease. Patients and methods: In a retrospective investigation 40 patients with chronic renal failure undergoing primarily PTCA and 65 patients undergoing CABG were included. Both groups were comparable for gender, duration on dialysis and the number of cardiovascular risk factors per patient. Patients undergoing PTCA were younger (53 ± 12 years vs. 57 ± 8 years; p < 0.05) and more often diabetics (30% vs. 14%; p < 0.05). Results: Most patients in both groups had a multi-vessel disease (95% in the CABG group vs. 74% in the PTCA group), in the CABG group there were significantly more patients with a triple-vessel disease (62% with vs. 40%in the PTCA group; p < 0.01), PTCA was primarily successful in 95% of the patients while complete revascularization was achieved in 88% of patients undergoing CABG. The perioperative mortality after CABG was 4.8% as compared to none after interventional revascularisation. The cumulative freedom of angina after 6, 12 and 24 months after intervention was significantly lower after PTCA (54%, 40%, 29%) than after bypass grafting (97%, 94%, 90%, p < 0.001). The frequency of reinterventions following PTCA was significantly higher compared to patients following CABG (p < 0.001). After PTCA 15 patients needed further revascularisations, 8 of them underwent CABG, whereas after CABG only two patients required additional myocardial revascularisation. There was no significant difference in the overall mortality between both groups; the survival rate after 12 and 24 months was 95% and 82% after PTCA and 93% and 86% after CABG, respectively. Condition: Although patients receiving CABG had a more severe coronary artery disease the overall mortality was comparable and clinical and functional outcome was improved compared to patients after coronary angioplasty. This revised version was published online in June 2006 with corrections to the Cover Date.     

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.     

Surgical treatment of thoracic aortic aneurysm in patients with concomitant coronary artery disease.

OBJECTIVE: Surgical treatment of thoracic aortic surgery in patients with coronary artery disease was investigated. METHODS: Between 1990 and April 2003, 330 patients underwent elective thoracic aortic surgery. Fifty-six patients who underwent aortic root reconstruction were excluded and 274 patients were examined. Fifty-four (20%) patients showed concomitant coronary artery disease. Ten had undergone coronary revascularization previously; and 3 underwent coronary revascularization [2 coronary artery bypass grafting (CABG), 1 percutaneous transluminal coronary angioplasty (PTCA)] before aortic surgery. Twenty-three patients underwent elective CABG simultaneously and 2 patients had additional coronary artery bypass because of cardiac ischemia during operation. The number of patients who underwent thoracic aortic surgery including Asc Ao+AVR was 2, hemi arch 1, total arch 15, distal arch 5, distal arch+LV aneurysmectomy 1, and thoracoabdominal Ao 1. Two patients underwent coronary revascularization with arterial grafts and the others with SVG grafts. RESULTS: There was one hospital death (4%). In patients without coronary bypass, 2 patients suffered cardiac ischemic events. CONCLUSION: Our thoracic aortic operations with concomitant CABG using SVG were overall successful. Our current strategies for thoracic aortic surgery in patients with concomitant coronary artery disease include conducting a dipyridamole myocardial perfusion-imaging test first in patients not at risk of coronary artery disease, and if the test is positive, coronary angiography is performed and aggressive coronary revascularization is conducted where possible.     

Emergency surgery after unsuccessful coronary angioplasty: a review of 15 years' experience

BACKGROUND: Emergency coronary artery bypass grafting (CABG) is occasionally necessary for failed percutaneous transluminal coronary angioplasty (PTCA). The aim of this study was to assess the outcome of patients receiving emergency CABG after unsuccessful PTCA over a 15-year study period. METHODS: From January 1982 through December 1996, 74 patients underwent emergency CABG after unsuccessful PTCA (crash group). This group was compared with a matched group of 74 patients having primary elective CABG (control group). RESULTS: All 74 crash group patients were to have PTCA of one coronary system. After PTCA failure, 58 patients (78.3%) developed electrocardiographic changes of evolving acute myocardial infarction (AMI). The overall rate of AMI was 8.1% for the crash group and 2.7% for the control group. Two patients in the crash group died, with no deaths in the control group. There was no significant difference between mean in-hospital length of stay. CONCLUSIONS: With prompt, aggressive, and complete myocardial revascularization, patients who required emergency CABG after PTCA failure had an outcome not significantly different from that of patients having elective CABG.     

