Intraoperative graft assessment and imaging of native coronary arteries.
Ontology highlight
ABSTRACT:
SUBMITTER: Di Giammarco G
PROVIDER: S-EPMC7525909 | BioStudies | 2018-01-01
REPOSITORIES: biostudies
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Project description:Patients with functional ischemia often do not complain of chest symptoms even in early occlusion after coronary artery bypass grafting (CABG). The clinical evidence indicating the necessity of revascularization for these patients is unclear. A 70-year-old man who underwent 3 stent implant procedures to treat repeated in-stent restenosis to the left anterior descending artery (LAD) felt effort-related chest pain. Coronary angiography revealed that the patient's jailed diagonal had severe stenosis with delay and the LAD had intermediate stenosis. The instantaneous wave-free ratio (iFR) value of the LAD equalled 0.75. The patient underwent sequential CABG, where the left internal mammary artery (LIMA) to the LAD and diagonal artery grafts were performed. Although his effort-related chest pain disappeared, coronary and bypass angiography did not show flow competition in the diagonal branch and early occlusion in the LIMA to LAD graft was confirmed. The physiological assessment of the LAD did not reveal myocardial ischemia (iFR = 0.89 and fractional flow reserve = 0.87). This case highlights the importance of physiological assessment to detect cases of early graft occlusion. Although the LAD was not perfused from the CABG, the iFR value improved dramatically and pharmacological therapy without revascularization was successful for this patient. <Learning objective: The patient underwent coronary artery bypass grafting due to ischemia in the left anterior descending artery and diagonal branch. However, myocardial ischemia in two coronary artery branches was sufficiently improved by only one coronary artery bypass in this case. Physiological reassessment for early occlusion after bypass surgery is recommended for patients with myocardial ischemia.>.
2020-01-01 | S-EPMC7054663 | BioStudies
Project description:Pseudoaneurysm formation has been reported in degenerated coronary artery saphenous vein bypass grafts, as well as in native coronary arteries after interventional procedures or blunt trauma. In contrast, pseudoaneurysm formation arising from the anastomotic site of native coronary vessels soon after coronary artery bypass grafting is rare, and neither the clinical presentation of this phenomenon nor its treatment is well described. We present the case of a 63-year-old man, a recent coronary artery bypass grafting patient, who presented with acute coronary syndrome due to a large and expanding pseudoaneurysm of the saphenous vein-to-ramus intermedius artery graft anastomosis. After several attempts, we successfully treated the pseudoaneurysm by means of percutaneous coil embolization. To our knowledge, this is the first report of acute coronary syndrome secondary to a pseudoaneurysm at the coronary artery-saphenous vein graft anastomosis. In addition, this appears to be the first report of the percutaneous treatment of such a pseudoaneurysm by means of coil embolization.
1000-01-01 | S-EPMC4473626 | BioStudies
Project description:BACKGROUND:The internal mammary artery (IMA) is the preferred conduit for bypassing the left anterior descending (LAD) artery in patients undergoing coronary artery bypass grafting. Systematic evaluation of the frequency and predictors of IMA failure and long-term outcomes is lacking. METHODS AND RESULTS:The Project of Ex-vivo Vein Graft Engineering via Transfection (PREVENT) IV trial participants who underwent IMA-LAD revascularization and had 12- to 18-month angiographic follow-up (n=1539) were included. Logistic regression with fast false selection rate methods was used to identify characteristics associated with IMA failure (?75% stenosis). The relationship between IMA failure and long-term outcomes, including death, myocardial infarction, and repeat revascularization, was assessed with Cox regression. IMA failure occurred in 132 participants (8.6%). Predictors of IMA graft failure were LAD stenosis <75% (odds ratio, 1.76; 95% confidence interval, 1.19-2.59), additional bypass graft to diagonal branch (odds ratio, 1.92; 95% confidence interval, 1.33-2.76), and not having diabetes mellitus (odds ratio, 1.82; 95% confidence interval, 1.20-2.78). LAD stenosis and additional diagonal graft remained predictive of IMA failure in an alternative model that included angiographic failure or death before angiography as the outcome. IMA failure was associated with a significantly higher incidence of subsequent acute (<14 days of angiography) clinical events, mostly as a result of a higher rate of repeat revascularization. CONCLUSIONS:IMA failure was common and associated with higher rates of repeat revascularization, and patients with intermediate LAD stenosis or with an additional bypass graft to the diagonal branch had increased risk for IMA failure. These findings raise concerns about competitive flow and the benefit of coronary artery bypass grafting in intermediate LAD stenosis without functional evidence of ischemia. CLINICAL TRIAL REGISTRATION:URL: http:/www.clinicaltrials.gov. Unique identifier: NCT00042081.
