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Clinically-driven angiography after coronary artery bypass surgery: Results from the SWEDEHEART registry
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
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 [en]
CABG, Coronary artery bypass surgery, angiography, graft failure
National Category
Surgery
Research subject
Thorax Surgery
Identifiers
URN: urn:nbn:se:uu:diva-390467ISBN: 978-91-513-0742-8 (print)OAI: oai:DiVA.org:uu-390467DiVA, id: diva2:1347550
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
List of papers
1. Graft failure and recurrence of symptoms after coronary artery bypass grafting
Open this publication in new window or tab >>Graft failure and recurrence of symptoms after coronary artery bypass grafting
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2018 (English)In: Scandinavian Cardiovascular Journal, ISSN 1401-7431, E-ISSN 1651-2006, Vol. 52, no 3, p. 113-119Article in journal (Refereed) Published
Abstract [en]

Objectives: Saphenous vein grafts (SVGs) most often used in coronary artery bypass grafting (CABG) are subject to graft disease and have poor long-term patency, however the clinical implication of this is not completely known. We aim to assess the influence of graft failure on the postoperative recurrence of coronary artery disease (CAD) symptoms in relation to the contribution from progression of atherosclerosis in the native coronary vessels.

Design: Within the SWEDEHEART registry we identified 46,663 CABG cases between 2001 and 2015 with patient age 40-80 years where single internal mammary artery (IMA) anastomosis (IMA), single IMA with one (1SVG) or multiple SVG anastomoses (2+ SVG) had been performed. Clinical characteristics as well as mortality and postoperative incidence of coronary angiography were recorded and multivariable adjusted hazard ratios were calculated. Indications for the angiographies and occurrence of graft failure were also registered.

Results: The adjusted hazard ratio for death was similar for the three groups. The adjusted hazard ratio for being submitted to angiography as compared to 2+ SVG was (95% CI) 1.24 (1.06-1.46) for IMA and 1.21 (1.15-1.28) for 1SVG. Failed grafts were found at the first postoperative angiography with preceding CAD symptoms in 21.4% of patients in the IMA group, 41.6% in the 1SVG group and 61.1% in the 2+ SVG group.

Conclusions: A substantial amount of angiographies occur in patients without any graft failure and a large part of postoperative recurrence of CAD symptoms and are likely attributed to IMA failure or progression of atherosclerosis in the native coronary arteries.

Place, publisher, year, edition, pages
TAYLOR & FRANCIS LTD, 2018
Keywords
Coronary artery bypass grafting, graft failure, registry study
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:uu:diva-356335 (URN)10.1080/14017431.2018.1442930 (DOI)000432282000002 ()29508655 (PubMedID)
Available from: 2018-07-26 Created: 2018-07-26 Last updated: 2019-09-01Bibliographically approved
2. No improvements in long-term outcome after coronary artery bypass grafting with arterial grafts as a second conduit: a Swedish nationwide registry study
Open this publication in new window or tab >>No improvements in long-term outcome after coronary artery bypass grafting with arterial grafts as a second conduit: a Swedish nationwide registry study
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2018 (English)In: European Journal of Cardio-Thoracic Surgery, ISSN 1010-7940, E-ISSN 1873-734X, Vol. 53, no 2, p. 448-454Article in journal (Refereed) Published
Abstract [en]

OBJECTIVES: Coronary artery bypass grafting using saphenous vein grafts (SVGs) in addition to the left internal mammary artery (IMA) graft is vitiated by poor long-term patency of the vein grafts. Hypothetically, the increased use of arterial grafts could confer even better outcomes. Our goal was to evaluate results after coronary artery bypass grafting in Sweden, where arterial grafts were used as a second conduit.

METHODS: Within the Swedish Web System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART) registry, we identified patients who had coronary artery bypass grafting from 2001 to 2015 using the IMA and the SVG, the radial artery (RA) or the additional IMA [bilateral IMA (BIMA)] as a second conduit. Deaths, postoperative incidence of coronary angiography and need for reintervention were recorded, and multivariable adjusted hazard ratios were calculated for different types of grafts.

RESULTS: The study population comprised 45 319 cases of IMA + SVG, 1225 cases of IMA + RA and 1697 cases of BIMA. The mean follow-up time (SD) was 9.2 (4.2) years for IMA + SVG, 11.2 (4.0) years for IMA + RA grafts and 9.2 (5.2) years for the BIMA graft. The adjusted hazard ratio for death was (95% confidence interval) 1.06 (0.95-1.18) for IMA + RA and 1.21 (1.10-1.33) for BIMA grafts compared with IMA + SVG. The adjusted hazard ratio for the first angiographic examination was (95% confidence interval) 0.89 (0.78-1.01) for IMA + RA and 1.07 (0.96-1.20) for BIMA grafts. The adjusted hazard ratio for the need for reintervention was (95% confidence interval) 0.88 (0.74-1.04) for IMA + RA and 1.14 (0.98-1.32) for BIMA grafts.

CONCLUSIONS: Patients who had arterial grafts as second conduits did not demonstrate a better outcome in any of the studied end-points. Radial artery grafts seem to be preferable to BIMA grafts as an alternative to an SVG.

Keywords
BIMA, Coronary artery bypass grafting (CABG), Radial artery, Registry study
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:uu:diva-342951 (URN)10.1093/ejcts/ezx280 (DOI)000424256500023 ()28958083 (PubMedID)
Note

Correction in: European Journal of Cardio-Thoracic Surgery, Volume: 53, Issue: 5, Pages: 1098-1098, DOI: 10.1093/ejcts/ezy123

Available from: 2018-02-23 Created: 2018-02-23 Last updated: 2019-09-01Bibliographically approved
3. Long-term clinical outcomes after coronary artery bypass grafting with pedicled saphenous vein grafts
Open this publication in new window or tab >>Long-term clinical outcomes after coronary artery bypass grafting with pedicled saphenous vein grafts
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.

Keywords
CABG, Coronary artery bypass grafting, No-touch, Pedicled vein grafts
National Category
Surgery
Identifiers
urn:nbn:se:uu:diva-369713 (URN)10.1186/s13019-018-0800-z (DOI)000451321400001 ()30477543 (PubMedID)
Available from: 2018-12-17 Created: 2018-12-17 Last updated: 2019-09-01Bibliographically approved
4. Long-term outcome after coronary endarterectomy adjunct to coronary artery bypass grafting.
Open this publication in new window or tab >>Long-term outcome after coronary endarterectomy adjunct to coronary artery bypass grafting.
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.

Keywords
Coronary artery bypass grafting, Coronary endarterectomy, Reintervention, Survival
National Category
Surgery
Identifiers
urn:nbn:se:uu:diva-390464 (URN)10.1093/icvts/ivy363 (DOI)30698788 (PubMedID)
Available from: 2019-08-10 Created: 2019-08-10 Last updated: 2019-09-01
5. Discovery of failed grafts after coronary artery bypass grafting during clinically-driven angiography.
Open this publication in new window or tab >>Discovery of failed grafts after coronary artery bypass grafting during clinically-driven angiography.
(English)Manuscript (preprint) (Other academic)
National Category
Surgery
Research subject
Thorax Surgery
Identifiers
urn:nbn:se:uu:diva-390465 (URN)
Available from: 2019-08-10 Created: 2019-08-10 Last updated: 2019-09-01

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Citation style
  • apa
  • ieee
  • modern-language-association-8th-edition
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  • Other locale
More languages
Output format
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