Revascularization after thrombolytic therapy for acute myocardial infarction: an analysis of 573 patients

From October, 1981, to January, 1987, at our center, 891 patients received streptokinase within 6 hours of acute myocardial infarction. A total of 318 patients were treated medically, while 388 patients (43.5%) underwent coronary artery bypass grafting (CABG) alone and 185 (20.7%) were treated with percutaneous coronary angioplasty (PTCA). Subsequent CABG was performed in 37 of 185 PTCA patients after unsuccessful angioplasty. Group characteristics were similar. However, multiple-vessel coronary artery disease was present in 70.3% of CABG patients compared with 24.1% in the PTCA groups. Procedure mortality was 3.6% for CABG alone, 5.4% for PTCA alone, and 13.5% for the combined angioplasty and operation group (p less than 0.05 compared with CABG). All deaths in the PTCA group with subsequent CABG occurred in those patients taken emergently to CABG (5 of 20 patients). We conclude that with proper patient selection both forms of revascularization are safe and effective. However, emergency coronary bypass surgery in the event of failed angioplasty has a high risk.     

Outcome After Myocardial Revascularization and Renal Transplantation: A 25-Year Single-Institution Experience

BACKGROUND AND OBJECTIVE: Cardiac disease is a common cause of death in renal transplant recipients. This study retrospectively analyzes the results of myocardial revascularization procedures in these patients and makes recommendations for managing coronary atherosclerosis in patients with renal disease who already have a transplanted kidney or who may receive a kidney transplant. METHODS: Patients who had myocardial revascularization (coronary artery bypass grafting [CABG] or percutaneous transluminal coronary angioplasty [PTCA]) and renal transplantation at the authors' institution between 1968 and 1994 were analyzed. Patient, procedural, and institutional variables were used for actuarial analyses of survival, as well as multivariate analyses of risk factors for death. RESULTS: Eighty-three of 2989 renal transplant patients required myocardial revascularization either before or after their transplant, and diabetes mellitus was the cause of renal failure in 42% of these patients. Standard coronary angiography, CABG, and PTCA techniques were used without periprocedural renal allograft loss. Actuarial patient survival was 89%, 77%, and 65% at 1, 3, and 5 years after the last procedure (transplantation or revascularization). Cardiac disease was the most common mode of death. Early-phase risk factors for death by multivariate analysis included hypertension and revascularization before 1989. Late-phase risk factors for death included diabetes mellitus, higher number of pre-CABG myocardial infarctions, renal transplantation before 1984, older age, and unstable angina before CABG. CONCLUSIONS: Myocardial revascularization can be performed with acceptable short- and long-term results in patients with renal disease who have renal transplantation either before or after the revascularization procedure. Diabetes mellitus was a highly prevalent condition among these patients, and cardiac disease was their most common mode of death. PTCA and CABG, as performed at this institution, posed little risk for renal allograft loss. Modification of risk factors for coronary atherosclerosis, rigorous cardiac evaluation of patients at risk for coronary artery disease before renal transplantation, and aggressive use of revascularization procedures to decrease the incidence of myocardial infarction are proposed as ways to prolong the survival of renal transplant patients with ischemic heart disease.     

Minimally invasive coronary artery bypass grafting decreases hospital stay and cost.

