Coronary artery bypass surgery surgical procedure
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Coronary Artery Bypass Surgery Microchapters | |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Associate Editors-in-Chief: Cafer Zorkun, M.D., Ph.D. [2],Mohammed A. Sbeih, M.D. [3]
The Traditional coronary artery bypass grafting procedure (simplified)
The method of harvesting vein grafts may be associated with late vein graft patency. In one small study of 40 patients randomized to endoscopic vs traditional techniques, no difference was seen in angiographic patency at 3 months.[1]Another small randomized study of 144 patients who returned for angiography at 6 months and demonstrated an occlusion rate of 21.7% for the endoscopic approach vs 17.6% for the open approach.[2] In a non-randomized subgroup analysis from the PREVENT IV study, harvesting of vein-grafts with the use of endoscopy (endoscopic harvesting) was associated with a higher rate of saphenous vein graft failure at 12-18 months compared with open harvesting of the veins under direct visualization (46.7% vs. 38.0%, P<0.001 at 12-18 months).[3] Likewise, clinical outcomes were worse at 3 years: use of endoscopy was associated with higher rates of death, myocardial infarction, or repeat revascularization (20.2% vs. 17.4%; p=0.04), death or myocardial infarction (9.3% vs. 7.6%; p=0.01), and death (7.4% vs. 5.8%; adjusted hazard ratio, 1.52; 95% CI, 1.13 to 2.04; p=0.005). Although these observational data are provocative, further randomized clinical trials involving large numbers of patients from multiple centers with long term follow-up would be needed to compare the safety and effectiveness of the two harvesting techniques.
Perioperative MI is associated with a higher rate of SVG failure
The rate of one-year saphenous vein graft failure has been documented to be 62.4% of patients with and 43.8% of patients without perioperative MI (p <0.001).[4]
Smaller target vessels are associated with a higher rate of SVG failure
The rate of SVG occlusion at one year is about twice as high in those SVGs that are anastomosed to a target vessel with a diameter < 2.0 mm.[5] The rate of SVG occlusion at one year in target vessels less than or equal to 2.0 mm in diameter was 20.1% on aspirin and 32.3% off aspirin (p = 0.008), while in those SVGs anastomosed to target vessels > 2.0 mm in diameter the rates were lower: 8.7% and 9.0% respectively. The converse of this, is that larger conduits have been associated with higher rates of SVG occlusion.[2]
Target artery location
In a multivariate model in a small study, SVG grafting to the diagonal branch has been associated with 1.76 times higher rates of SVG occlusion.[2]
Graft flow
Poorer graft flow has been associated with higher rates of SVG occlusion.[2]
Serum cholesterol
A serum cholesterol > 225 mg/dl has been associated with higher rates of SVG failure at 3 years in a multivariate model from a large VA cooperative study.[6]
Pharmacotherapy
Early post-operative aspirin has been associated with a lower rate of SVG failure for the first 3 years after CABG in a large number of randomized trials.[7][8][9][10][11][12][13][14] [15][16][17][18][19][20]
Factors not associated with saphenous vein graft patency
Although a creatinine clearance < 60 ml / sec has been associated with higher rates of death / MI/ and revascularization, it was not associated with a higher rate of SVG or internal thoracic artery failure rates. [21] In one large VA cooperative study, age, race, smoking history, high density lipoprotein cholesterol, vein source (thigh vs. calf) were not associated with 3 year SVG patency.[6]
Association of saphenous vein graft failure with clinical events
In the PREVENT IV study, SVG failure was associated with a 13.9% rate of death and MI (122/878) vs 0.9% (9/1,042) for those patients without SVG failure (these numbers exclude peri-operative MI).[22] Likewise, the rate of death / MI / and revascularization was higher among patients with SVG failure (26.0% vs 1.8%). Despite these elevated rates of adverse events, it shoud be noted that about half of the patients with SVG failure did not have clinical events. This may be because the native artery remained open or because there was extensive collaterals. It should slo be noted that the development of heart failure or angina following SVG failure may not be captured in the endpoint of death / MI / and revascularization.
In a large cohort of 1,388 patients who underwent a first coronary artery bypass graft procedure, vein graft patency was temporally related both to reoperation as well as survival.[23]
Other non-atherosclerotic saphenous vein graft diseases
Saphenous vein graft aneurysms
This disease process is also known as SVGA, aortocoronary saphenous vein graft aneurysms, saphenous vein graft aneurysm disease and saphenous vein graft aneurysmal dilatation and is defined as a local dilation of the vessel more than 1.5 X the adjacent reference segment. The aneurysms can be up to 14 cm in diameter.
Classification
- True aneurysms: All 3 layers of the vessel wall are involved
- Pseudoaneurysms: There is disruption of 1 or more layers of the vessel wall.
