Complete arterial revascularization using T-graft technique in diabetics with coronary three-vessel disease

BACKGROUND: Coronary revascularization using exclusively arterial grafts holds the promise of improved long-term patency. The T-graft approach achieves this goal with only two arterial grafts in coronary 3-vessel disease. Arterial grafts in diabetics, however, exhibit more frequently atherosclerotic wall abnormalities, and higher levels of endothelin-1 were found in diabetic arterial grafts, which may be associated with a higher incidence of vasoconstriction. The objective of this prospective study was to compare functional und angiographic parameters of arterial T-grafts in diabetics and nondiabetics. METHODS: Coronary angiography was performed consecutively in 20 patients with insulin-dependent diabetes mellitus (IDDM), 20 patients with non-insulin-dependent diabetes mellitus (NIDDM), and 100 non-diabetics one week after complete arterial revascularization with T-grafts. Graft patency was assessed, and the diameter of the proximal left internal mammary artery (IMA) graft was measured using quantitative coronary analysis. Absolute flow volume in the proximal left IMA was measured using the flow-wire technique at baseline and after an adenosine injection into the graft to induce maximal hyperemia. Coronary flow reserve (CFR) was calculated as the ratio of maximal to baseline flow. RESULTS: There was no difference between patients with IDDM, patients with NIDDM and non-diabetics with respect to patency (98.3% vs. 98.8% vs. 97,8%, n.s.), graft lumen diameter (3.42 +/- 0.48 vs. 3.36 +/- 0.50 vs. 3.38 +/- 0.41 mm, n.s.), baseline flow (78.4 +/- 34.3 vs. 83.1 +/- 36.6 vs. 81.5 +/- 39.0 ml/min, n.s.), and CFR (1.85 +/- 0.37 vs. 1.89 +/- 0.44 vs. 1.90 +/- 0.40, n.s.). CONCLUSION: Baseline parameters (graft diameter and quantitative graft flow), patency and CFR are identical in diabetics and non-diabetics. Our results suggest that diabetic patients with coronary 3-vessel disease take comparable profit from complete arterial revascularization using the T-graft technique as non-diabetics.     

Midterm results of coronary bypass surgery exclusively with arterial revascularization

INTRODUCTION AND OBJECTIVES: In recent years, the exclusive use of arterial grafts in coronary surgery has been the surgical option to achieve maximum survival and minimum recurrence of coronary events. The aim of this study was to analyze the surgical results and follow up of this approach. PATIENTS AND METHODS: Over a period of six and a half years, 87 patients underwent coronary surgery using arterial grafts alone for revascularization. The mean age of the patients was 62 +/- 1 years with 78 men and 9 women; 22 patients (25%) were clinically unstable. The number of vessels affected per patient was 1.83 +/- 0.1, and the number of patients with one, two and three affected vessels, were 38 (44%), 26 (30%) and 23 (26%), respectively. The mean ejection fraction was 63 +/- 1.6. Emergency surgery was carried out in 13 cases (16%). RESULTS: A total of 1.9 +/- 0.1 grafts were implanted per patient and complete revascularization was achieved in 65 cases (75%). The left mammary artery was used in 87 cases (100%), the right mammary artery in 31 (35.6%) and the radial artery in 20 cases (23%). Hospital mortality was 1.1% (one case). During the postoperative period, 3 patients (3.4%) presented myocardial infarction, 12 (13.8%) atrial fibrillation and there were 3 cases of sternal dehiscence.A total of 86 patients (98.9%) were followed over a mean period of 24.5 +/- 0.5 months. Survival, angina-free period and period free of any coronary event at 5 years were 97 +/- 0.05%, 89 +/- 0.1% and 87 +/- 0.1% respectively (mean +/- standard error, CI 95%). On multivariate analysis, the presence of peripheral vascular disease (p < 0.015) and the development of low cardiac output (p < 0.04) or atrial fibrillation (p < 0.04) during the postoperative period were predictive factors for the appearance of coronary events during follow-up. CONCLUSIONS: Surgery exclusively with arterial grafts achieves good medium term results in relation to survival and time free of coronary events.     