OBJECTIVE: The authors performed a retrospective cost analysis for patients undergoing revascularization of their left anterior descending (LAD) coronary artery either by standard coronary artery bypass grafting (CABG), percutaneous transluminal coronary angioplasty (PTCA), or minimally invasive coronary artery bypass grafting (MICABG). SUMMARY BACKGROUND DATA: Minimally invasive CABG has become a safe and effective alternative treatment for single-vessel coronary artery disease. However, the acceptance of this procedure as a routine alternative for the treatment of coronary artery disease will depend on both long-term graft patency rates as well as a competitive market cost. METHODS: The authors conducted a retrospective analysis of three patient groups undergoing LAD coronary revascularization from January 1995 to July 1996. Ten patients were selected randomly from this period after PTCA of an LAD lesion with or without stenting. Nine patients underwent standard CABG on cardiopulmonary bypass with a left internal mammary artery. Nine patients received MICABG via a limited left anterior thoracotomy and left internal mammary artery to LAD grafting without the use of cardiopulmonary bypass. RESULTS: Percutaneous transluminal coronary angioplasty (n = 10) was unsuccessful in two patients. One patient in the MICABG group (n = 9) was converted successfully to conventional CABG because of an intramyocardial LAD and dilated left ventricle. There was no operative morbidity or mortality in any group. Average length of stay postprocedure was decreased significantly for both the MICABG and PTCA groups when compared with that of conventional CABG (n = 9) (2.7 + 0.26, p = 0.009, and 2.6 + 0.54, p = 0.006, vs. 4.8 + 0.46, respectively). Total hospital costs for the MICABG and PTCA groups were significantly less when compared with those of standard CABG ($10,129 + 1104, p = 0.0028, and $9113 + 3,039, p = 0.0001, vs. $17,816 + 1043, respectively). There were no statistically significant differences between the MICABG and PTCA groups. CONCLUSIONS: The final role of minimally invasive CABG is unclear. This procedure is clearly cost effective when compared with that of PTCA and conventional CABG. The long-term patency rates for MICABG will determine its overall efficacy.     

Surgical treatment of thoracic aortic aneurysm in patients with concomitant coronary artery disease

Objective: Surgical treatment of thoracic aortic surgery in patients with coronary artery disease was investigated. Methods: Between 1990 and April 2003, 330 patients underwent elective thoracic aortic surgery. Fifty-six patients who underwent aortic root reconstruction were excluded and 274 patients were examined. Fifty-four (20%) patients showed concomitant coronary artery disease. Ten had undergone coronary revascularization previously; and 3 underwent coronary revascularization [2 coronary artery bypass grafting (CABG), 1 percutaneous transluminal coronary angioplasty (PTCA)] before aortic surgery. Twenty-three patients underwent elective CABG simultaneously and 2 patients had additional coronary artery bypass because of cardiac ischemia during operation. The number of patients who underwent thoracic aortic surgery including Asc Ao+AVR was 2, hemi arch 1, total arch 15, distal arch 5, distal arch+LV aneurysmectomy 1, and thoracoabdominal Ao 1. Two patients underwent coronary revascularization with arterial grafts and the others with SVG grafts. Results: There was one hospital death (4%). In patients without coronary bypass, 2 patients suffered cardiac ischemic events. Conclusion: Our thoracic aortic operations with concomitant CABG using SVG were overall successful. Our current strategies for thoracic aortic surgery in patients with concomitant coronary artery disease include conducting a dipyridamole myocardial perfusion-imaging test first in patients not at risk of coronary artery disease, and if the test is positive, coronary angiography is performed and aggressive coronary revascularization is conducted where possible.     

Percutaneous transluminal coronary angioplasty in patients with previous coronary artery bypass grafting]

Percutaneous transluminal coronary angioplasty (PTCA) has been used to treat patients with previous coronary artery bypass grafting (CABG). Seven patients with previous CABG underwent coronary artery or vein graft angioplasty following a recurrence of symptoms. Fifteen lesions were attempted in 7 patients. The primary angiographic success rate was 100%. The primary angiographic success rate was defined as reduction of a stenosis by at least 20% of the vessel diameter, leaving a stenosis of less than 60%. There were no complications following PTCA such as death or myocardial infarction. No patients were referred for urgent surgery. Three patients have undergone another PTCA after 3 months and remain well. All patients at follow-up continue to have improved symptoms. Our experience suggests that the patients with recurrence of coronary artery or bypass stenosis following CABG may be suitable for PTCA.     

