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Long-term clinical outcomes after coronary artery bypass grafting with pedicled saphenous vein grafts
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery. Department of Cardiothoracic Surgery and Anaesthesia, Uppsala University Hospital, Uppsala, Sweden.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery. Department of Cardiothoracic Surgery and Anaesthesia, Uppsala University Hospital, Uppsala, Sweden.
2018 (English)In: Journal of Cardiothoracic Surgery, ISSN 1749-8090, E-ISSN 1749-8090, Vol. 13, no 1, article id 122Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Coronary artery bypass grafting (CABG) using saphenous vein grafts (SVG) is vitiated by poor long-term patency of the vein grafts. Pedicled SVG harvested with the "no-touch" (NT) technique have demonstrated improved patency and could confer better outcomes. We aim to compare long-term results after CABG where NT or conventional technique was used for vein graft harvesting in a hypothesis-generating registry-based study.

METHODS: Two propensity score matched cohorts (1349 patients) undergoing CABG with veins harvested with NT (NTT) or conventional (CT) technique in Sweden over the period 2005-2015 were used to compare long-term outcomes. Mortality, postoperative incidence of coronary angiography and need for reintervention was recorded and multivariable hazard ratios adjusted for risk factors were calculated.

RESULTS: The mean follow-up time (SD) was 6.8 (3.3) years for NTT and 6.6 (3.2) years for CT. The adjusted hazard ratios for death, first angiography and need for reintervention for NTT patients were (95% CI) 0.97 (0.80-1.19), 0.76 (0.63-0.93), 0.91 (0.78-1.05), and 0.91 (0.71-1.17), respectively. Failed grafts were found in 43.2% of NTT patients and 53.6% of CT patients at angiography.

CONCLUSIONS: In this study NT grafting was associated with a lower risk for repeat angiography, however no difference could be observed for mortality and need for reintervention. The earlier reported improvements in patency of NT veins could possibly be reflected in an improved clinical outcome during the first 10 years after surgery.

Place, publisher, year, edition, pages
2018. Vol. 13, no 1, article id 122
Keywords [en]
CABG, Coronary artery bypass grafting, No-touch, Pedicled vein grafts
National Category
Surgery
Identifiers
URN: urn:nbn:se:uu:diva-369713DOI: 10.1186/s13019-018-0800-zISI: 000451321400001PubMedID: 30477543OAI: oai:DiVA.org:uu-369713DiVA, id: diva2:1271214
Available from: 2018-12-17 Created: 2018-12-17 Last updated: 2019-09-01Bibliographically approved
In thesis
1. Clinically-driven angiography after coronary artery bypass surgery: Results from the SWEDEHEART registry
Open this publication in new window or tab >>Clinically-driven angiography after coronary artery bypass surgery: Results from the SWEDEHEART registry
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The success of coronary artery bypass grafting (CABG) arguably depends on the patency rate of the conduits. The saphenous vein grafts (SVGs) most often used are subject to graft disease and their reduced long-term patency compared to left internal mammary artery (IMA) grafts is well established. Postoperative coronary artery disease (CAD) symptoms, such as angina or myocardial infarction can undoubtedly be linked to graft failure or progression of atherosclerosis in the native coronary vessels, but the contribution from each of these processes is not completely understood.

The aim of this thesis was to use clinically-driven angiography as the main outcome measure in studying different bypass conduits and surgical techniques. This endpoint has a very low risk of misclassification, and is likely to have a high association with recurrence of CAD symptoms. The SWEDEHEART registry provides extensive data on all patients undergoing cardiac surgery in Sweden as well as records of angiographies and coronary interventions.

We studied the incidence of postoperative angiography in 46 663 CABG patients operated with IMA and SVGs. Young age, female sex, presence of diabetes, normal left ventricle function, previous PCI, prior MI, emergency surgery and one or two distal anastomoses were associated with a higher risk. We also studied 6 977 CABG operated individuals with three or more grafted vessels that experienced a postoperative angiography and had available records on individual graft patency. Almost one third of catheterized individuals with CAD symptoms did not demonstrate any failed grafts and in 18% of early and 10% of late angiographies the IMA-graft had failed.

We compared 862 patients operated with bilateral IMA grafts and 1036 cases of IMA and radial artery grafts with 46 343 cases of IMA and SVGs. When adjusted for risk factors no improvement in outcome could be seen for patients operated with multiple arterial grafts. We also compared 1371 patients operated with “no-touch” SVGs with a propensity-matched cohort of patients with conventional SVGs. An improvement in the risk for angiography could be seen for the “no-touch” group but not for the need of repeat intervention or survival.

Postoperative angiography is a useful endpoint in studying long-term outcome after CABG surgery. It is less sensitive than mortality to variations in the baseline covariates and thereby possibly less susceptible to confounding by indication. The causation behind the return of CAD symptoms after CABG surgery and the relative importance of the individual contributions from vein graft failures, failure of the IMA graft, as well as from progression of atherosclerotic plaques in both grafted and non-grafted coronary arteries, remains to be determined.

Place, publisher, year, edition, pages
Uppsala: , 2019. p. 45
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1595
Keywords
CABG, Coronary artery bypass surgery, angiography, graft failure
National Category
Surgery
Research subject
Thorax Surgery
Identifiers
urn:nbn:se:uu:diva-390467 (URN)978-91-513-0742-8 (ISBN)
Public defence
2019-10-25, Enghoffsalen, Akademiska sjukhuset, Ingång 50, Uppsala, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2019-10-03 Created: 2019-09-01 Last updated: 2019-10-15

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Janiec, MikaelThelin, Stefan

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