Complete arterial coronary artery bypass grafting versus conventional revascularization--early results

BACKGROUND: Complete arterial coronary artery bypass grafting (CABG) offers the potential to improve long-term results. However, an increased perioperative risk has been controversially discussed. New operative techniques (skeletonization of the ITA/ T-grafts/utilization of the radial artery (RA)) may decrease perioperative risk. We compared the outcome after conventional with that after complete arterial CABG. MATERIAL AND METHODS: Three consecutive groups of patients were analyzed. In group I (n = 50), CABG was performed using left ITA and vein grafts. The other two groups received complete arterial CABG with either both ITA's (group II; n = 52) or left ITA and RA (group III; n = 52). RESULTS: A mean of 3.9+/-0.8 (I) versus 4.2+/-0.8 (II) and 3.9+/-0.9 (III) anastomoses were performed per patient (ns). Mean operating time was significantly prolonged in group II (II: 252+/-54; p<0.0001; vs. I: 191+/-36; III: 203+/-33). Mean ischemic time was significantly prolonged in group II and III (II:65+/-20; p<0.0001; III: 68+/-16; p<0.0001; vs. I: 51+/-15). Mean bypass time (I: 83+/-23; II: 95+/-41; III: 91+/-21), the rate of postoperative complications and in-hospital mortality (I: n = 0; II: n = 2; III: n = 0; ns) showed no significant differences. Conclusions: Complete arterial CABG using modern surgical techniques is as safe as the conventional surgical approach using left ITA and vein graft.     

Coronary revascularization in diabetic patients

The prevalence of diabetes is growing worldwide. Diabetics are predisposed to coronary artery disease due to an increased rate of atherosclerosis. The optimal treatment for these patients remains uncertain. Randomized trials compared percutaneous coronary intervention (PCI) to coronary artery bypass surgery (CABG) to determine the most suitable revascularization strategy. Meta-analyses suggest a survival advantage in favor of surgery over angioplasty or stenting with bare-metal stents (BMS). New evidence was needed since advances in medical therapy, PCI technology, and surgical techniques have emerged. The Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) trial was the first to compare a drug-eluting stent to CABG and showed an increased rate of major adverse cardiac or cerebrovascular events after PCI. Results are mainly driven by the increased rates in patients with high lesion complexity; therefore, the current evidence suggests that diabetic patients with complex coronary disease have better outcomes with CABG.     

Complete myocardial revascularization using arterial grafts only in patients with unstable angina: impact on early outcome

OBJECTIVE: The aims of this study were 1) to assess early clinical outcomes for patients with unstable angina (UA) who undergo urgent/emergent coronary artery bypass grafting (CABG); and 2) to evaluate the feasibility and safety of complete revascularization using strictly arterial grafts in this patient group. PATIENTS AND METHODS: Between September 2001 and May 2005, a total of 961 patients underwent CABG at our center. One hundred and sixty-seven (17.4 %) of these individuals underwent urgent or emergent CABG because of UA, and 794 (82.6 %) underwent elective CABG for stable angina (SA). Of the 167 patients with UA, 59 (35.3 %) underwent complete revascularization using arterial grafts only (AO subgroup: internal thoracic arteries and radial arteries) and the other 108 received a combination of arterial and venous grafts (AV subgroup: 1 internal thoracic artery plus saphenous vein grafts). RESULTS: The UA group had a significantly higher proportion of women and a significantly higher rate of left main coronary artery disease than the SA group ( P = 0.016 and P = 0.0001, respectively). Cardiopulmonary bypass time was significantly longer in the UA group ( P = 0.01). Higher proportions of the UA group required inotropic support ( P = 0.001), intra-aortic balloon pump support ( P = 0.001), and re-exploration for bleeding or cardiac tamponade ( P = 0.005). This group also had a significantly longer mean time on mechanical ventilation ( P = 0.001) and a longer mean intensive care unit stay ( P = 0.01). The rates of operative mortality (first 30 days) in the SA and UA groups were 1.8 % and 6 %, respectively ( P = 0.001). There were no statistical differences between the AO and AV subgroups with respect to any of the preoperative or intraoperative findings. The AO group had a significantly shorter mean intensive care unit stay than the AV group ( P = 0.05). The AV group had a roughly fivefold higher operative mortality than the AO group (8.3 % vs. 1.7 %, respectively), but this difference was not statistically significant ( P = 0.17). CONCLUSION: Urgent or emergent CABG in the setting of UA is associated with increased but acceptable rates of mortality and morbidity. Complete myocardial revascularization using arterial grafts only (combinations of internal thoracic and radial arteries) is feasible and safe in this patient group.     