Coronary Artery Bypass Following Percutaneous Transluminal Coronary Angioplasty

During a 4-year period, 286 patients underwent coronary artery bypass grafting (CABG) following percutaneous transluminal coronary angioplasty (PTCA). Seventy-three patients had single-vessel and 213 (74.5%) had multivessel coronary artery disease. Twenty-nine patients underwent PTCA because of an evolving acute myocardial infarction (MI). Forty-two patients had previously undergone 47 CABG procedures.One hundred fifteen patients underwent CABG on an emergency basis. Indications for emergency CABG after PTCA were prolonged chest pain (79.1%), worsening of coronary artery obstruction (59.1%), “current of injury” by electrocardiogram (31.3%), cardiogenic shock (27.8%), and, in a lesser incidence, ventricular fibrillation, coronary artery dissection (without obstruction), heart block, and intractable cardiac arrest. The 286 patients underwent 2.1 CABG procedures per patient with a thirty-day mortality of 6.3% (18 patients). The incidence of acute MI was 43.5 versus 4.1%; low cardiac output syndrome, 34.8 versus 7.0%; and operative death, 11.3 versus 2.9% in the emergency and nonemergency groups, respectively. Other significant predictors of operative death were previous CABG (16.7 versus 4.5%), multivessel coronary artery disease (8.0 versus 1.4%), and preoperative cardiogenic shock (15.6 versus 3.2%). Late follow-up reveals a mortality of 1.4% per year in those patients who were early survivors of CABG.     

PTCA of the left main stem following protective coronary artery bypass grafting

Percutaneous transluminal coronary angioplasty (PTCA) was performed in 14 patients with significant left main stem stenosis following protective coronary artery bypass grafting (CABG). The procedure was successful in 13/14 patients (93%), achieving a decrease in mean diameter stenosis from 74% +/- 7% to 31% +/- 12% (P less than 0.01). Accordingly, the absolute stenosis diameter increased from 0.9 mm +/- 0.3 mm to 2.4 mm +/- 0.5 mm (P less than 0.01). Dissection of the left main stem artery and a transient significant fall of blood pressure each occurred in one patient. No other serious complications were noted. Eight of 13 patients (62%) with successful PTCA underwent control angiography. Restenosis had occurred in 3 of 8 patients (38%) with total occlusion of the left main stem in 1 patient. All bypass grafts were found to be patent at follow-up. Clinical evaluation in all 14 patients revealed no serious events (death, myocardial infarction, repeat revascularization procedure) during a mean follow-up period of 27 months (range 6-39 months). PTCA of the left main stem following CABG can be considered a relatively safe and effective procedure with a marked restenosis-rate but beyond that, an uncomplicated long-term follow-up.     

Coronary Artery Bypass Surgery Versus Percutaneous Coronary Artery Intervention in Patients on Chronic Hemodialysis: Does a Drug‐Eluting Stent Have an Impact on Clinical Outcome?