Epidemiology and demographics
Over the course f a SVGs 7 year lifetime, the risk of aneurysm development is 14%. True aneurysms outnumber false ones by a ratio of 2:1.
Pathophysiology
Causes of saphenous vein graft aneurysms include the following:
- Atherosclerosis
- Hypertension
- Mycotic
- Postoperative mediastinitis
- Previous aneurysms
- Torn sutures
Natural history and complications
SVGAs can rupture which is associated with a high rate of morbidity and even mortality. They can also be a nidus for embolization.
Diagnosis
History
If a patient with a history of CABG develops chest pain and has a mediastinal mass, an SVGA should be suspected.
The majority of patients are asymptomatic with a true aneurysm, and most often the SVGA is an incidental finding on an imaging study. If the patient is symptomatic, about half the time it presents as an acute coronary syndrome. Very rarely tamponade from compression of the right atrium or ischemia due to compression of the left internal mammary artery bypass graft has been observed.
In contrast to true aneurysms, patients with false aneurysms are symptomatic in 85% of cases. About two thirds of the time they present with an acute coronary syndrome. If a patient with an SVGA does present with chest pain or hemoptysis, it may be due to the formation of a fistula.
Physical examination
Rarely on physical examination a murmur will be auscultated or cutaneous bleeding will be observed (both due to a fistula).
Imaging
SVGA can be definitively diagnosed on either coronary angiography or CT angiography. On occasion, an SVGA can be observed as either hilar or mediastinal mass on chest x ray.
Management
Pharmacologic management consists of aspirin and lipid-lowering therapy. The benefit if any of coumadin and beta-blockers is not known.
A surgery or a percutaneous intervention is suggested if:
- A pseudoaneurysm is present
- The aneurysm is more than 2 cm greater than the adjacent vessel
- A fistula is present (surgery, coiling, or stenting)
- If the aneurysm is mycctic (surgery)
Surgery
There are multiple surgical approaches to repairing an aneurysm:
- Ligate the aneurysm-containing SVG and place a new SVG.
- Resect the aneurysmal portion of the diseased graft and sew a new SVG segment in in an end-to-end fashion
- Ligate the old SVG without revascularization
- Evacuate the hematoma and repair the SVG with a venous patch graft.
Percutaneous intervention
In the past, percutaneous intervention was reserved for patients who were too sick to undergo surgery. However, due to the improved tools that are available, more patients are undergoing percutaneous intervention as described below:
- Coil embolization: This technique has evolved so that a stent excludes the coil form lying in the lumen of the SVG.
- Covered stents: The JOSTENT Coronary Stent Graft (Abbott Vascular, Redwood City, Calif) can be used to exclude the aneurysm form the body of the SVG. The device is made up of an ultra-thin layer of polytetrafluoroethylene (PTFE).
- Multiple overlapping stents can be used to exclude the aneurysm.
Amyloidosis of saphenous coronary bypass grafts
Amyloid has been associated with accelarated disease in saphenous vein grafts.[24] [25] [26] [27] [28]
Rupture of the saphenous vein coronary artery bypass grafts
Aspergillus species causing a necrotizing vasculitis have been associated with rupture of a saphenous vein grafts.
References
- ↑ Perrault LP, Jeanmart H, Bilodeau L, Lespérance J, Tanguay JF, Bouchard D, Pagé P, Carrier M (2004). "Early quantitative coronary angiography of saphenous vein grafts for coronary artery bypass grafting harvested by means of open versus endoscopic saphenectomy: a prospective randomized trial". J. Thorac. Cardiovasc. Surg. 127 (5): 1402–7. doi:10.1016/j.jtcvs.2003.10.040. PMID 15115999. Retrieved 2010-07-23. Unknown parameter
|month=ignored (help) - ↑ 2.0 2.1 2.2 2.3 Yun KL, Wu Y, Aharonian V, Mansukhani P, Pfeffer TA, Sintek CF, Kochamba GS, Grunkemeier G, Khonsari S (2005). "Randomized trial of endoscopic versus open vein harvest for coronary artery bypass grafting: six-month patency rates". J. Thorac. Cardiovasc. Surg. 129 (3): 496–503. doi:10.1016/j.jtcvs.2004.08.054. PMID 15746730. Retrieved 2010-07-23. Unknown parameter