糖尿病患者的冠状动脉再血管化手术

Although percutaneous coronary interventions and cardiac surgery have improved their techniques in recent years coronary revaseularization represents still a particular problem in diabetic patients （DM）.     

全动脉化冠状动脉旁路移植术在左心功能不全患者中的应用

目的:评估2根动脉桥血管全动脉化冠状动脉(冠脉)旁路移植术在左心功能不全患者中应用的可行性和安全性。方法:前瞻性收集1994年11月~2002年8月用2根动脉桥血管进行全动脉化冠脉旁路移植术的179例左室射血分数(LVEF)<50%(正常≥70%)的冠脉多支病变临床病例进行研究。其中急性冠脉综合征3例,不稳定型心绞痛43例;LVEF<30)例;2次手术14例,3次手术3例。82%的患者应用含有左侧乳内动脉的Y型桥(其中右乳内动脉40.8%,桡动脉33.5%,其他7.8%)。结果:左心功能不全组围术期死亡率2·2%,心肌梗死1.7%,脑血管意外0.6%,胸骨感染3.3%,呼吸衰竭7.8%,与左心功能正常组相比较差异无统计学意义。结论:左心功能不全患者可以安全地用2根动脉桥血管进行全动脉化冠脉旁路移植术。桡动脉长于右乳内动脉,即使左心功能不全(左室扩大)的情况下也足以完成全动脉化冠脉旁路移植术。     

Long-term results of myocardial revascularization

During 1970 to 1977, among 1,733 patients who underwent isolated coronary bypass grafting, the operative mortality was 2.5 percent. Actuarial 5 year survival is 88.1 percent. At an average follow-up of 46 months (range 13 to 108), 90 percent of patients remain angina-free or with symptomatic improvement. The 5 year survival rate of patients with single vessel coronary artery disease is 97.9 percent. In patients with multivessel disease, operative survival appears to be favorably influenced by the presence of normal preoperative ventricular function. Late survival is significantly better in patients with multivessel disease with normal preoperative ventricular function or with complete revascularization. Risk of perioperative myocardial infarction has been appreciably reduced by the introduction of cold potassium chloride cardioplegia. Late myocardial infarction has occurred at an average annual risk of 1.46 percent. These data show that long-term survival and a small incidence of late myocardial infarction after myocardial revascularization are more likely in patients who undergo complete revascularization before significant left ventricular myocardial damage has occurred.     

Physiology of in-situ arterial revascularization in coronary artery bypass grafting: Preoperative,intraoperative and postoperative factors and influences