Abstract   Coronary revascularization methods continue to be refined, and the emergence of the drug-eluting stent (DES) has especially changed clinical practice related to ischemic heart disease. For chronic hemodialysis (HD) patients, however, the impact of DES on clinical outcome is yet to be determined. Forty-six consecutive chronic HD patients who underwent myocardial revascularization in our institute were retrospectively reviewed. Twenty-eight patients underwent coronary artery bypass surgery (CABG) and 18 patients underwent percutaneous coronary artery intervention (PCI). Patient characteristics were similar between the two groups. In the CABG group, bilateral internal thoracic artery (ITA) bypass grafting was performed in 27 patients and off-pump CABG was performed in 20 patients. In the PCI group, a DES was used in 12 patients. The number of coronary vessels treated per patient was higher in the CABG group (CABG: 4.25 ± 1.32 vs. PCI: 1.44 ± 0.78; p < 0.001). Two-year survival rates were similar between the two groups (CABG: 94.1% vs. PCI: 73.9%; p = 0.41), but major adverse cardiac event-free survival (CABG: 85.9% vs. PCI: 37.1%; p = 0.001) and angina-free survival (CABG: 84.9% vs. PCI: 28.9%; p < 0.001) rates were significantly higher in the CABG group. The one-year patency rate for the CABG grafts was 93.3% (left ITA: 100%, right ITA: 84.6%, sapenous vein: 90.9%, gastro-epiploic artery: 100%), and six-month restenosis rate for PCI was 57.1% (balloon angio-plasty: 75%, bare metal stent 40%, DES: 58.3%). Even in the era of DES, clinical results favored CABG. The difference in clinical results is due to the sustainability of successful revascularization.     

Surgical revascularization following unsuccessful percutaneous transluminal coronary angioplasty

From September, 1980, through August, 1981, 353 patients underwent attempted percutaneous transluminal coronary angioplasty (PTCA). Twenty-seven patients (7.6%) subsequently underwent elective myocardial revascularization without death or complicating PTCA. Surgical support in the first 2 months involved a fully-staffed operating room standing idle. During the last 10 months, patients requiring emergency revascularization were accommodated in the first operating room available. All 17 patients undergoing emergency revascularization had severe chest pain and 12 patients had ST-segment elevation on the electrocardiogram. The average time from onset of ischemia to revascularization was 135 minutes and did not change over the period of study. Improvement in the electrocardiogram and myocardial function were frequently noted with restoration of flow by the vein graft. Two patients (12%) required inotropic drug support following revascularization. All 12 patients with ST-segment elevation preoperatively had elevated myocardial enzyme levels postoperatively, including five patients (29%) with new Q waves on the electrocardiogram. Myocardial necrosis did not correlate with time to revascularization, number of diseased vessels, the artery being instrumented, the mechanism of ischemia, or the presence of collateral flow. There were no deaths. Because of the high incidence of myocardial infarction despite prompt revascularization, we now routinely insert the intra-aortic balloon pump in the catheterization laboratory in patients with refractory myocardial ischemia requiring emergency revascularization. Prompt safe revascularization for acute ischemia following PTCA can be achieved without expensive and inefficient standby of cardiac surgical facilities. Transmural myocardial ischemia following complicated PTCA is frequently associated with evidence of myocardial necrosis despite prompt surgical revascularization. Greater salvage of ischemic myocardium may be possible if the intra-aortic balloon pump is used in the interval between PTCA-induced injury and surgical revascularization.     

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.     

Comparative study of CABG following PTCA and PTCA following CABG]

Forty-five cases of PTCA with prior CABG and 14 cases of CABG with prior PTCA were studied on their pathogenesis and results. Ninety-four PTCA procedures were performed electively after CABG on 45 patients and 145 lesions. Lesion success rates were 95.8% in stenosis and 55.6% in occluded vessel. The mortality was none and no emergent surgery was needed. Causes of PTCA following CABG included the progression of coronary artery disease (13.1%), graft stenosis (15.0%), graft occlusion (31.0%), incomplete revascularization (13.8%), restenosis after the initial procedure (26.2%). Especially percentage of the progression of coronary artery disease was increased with a lapse of time, and it was 31.7% in PTCA group over 3 years after CABG. Fourteen patients with prior PTCA were received CABG because of unsuccessful PTCA (50.0%), progression to LMCD (21.4%), restenosis (21.4%), and PTCA complication (7.1%). Both interventions were appropriate and useful to reduce the recurrent ischemia and cardiac events with each other. Myocardial revascularization should not be considered either PTCA or CABG, but PTCA and CABG. In conclusion the strategy that much more benefits can be obtained from supplementary use of PTCA and CABG makes it possible to reduce the mortality and morbidity associated with intervention.     