|month=ignored (help) - ↑ Lopes RD, Hafley GE, Allen KB, Ferguson TB, Peterson ED, Harrington RA, Mehta RH, Gibson CM, Mack MJ, Kouchoukos NT, Califf RM, Alexander JH (2009). "Endoscopic versus open vein-graft harvesting in coronary-artery bypass surgery". The New England Journal of Medicine. 361 (3): 235–44. doi:10.1056/NEJMoa0900708. PMID 19605828. Retrieved 2010-07-12. Unknown parameter
|month=ignored (help) - ↑ Yau JM, Alexander JH, Hafley G, Mahaffey KW, Mack MJ, Kouchoukos N, Goyal A, Peterson ED, Gibson CM, Califf RM, Harrington RA, Ferguson TB (2008). "Impact of perioperative myocardial infarction on angiographic and clinical outcomes following coronary artery bypass grafting (from PRoject of Ex-vivo Vein graft ENgineering via Transfection [PREVENT] IV)". The American Journal of Cardiology. 102 (5): 546–51. doi:10.1016/j.amjcard.2008.04.069. PMID 18721510. Retrieved 2010-07-14. Unknown parameter
|month=ignored (help) - ↑
ref name="pmid2680158">Goldman S, Copeland J, Moritz T, Henderson W, Zadina K, Ovitt T, Doherty J, Read R, Chesler E, Sako Y (1989). "Saphenous vein graft patency 1 year after coronary artery bypass surgery and effects of antiplatelet therapy. Results of a Veterans Administration Cooperative Study". Circulation. 80 (5): 1190–7. PMID 2680158. Retrieved 2010-07-22. Unknown parameter
|month=ignored (help) - ↑ 6.0 6.1 Goldman S, Zadina K, Krasnicka B, Moritz T, Sethi G, Copeland J, Ovitt T, Henderson W (1997). "Predictors of graft patency 3 years after coronary artery bypass graft surgery. Department of Veterans Affairs Cooperative Study Group No. 297". J. Am. Coll. Cardiol. 29 (7): 1563–8. PMID 9180120. Retrieved 2010-07-23. Unknown parameter
|month=ignored (help) - ↑ Goldman S, Copeland J, Moritz T, Henderson W, Zadina K, Ovitt T, Doherty J, Read R, Chesler E, Sako Y (1988). "Improvement in early saphenous vein graft patency after coronary artery bypass surgery with antiplatelet therapy: results of a Veterans Administration Cooperative Study". Circulation. 77 (6): 1324–32. PMID 3286040. Retrieved 2010-07-22. Unknown parameter
|month=ignored (help) - ↑ Goldman S, Copeland J, Moritz T, Henderson W, Zadina K, Ovitt T, Doherty J, Read R, Chesler E, Sako Y (1989). "Saphenous vein graft patency 1 year after coronary artery bypass surgery and effects of antiplatelet therapy. Results of a Veterans Administration Cooperative Study". Circulation. 80 (5): 1190–7. PMID 2680158. Retrieved 2010-07-22. Unknown parameter
|month=ignored (help) - ↑ Goldman S, Copeland J, Moritz T, Henderson W, Zadina K, Ovitt T, Kern KB, Sethi G, Sharma GV, Khuri S (1994). "Long-term graft patency (3 years) after coronary artery surgery. Effects of aspirin: results of a VA Cooperative study". Circulation. 89 (3): 1138–43. PMID 8124800. Retrieved 2010-07-22. Unknown parameter
|month=ignored (help) - ↑ Chesebro JH, Clements IP, Fuster V, Elveback LR, Smith HC, Bardsley WT, Frye RL, Holmes DR, Vlietstra RE, Pluth JR, Wallace RB, Puga FJ, Orszulak TA, Piehler JM, Schaff HV, Danielson GK (1982). "A platelet-inhibitor-drug trial in coronary-artery bypass operations: benefit of perioperative dipyridamole and aspirin therapy on early postoperative vein-graft patency". N. Engl. J. Med. 307 (2): 73–8. PMID 7045659. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ Chesebro JH, Fuster V, Elveback LR, Clements IP, Smith HC, Holmes DR, Bardsley WT, Pluth JR, Wallace RB, Puga FJ (1984). "Effect of dipyridamole and aspirin on late vein-graft patency after coronary bypass operations". N. Engl. J. Med. 310 (4): 209–14. PMID 6361561. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ Mangano DT (2002). "Aspirin and mortality from coronary bypass surgery". N. Engl. J. Med. 347 (17): 1309–17. doi:10.1056/NEJMoa020798. PMID 12397188. Retrieved 2010-07-22. Unknown parameter
