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Long-term outcome after coronary endarterectomy adjunct to coronary artery bypass grafting
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
Department of Clinical Sciences, Lund, Department of Cardiothoracic Surgery, Lund, Lund University, Skåne University Hospital, Sweden.
Department of Clinical Sciences, Lund, Department of Cardiothoracic Surgery, Lund, Lund University, Skåne University Hospital, Sweden.
2019 (English)In: Interactive Cardiovascular and Thoracic Surgery, ISSN 1569-9293, E-ISSN 1569-9285, Vol. 29, no 1, p. 22-27Article in journal (Refereed) Published
Abstract [en]

OBJECTIVES: Coronary endarterectomy (CE) in coronary artery bypass grafting (CABG) is occasionally required to achieve revascularization in diffusely diseased vessels. Its beneficial effect has been questioned because of an increased risk of perioperative mortality and morbidity; however, its influence on the long-term outcome remains uncertain. The purpose of the study was to evaluate the impact of adjunct CE on the incidence of a first postoperative angiogram and the need for repeat intervention and on late deaths after CABG.

METHODS: Two propensity-matched cohorts of patients undergoing CABG with CE (537 patients) and without adjunct CE (no CE) (537 patients) in Sweden over the period 2000-2015 were used to compare long-term outcomes. Mortality rates, postoperative incidence of coronary angiography and the need for reintervention were determined using the Kaplan-Meier method.

RESULTS: The mean follow-up time (standard deviation) was 9.9 (4.6) years for CE and 10.0 (4.6) years for no CE. Overall survival, clinically driven angiography and coronary reintervention during follow-up (95% confidence interval) at 10 years were 65.8% (60.8-70.3), 28.2% (23.8-34.3) and 11.6% (8.7-15.3), respectively, for CE and 70.7% (65.9-74.9), 21.7% (17.8-26.3) and 12.7% (9.7-16.6), respectively, for no CE. There was a significant difference in the use of postoperative angiography between the 2 groups (P = 0.02).

CONCLUSIONS: Although patients are subjected to an increased risk of repeat angiography, CE seems to be an acceptable treatment alternative in patients who have diffuse coronary artery disease that cannot be treated effectively by CABG alone.

Place, publisher, year, edition, pages
Oxford University Press, 2019. Vol. 29, no 1, p. 22-27
Keywords [en]
Coronary artery bypass grafting, Coronary endarterectomy, Reintervention, Survival
National Category
Surgery Cardiac and Cardiovascular Systems
Identifiers
URN: urn:nbn:se:uu:diva-390464DOI: 10.1093/icvts/ivy363ISI: 000493286900004PubMedID: 30698788OAI: oai:DiVA.org:uu-390464DiVA, id: diva2:1341740
Available from: 2019-08-10 Created: 2019-08-10 Last updated: 2019-11-18Bibliographically 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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