Surgical revascularization with coronary artery bypass grafting(CABG) has become established as the most effective interventional therapy for patients with moderately severe and severe stable ischemic heart disease(SIHD). This recommendation is based on traditional 5-year outcomes of mortality and avoidance of myocardial infarction leading to reintervention and/or cardiac death. However, these results are confounded in that they challenge the traditional CABG surgical tenets of completeness of anatomic revascularization, the impact of arterial revascularization on late survival, and the lesser impact of secondary prevention following CABG on late outcomes. Moreover, the emergence of physiologic-based revascularization with percutaneous cardiovascular intervention as an alternative strategy for revascularization in SIHD raises the question of whether there are similar physiologic effects in CABG. Finally, the ongoing ISCHEMIA trial is specifically addressing the importance of the physiology of moderate or severe ischemia in optimizing therapeutic interventions in SIHD. So it is time to address the role that physiology plays in surgical revascularization. The long-standing anatomic framework for surgical revascularization is no longer sufficient to explain the mechanisms for short-term and long-term outcomes in CABG. Novel intraoperative imaging technologies have generated important new data on the physiologic blood flow and myocardial perfusion responses to revascularization on an individual graft and global basis. Long-standing assumptions about technical issues such as competitive flow are brought into question by real-time visualization of the physiology of revascularization. Our underestimation of the impact of Guideline Directed Medical Therapy, or Optimal Medical Therapy, on the physiology of preoperative SIHD, and the full impact of secondary prevention on post-intervention SIHD, must be better understood. In this review, these issues are addressed through the perspective of multi-arterial revascularization in CABG, which is emerging(after 30 years) as the "standard of care" for CABG. In fact, it is the physiology of these arterial grafts that is the mechanism for their impact on long-term outcomes in CABG. Moreover, a better understanding of all of these preoperative, intraoperative and postoperative components of the physiology of revascularization that will generate the next, more granular body of knowledge about CABG, and enable surgeons to design and execute a better surgical revascularization procedure for patients in the future.     

Anatomic results of the endoluminal revascularization of renal arterial stenoses. A retrospective study of 113 patients]

The aim of the study was to evaluate the anatomic results of percutaneous transluminal renal angioplasty in a population of 113 hypertensive patients (66 men, mean age 63 years) who had a significant renal artery stenosis (atheromatous in 105 patients and fibrodysplastic in the eight others). Conventional angioplasty was performed in 89 arteries, and stent implantation in 46 cases. Stenting was associated with a better immediate result than simple angioplasty for atheromatous stenoses (rate of residual stenosis < 30% = 93.5% and 71.2% respectively, p < 0.003). Technical success for angioplasty of atheromatous stenoses was achieved in 73.8% of procedures involving non ostial lesions and 51.6% for ostial stenoses (p = 0.05). Restenosis was detected 6.3 +/- 0.3 months later (by echodoppler and/or helical computed tomography angiography) in 9.1% of cases after stent implantation and in 47% after simple angioplasty (p = 0.00017). The presence of a residual stenosis < 30% immediately after revascularization was associated with a significantly (26.4% versus 50%, p = 0.044) lower rate of restenosis. In conclusion, this study confirms the utility of percutaneous transluminal renal angioplasty for treatment of renovascular hypertension, particularly with the utilisation of stents for atheromatous and ostial stenoses.     

Complete off-pump coronary revascularization in patients with dialysis-dependent renal disease

Patients who have dialysis-dependent renal disease frequently present with coronary artery disease but are considered at high risk for coronary artery bypass grafting. From 1 September 2000 through 31 August 2003, we performed complete off-pump coronary revascularization in 6 patients who had end-stage dialysis-dependent renal failure, and we prospectively studied the perioperative and early postoperative results. The effect of off-pump coronary artery bypass grafting on mortality, morbidity, postoperative complications, and transfusion requirements in this group of patients was investigated. No perioperative deaths or ischemic cardiac events were observed after off-pump coronary artery bypass grafting. In all patients, anginal symptoms were relieved during the postoperative period. The mean duration of follow-up was 172 +/- 12.4 months. Patients with dialysis-dependent chronic renal failure who present with coronary artery disease should be thoroughly evaluated preoperatively for risk factors and coexistent severe diseases. We believe that in patients with end-stage dialysis-dependent chronic renal failure, off-pump coronary revascularization is a good alternative.     

Multivessel total arterial revascularization via left thoracotomy

Off-pump coronary artery bypass grafting is now becoming the preferred method of coronary revascularization. The trend is towards complete revascularization, preferably arterial. We are describing here a method of multivessel, total arterial, complete revascularization via an anterolateral thoracotomy approach in 27 patients. There was an average of 3.2 grafts/patient. Angiograms were performed in 9 patients (33.33 %). There were no operative mortalities. None of the patients required conversion to cardiopulmonary bypass or midsternotomy.