Emergency aorto-coronary bypass grafting following complications of coronary angioplasty

Acute myocardial ischaemia during percutaneous transluminal coronary angioplasty (PTCA) and allied procedures often necessitates emergency coronary artery bypass grafting (CABG). Between July 1987 and December 1993, a total of 1221 patients underwent PTCA for occlusive coronary artery disease. Twentytwo (1.8%) of them required emergency CABG for various complications. The most common complications leading to emergency CABG were intimal dissection and acute occlusion. Sixteen (72.7%) of these 22 patients were haemodynamlcally unstable when received in the operation suite. Seven of them were on percutaneousfemorofemoral cadiopulmonary bypass support, three on external cardiac massage and six supported with inotropes. The remaining six patients were haemodynamically stable. There were eight (36.3%) deaths, all in the haemodynamically unstable subset of patients. This study suggests that for better outcome from emergency CABG following complications of angioplasty, patient needs to be referred for surgery early while haemodynamics are still stable. Persistence with nonsurgical caiheter manoeuvres to treat ischaemia following an angioplasty complication results in inordinate delay leading to haemodynamic instability, the latter predicting a poor prognosis following emergency CABG.     

Overview: Japanese guidelines for myocardial revascularization to treat stable ischemic heart disease 2012

Since its introduction in the early 1970s, coronary artery bypass grafting (CABG) has become an established surgical treatment for coronary artery disease (CAD). Percutaneous coronary intervention (PCI), first clinically applied in 1977, was promoted as an alternative to CABG during the mid-1980s. Along with the nationwide expansion of PCI, the ratio of PCI to CABG has exceeded 6–7:1. The Japanese Circulation Society (JCS) published “Guidelines on elective coronary intervention, including coronary artery bypass grafting (CABG), for ischemic heart disease in 2000” and “Guidelines on the selection of bypass conduits and operative procedures in coronary artery bypass grafting for ischemic heart disease”. The society intended to revise these guidelines in 2010 and to issue two new guidelines specific either to PCI or CABG. They also planned to issue joint guidelines for myocardial revascularization and PCI/CABG, which are primary indications for patients with stable CAD, especially with those with more complex left main trunk disease and/or multi-vessel disease. The scientific committee of JCS established the “Council for myocardial revascularization” that consisted of experts including interventional and non-interventional cardiologists, cardiac surgeons and physicians specialized in diabetes or nephrology selected by medical and surgical societies. After over 10 rounds of meetings, the Council prepared primary guidelines for myocardial revascularization to treat stable CAD, PCI/CABG. These guidelines consist of (1) Statements about myocardial revascularization, (2) Interpretation of the statements and (3) Indications for PCI/CABG including a table.     

European criteria for the appropriateness and necessity of coronary revascularization procedures.

OBJECTIVES: Large variations in the use of coronary revascularization procedures have led many countries to apply the RAND appropriateness method to develop specific criteria describing patients who should be offered these procedures. The method is based on the work of a multidisciplinary expert panel that reviews a synthesis of the scientific evidence and rates the appropriateness of a comprehensive list of indications for the procedure being studied. Previous studies, however, have all involved single-country panels. We tested the feasibility of carrying out a multinational panel to rate the appropriateness and necessity of coronary revascularization, thereby producing recommendations for common European criteria. METHODS: Using the RAND methodology, a multispecialty (interventional cardiologists, non-interventional cardiologists and cardiovascular surgeons), multinational (The Netherlands, Spain, Sweden, Switzerland and the United Kingdom) panel rated the appropriateness and necessity of indications for percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft surgery (CABG). A synthesis of the evidence and list of indications for PTCA and CABG were sent to 15 panelists, three from each country, who performed their ratings in three rounds. RESULTS: For PTCA, 24% of the indications were appropriate and necessary, 16% were appropriate, 43% were uncertain and 17% were inappropriate. The corresponding values for CABG were 33% appropriate and necessary, 7% appropriate, 40% uncertain and 20% inappropriate. The proportion of indications rated with disagreement was 4% for PTCA and 7% for CABG. CONCLUSION: Multinational panels appear to be a feasible method of addressing issues concerning the appropriateness and necessity of medical procedures in western European countries. The criteria produced provide a common tool that can be used to measure the overuse and underuse of medical procedures and to guide decision-making.     