2016-01-01 | S-EPMC4814323 | BioStudies
Project description:Background:It is generally agreed that using a bilateral internal thoracic artery (BITA) composite graft improves long-term survival after coronary artery bypass grafting (CABG). Although the left internal thoracic artery (LITA)-based Y-composite graft is widely adopted, technical or anatomical difficulties necessitate complex configurations. We aimed to investigate whether BITA configuration impacts survival or patency in patients undergoing coronary revascularization. Methods:Between January 2006 and June 2017, 1,161 patients underwent CABG at Seoul National University Bundang Hospital, where the standard technique is a LITA-based Y-composite graft with the right internal thoracic artery (RITA) sequentially anastomosed to non-left anterior descending (LAD) targets. Total of 160 patients underwent CABG using BITA with modifications. Their medical records and imaging data were reviewed retrospectively to investigate technical details, clinical outcomes, and graft patency. Results:Modifications of the typical Y-graft (group 1, n=90), LITA-based I-graft (group 2, n=39), and RITA-based composite graft (group 3, n=31) were used due to insufficient RITA length (47%), problems using LITA (28%), and target vessel anatomy (25%). The overall 30-day mortality rate was 1.9%. Among 116 patients who underwent computed tomography or conventional angiography at a mean interval of 29.9±33.1 months postoperatively, the graft patency rates were 98.7%, 95.3%, and 83.6% for the LAD, left circumflex artery, and right coronary artery territories, respectively. Patency rates for the inflow, secondary, and tertiary grafts were 98.2%, 90.5%, and 80.4%, respectively. The RITA-based graft (group 3) had the lowest patency rate of the various configurations (p<0.011). Conclusion:LITA-based Y composite graft, showed satisfactory clinical outcomes and patency whereas modifications of RITA-based composite graft had the lowest patency and 5-year survival rates. Therefore, when using RITA-based composite graft, other options should be considered before proceeding atypical configurations.
2020-01-01 | S-EPMC7155177 | BioStudies
Project description:We present the case of 56-year-old woman who required complex coronary artery bypass grafting for high-risk anomalous left main coronary artery (LMCA) originating from right coronary cusp including conventional reimplantation of the LMCA plus left internal mammary artery (LIMA) graft to the left anterior descending (LAD) and saphenous vein graft (SVG) to the left circumflex (LCx). On subsequent cardiac computed tomography screening and cardiac catheterization, the LIMA graft was occluded after just a few centimeters, but the SVG graft was patent with good run-off into the native LCx and also filled the LAD retrogradely. The reimplanted left main stem demonstrated at least moderate ostial stenosis although pressure wire assessment of this was not significant (fractional flow reserve 0.89), probably due to good retrograde filling of the LAD from the SVG to LCx, therefore, we did not proceed with ostial LMCA stenting. She remains on yearly review with a low threshold for further revascularization should the SVG to LCx develop progressive stenosis. This case illustrates how patients with anomalous LMCA may sometimes benefit from grafting in addition to conventional reimplantation.
2015-01-01 | S-EPMC4472642 | BioStudies
Project description:<h4>Background</h4>The inter-arterial anomalous course of the left main coronary artery (LMCA) originating from the right coronary sinus of Valsalva is a rare, though potentially lethal pathology. Coronary artery bypass grafting is a potential surgical therapy with previously reported success, however, there is concern for the possibility of graft occlusion in the setting of competitive native vessel flow.<h4>Case summary</h4>A 48-year-old gentleman presented to our facility with a non-ST elevation acute coronary syndrome. A malignant anomalous course of the LMCA was confirmed using invasive coronary angiography and computed tomography (CT). The patient underwent surgical revascularization of the left anterior descending artery with a left internal mammary artery (LIMA) graft, which was found to be atretic on follow-up CT. Seven years later the patient underwent repeat CT imaging, which confirmed recanalization of the previously atretic LIMA.<h4>Discussion</h4>We present the first documented case of a patient with spontaneous recanalization of an occluded LIMA following bypass surgery for an inter-arterial anomalous course of the LMCA. We postulate that the dynamic obstruction of the anomalous LMCA led to variable flow dependence on the bypass graft and subsequent atresia of the LIMA, due to the favourable native flow conditions in the absence of significant obstructive coronary disease. The exact mechanism of LIMA recanalization remains unclear, but in our case may have been partly mediated by a small increase in left main plaque.
2019-01-01 | S-EPMC6439389 | BioStudies
Project description:Off-pump coronary artery bypass grafting reduces postoperative morbidity and uses fewer resources than conventional surgical intervention with cardiopulmonary bypass. However, only 15% to 20% of coronary artery bypass grafting operations use off-pump coronary artery bypass. One reason for not using off-pump coronary artery bypass might be the surgeon's concern about the long-term patency of grafts performed with this technique. Therefore our objective was to compare long-term outcomes in patients randomized to off-pump coronary artery bypass or coronary artery bypass grafting with cardiopulmonary bypass.Participants in 2 randomized trials comparing off-pump coronary artery bypass and coronary artery bypass grafting with cardiopulmonary bypass were followed up for 6 to 8 years after surgical intervention to assess graft patency, major adverse cardiac-related events, and health-related quality of life. Patency was assessed by using multidetector computed tomographic coronary angiographic analysis with a 16-slice scanner. Two blinded observers classified proximal, body, and distal segments of each graft as occluded or not. Major adverse cardiac-related events and health-related quality of life were obtained from questionnaires given to participants and family practitioners.Patency was studied in 199 and health-related quality of life was studied in 299 of 349 survivors. There was no evidence of attrition bias. The likelihood of graft occlusion was no different between off-pump coronary artery bypass (10.6%) and coronary artery bypass grafting with cardiopulmonary bypass (11.0%) groups (odds ratio, 1.00; 95% confidence interval, 0.55-1.81; P > .99). Graft occlusion was more likely at the distal than the proximal anastomosis (odds ratio, 1.11; 95% confidence interval, 1.02-1.20). There were also no differences between the off-pump coronary artery bypass and coronary artery bypass grafting with cardiopulmonary bypass groups in the hazard of death (hazard ratio, 1.24; 95% confidence interval, 0.72-2.15) or major adverse cardiac-related events or death (hazard ratio, 0.84; 95% confidence interval, 0.58-1.24), or mean health-related quality of life across a range of domains and instruments.Long-term health outcomes with off-pump coronary artery bypass are similar to those with coronary artery bypass grafting with cardiopulmonary bypass when both operations are performed by experienced surgeons.