|month=ignored (help) - ↑ Lorenz RL, Schacky CV, Weber M; et al. (1984). "Improved aortocoronary bypass patency by low-dose aspirin (100 mg daily). Effects on platelet aggregation and thromboxane formation". Lancet. 1 (8389): 1261–4. PMID 6144975. Unknown parameter
|month=ignored (help) - ↑ Hockings BE, Ireland MA, Gotch-Martin KF, Taylor RR (1993). "Placebo-controlled trial of enteric coated aspirin in coronary bypass graft patients. Effect on graft patency". Med. J. Aust. 159 (6): 376–8. PMID 8377686. Unknown parameter
|month=ignored (help) - ↑ Sanz G, Pajarón A, Alegría E; et al. (1990). "Prevention of early aortocoronary bypass occlusion by low-dose aspirin and dipyridamole. Grupo Español para el Seguimiento del Injerto Coronario (GESIC)". Circulation. 82 (3): 765–73. PMID 2203555. Unknown parameter
|month=ignored (help) - ↑ Gavaghan TP, Gebski V, Baron DW (1991). "Immediate postoperative aspirin improves vein graft patency early and late after coronary artery bypass graft surgery. A placebo-controlled, randomized study". Circulation. 83 (5): 1526–33. PMID 2022014. Unknown parameter
|month=ignored (help) - ↑ Sharma GV, Khuri SF, Josa M, Folland ED, Parisi AF (1983). "The effect of antiplatelet therapy on saphenous vein coronary artery bypass graft patency". Circulation. 68 (3 Pt 2): II218–21. PMID 6347428. Unknown parameter
|month=ignored (help) - ↑ Brown BG, Cukingnan RA, DeRouen T; et al. (1985). "Improved graft patency in patients treated with platelet-inhibiting therapy after coronary bypass surgery". Circulation. 72 (1): 138–46. PMID 3874009. Unknown parameter
|month=ignored (help) - ↑ McEnany MT, Salzman EW, Mundth ED; et al. (1982). "The effect of antithrombotic therapy on patency rates of saphenous vein coronary artery bypass grafts". J. Thorac. Cardiovasc. Surg. 83 (1): 81–9. PMID 7033673. Unknown parameter
|month=ignored (help) - ↑ Goldman S, Copeland J, Moritz T; et al. (1990). "Internal mammary artery and saphenous vein graft patency. Effects of aspirin". Circulation. 82 (5 Suppl): IV237–42. PMID 2225410. Unknown parameter
|month=ignored (help) - ↑ Mehta RH, Hafley GE, Gibson CM, Harrington RA, Peterson ED, Mack MJ, Kouchoukos NT, Califf RM, Ferguson TB, Alexander JH (2008). "Influence of preoperative renal dysfunction on one-year bypass graft patency and two-year outcomes in patients undergoing coronary artery bypass surgery". The Journal of Thoracic and Cardiovascular Surgery. 136 (5): 1149–55. doi:10.1016/j.jtcvs.2008.02.085. PMID 19026795. Retrieved 2010-07-14. Unknown parameter
|month=ignored (help) - ↑ Alexander JH, Hafley G, Harrington RA, Peterson ED, Ferguson TB, Lorenz TJ, Goyal A, Gibson M, Mack MJ, Gennevois D, Califf RM, Kouchoukos NT (2005). "Efficacy and safety of edifoligide, an E2F transcription factor decoy, for prevention of vein graft failure following coronary artery bypass graft surgery: PREVENT IV: a randomized controlled trial". JAMA : the Journal of the American Medical Association. 294 (19): 2446–54. doi:10.1001/jama.294.19.2446. PMID 16287955. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ Fitzgibbon GM, Kafka HP, Leach AJ, Keon WJ, Hooper GD, Burton JR (1996). "Coronary bypass graft fate and patient outcome: angiographic follow-up of 5,065 grafts related to survival and reoperation in 1,388 patients during 25 years". J. Am. Coll. Cardiol. 28 (3): 616–26. PMID 8772748. Retrieved 2010-07-22. Unknown parameter
|month=ignored (help) - ↑ Marti MC, Bouchardy B, Cox JN. Aortocoronary bypass with autogenous saphenous vein grafts: histopathological aspects. Virchows Arch Abt A Path Anat 1971; 352: 255–66.
- ↑ Garrett HE, Dennis EW, DeBakey ME. Aortocoronary bypass with saphenous vein graft. JAMA 1973; 223: 792–4.
- ↑ Zemva A, Ferluga D, Zorc M, Popovic M, Porenta OV, Radovanovic N. Amyloidosis in saphenous vein aortocoronary bypass grafts. J Cardiovasc Surg 1990; 31: 441–4.
- ↑ Salerno TA, Wasan SM, Charrette EJ. Prospective analysis of heart biopsies in coronary artery surgery. Ann Thorac Surg 1979; 28: 436–9.
- ↑ Pelosi F, Capehart J, Roberts WC. Effectiveness of cardiac transplantation for primary (AL) cardiac amyloidosis. Am J Cardiol 1997; 79: 532–5.