Limited Left Thoracotomy for Reoperative Coronary Artery Bypass Grafting without Cardiopulmonary Bypass for Circumflex Grafting in Patients with Patent Internal Thoracic Artery Graft

Abstract Background: We describe our experience with the limited left thoracotomy strategy for reoperative coronary artery bypass graft (CABG)to the circumflex coronary artery system, emphasizing the indications, our particular operative technique, and early clinical follow-up. Methods: From January 2001 to January 2002, 8 consecutive patients underwent redo revascularization via limited left thoracotomy and without cardiopulmonary bypass. This operation was indicated for patients with recurrent myocardial ischemia confined to the lateral wall of the left ventricle, especially if a patent left internal thoracic artery (LITA)-to-left anterior descending coronary artery (LAD)graft was present. Results: All 8 patients underwent successful redo revascularization via limited left thoracotomy. Eight patients received 14 saphenous vein grafts (mean 1.7 grafts/patient). No instances of postoperative myocardial infarction or death occurred. During a follow-up period ranging from 1 to 12 months (mean, 5. 2 months), all patients were asymptomatic and without evidence of ischemia or infarction. Conclusions: For select patients who have patent LITA grafted into the LAD and who need redo CABG to the coronary artery circumflex system, the limited left thoracotomy approach without cardiopulmonary bypass is a safe operation and a less invasive alternative to repeat sternotomy and conventional CABG.     

Perioperative morbidity and mortality in combined vs. staged approaches to carotid and coronary revascularization

Between 1986 and 1994 we identified 57 patients who underwent carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) during the same hospitalization. Simultaneous CABG and CEA was performed in 28 patients (mean age 70.5 years, 58% male). Indications for CABG in these patients were myocardial infarction in two, crescendo angina in 19, congestive heart failure in two and left main or triple-vessel coronary artery disease noted during carotid preoperative evaluation in five. Indications for CEA were transient ischemic attack (TIA) in 12, crescendo TIA in six, cerebrovascular accident (CVA) in five, and asymptomatic stenosis in five. There were no postoperative myocardial infarctions or perioperative deaths. Two patients developed atrial fibrillation, and four patients had CVAs (two were ipsilateral to the side of CEA). Twenty-nine patients underwent staged procedures (i.e., not performed concomitantly but during the same hospitalization). Indications for CABG and CEA were comparable to those in the group undergoing simultaneous procedures. In 17 patients CEA was performed before CABG. There was a single CVA, the result of an intracerebral hemorrhage. Five of the 17 patients had a myocardial infarction and two died; one patient had first-degree heart block requiring a pacemaker. Four additional patients developed atrial fibrillation, one of whom required cardioversion. The remaining 12 patients had CABG followed by CEA. There were no CVAs, myocardial infarctions, arrhythmias, or deaths in this subgroup. These data demonstrate that the performance of simultaneous CABG and CEA procedures is associated with increased neurologic morbidity (14.3%), both ipsilateral and contralateral to the side of carotid surgery in contrast to staged CABG and CEA (3.4%). In addition, when staged carotid surgery preceded coronary revascularization in those with severe coronary artery disease, the combined cardiac complication and mortality rate was significantly higher than when coronary revascularization preceded CEA. This evidence suggests that when CABG and CEA must be performed during the same hospitalization, the procedures should be staged with CABG preceding CEA. Presented at the Twentieth Annual Meeting of the Peripheral Vascular Surgery Society, New Orleans, La., June 10, 1995.