2009-01-01 | S-EPMC2836483 | BioStudies
Project description:Autologous veins are the most widely used grafts for bypassing small arteries in coronary and peripheral arterial occlusive diseases. However, they have limited availability and cause donor-site morbidity. Here, we report a direct comparison of acellular biodegradable synthetic grafts and autologous veins as interposition grafts of rat carotid arteries, which is a good model for clinically relevant small arteries. Notably, extensive but transient infiltration of circulating monocytes at day 14 in synthetic grafts leads to a quickly-resolved inflammation and arterial-like tissue remodeling. The vein graft exhibits a similar inflammation phase except the prolonged presence of inflammatory monocytes. The walls of the remodeled synthetic graft contain many circumferentially aligned contractile non-proliferative smooth muscle cells (SMCs), collagen and elastin. In contrast, the walls of the vein grafts contain disorganized proliferating SMCs and thicken over time, suggesting the onset of stenosis. At 3 months, both grafts have a similar patency, extracellular matrix composition, and mechanical properties. Furthermore, synthetic grafts exhibit recruitment and re-orientation of newly synthesized collagen fibers upon mechanical loading. To our knowledge, this is the first demonstration of a biodegradable synthetic vascular graft with a performance similar to an autologous vein in small artery grafting.
2018-01-01 | S-EPMC6743079 | BioStudies
Project description:The saphenous vein is the most common conduit used in coronary artery bypass grafting (CABG) yet its failure rate is higher compared to arterial grafts. An improvement in saphenous vein graft performance is therefore a major priority in CABG. No-touch harvesting of the saphenous vein is one of the few interventions that has shown improved patency rates, comparable to that of the left internal thoracic artery. After more than two decades of no-touch research, this technique is now recognized as a Class IIa recommendation in the 2018 European Society of Cardiology and the European Association for Cardio-Thoracic Surgery guidelines on myocardial revascularization. In this review, we describe the structural alterations that occur in conventional versus no-touch saphenous vein grafts and how these changes affect graft patency. In addition, we discuss various strategies aimed at repairing saphenous vein grafts prepared at conventional CABG.
2020-01-01 | S-EPMC7089755 | BioStudies
Project description:Coronary artery bypass grafting success is limited by vein graft failure (VGF). Understanding the factors associated with VGF may improve patient outcomes.We examined 1828 participants in the Project of Ex Vivo Vein Graft Engineering via Transfection IV (PREVENT IV) trial undergoing protocol-mandated follow-up angiography 12 to 18 months post-coronary artery bypass grafting or earlier clinically driven angiography. Outcomes included patient- and graft-level angiographic VGF (≥75% stenosis or occlusion). Variables were selected by using Fast False Selection Rate methodology. We examined relationships between variables and VGF in patient- and graft-level models by using logistic regression without and with generalized estimating equations. At 12 to 18 months post-coronary artery bypass grafting, 782 of 1828 (42.8%) patients had VGF, and 1096 of 4343 (25.2%) vein grafts had failed. Demographic and clinical characteristics were similar between patients with and without VGF, although VGF patients had longer surgical times, worse target artery quality, longer graft length, and they more frequently underwent endoscopic vein harvesting. After multivariable adjustment, longer surgical duration (odds ratio per 10-minute increase, 1.05; 95% confidence interval, 1.03-1.07), endoscopic vein harvesting (odds ratio, 1.41; 95% confidence interval, 1.16-1.71), poor target artery quality (odds ratio, 1.43; 95% confidence interval, 1.11-1.84), and postoperative use of clopidogrel or ticlopidine (odds ratio, 1.35; 95% confidence interval, 1.07-1.69) were associated with patient-level VGF. The predicted likelihood of VGF in the graft-level model ranged from 12.1% to 63.6%.VGF is common and associated with patient and surgical factors. These findings may help identify patients with risk factors for VGF and inform the development of interventions to reduce VGF.http://www.clinicaltrials.gov. Unique identifier: NCT00042081.
2014-01-01 | S-EPMC4206593 | BioStudies