Relative importance of patient, procedural and anatomic risk factors for early vein graft thrombosis after coronary artery bypass graft surgery.
ABSTRACT The aim of the present study was to investigate the relative importance of a wide array of patient demographic, procedural, anatomic and perioperative variables as potential risk factors for early saphenous vein graft (SVG) thrombosis after coronary artery bypass graft (CABG) surgery.
The patency of 611 SVGs in 291 patients operated on at four different hospitals enrolled in the Reduction in Graft Occlusion Rates (RIGOR) study was assessed six months after CABG surgery by multidetector computed tomography coronary angiography or clinically-indicated coronary angiography. The odds of graft occlusion versus patency were analyzed using multilevel multivariate logistic regression with clustering on patient.
SVG failure within six months of CABG surgery was predominantly an all-or-none phenomenon with 126 (20.1%) SVGs totally occluded, 485 (77.3%) widely patent and only 16 (2.5%) containing high-grade stenoses. Target vessel diameter ≤ 1.5 mm (adjusted OR 2.37, P=0.003) and female gender (adjusted OR 2.46, P=0.01) were strongly associated with early SVG occlusion. In a subgroup analysis of 354 SVGs in which intraoperative graft blood flow was measured, lower mean flow was also significantly associated with SVG occlusion when analyzed as a continuous variable (adjusted OR 0.984, P=0.006) though not when analyzed dichotomously, <40 mL/min versus ≥ 40 mL/min (adjusted OR 1.86, P=0.08).
Small target vessel diameter, female gender and low mean graft blood flow are significant risk factors for SVG thrombosis within six months of CABG surgery in patients on postoperative aspirin therapy. This information may be useful in guiding revascularization strategies in selected patients.
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ABSTRACT: Background: Elevated urine 11-dehydro TXB(2) , an indicator of persistent thromboxane generation in aspirin-treated patients, correlates with adverse cardiovascular outcome and has recently been identified as an independent risk factor for vein graft thrombosis after cardiac bypass surgery in the Reduction in Graft Occlusion Rates (RIGOR) study. The polyclonal antibody-based ELISA used to measure 11-dehydro TXB(2) in these studies is no longer clinically available and has been supplanted by an FDA-cleared second-generation monoclonal antibody-based ELISA. Objectives: To compare the laboratory and clinical performance of the first- and second-generation assays in a well-defined study population. Methods: 11-dehydro TXB(2) was quantified in 451 urine samples from 229 RIGOR subjects using both ELISA. Ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) and spiking studies were used to investigate discordant assay results. The association of 11-dehydro TXB(2) to clinical outcome was assessed for each assay using multivariate modeling. Results: Median 11-dehydro TXB(2) levels were higher by monoclonal antibody- compared to polyclonal antibody-based ELISA (856 versus 399 pg/mg creatinine, p<0.000001), with the latter providing values similar to UPLC-MS/MS. This discrepancy was predominantly due to cross-reactivity of the monoclonal antibody with 11-dehydro-2,3-dinor TXB(2) , a thromboxane metabolite present in similar concentration but with poor direct correlation to 11-dehydro TXB(2) . In contrast to the first-generation ELISA, 11-dehydro TXB(2) measured by the monoclonal antibody-based ELISA failed to associate with risk of vein graft occlusion. Conclusion: Quantification of urine 11-dehydro TXB(2) by monoclonal antibody-based ELISA was confounded by interference from 11-dehydro-2,3-dinor TXB(2) which reduced the accuracy and clinical utility of this second-generation assay. © 2012 International Society on Thrombosis and Haemostasis.Journal of Thrombosis and Haemostasis 10/2012; · 6.08 Impact Factor
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ABSTRACT: To evaluate the effect of a 12-month course of weekly lipid apheresis on vein graft patency after coronary artery bypass grafting (CABG) in patients with hyperlipidemia refractory to statins. In a 12-month prospective controlled clinical trial we enrolled 34 male patients (mean age 57 ± 8 years) who passed through successful CABG and low-density lipoprotein cholesterol (LDL-C) level >2.6 mmol/L prior to the operation despite statin treatment. Patients were allocated into 2 groups: active (n = 17, weekly apheresis by cascade plasma filtration (CPF) plus atorvastatin), and control (n = 17, atorvastatin alone). Graft patency was evaluated by multislice computed tomography at 3 months and by angiography at 12 months after an operation. Both groups were comparable in clinical and biochemical characteristics. During each CPF procedure, LDL-C level decreased by 64 ± 9%, apoB - by 65 ± 8%, Lp(a) - by 52 ± 15%,; these changes were significant compared to baseline and the control group. Mean net difference in LDL-C level between apheresis and control groups was 1.1 ± 0.3 mmol/L. Vein graft patency at study end was 88.2% (45 of 51) in the apheresis group versus 72.7% (40 of 55) in the control group (p = 0.05). Use of apheresis was associated with decreased vein graft occlusions by 46%: relative risk 0.54; 95% confidence interval 0.27 to 1.02; p = 0.05. Our data suggest that the use of lipoprotein apheresis with CPF results in a better vein graft patency during the first year after CABG in patients with hyperlipidemia refractory to statins.Atherosclerosis. Supplements 01/2013; 14(1):101-5. · 4.94 Impact Factor
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ABSTRACT: A significant number of patients may not benefit from conventional techniques of myocardial revascularization due to diffuse coronary artery disease (CAD) or small coronary arterial sizes because of smaller arteries causing anastomotic technical difficulties and poor run-off. Diabetic patients have a more severe and diffuse coronary atherosclerosis with smaller coronary arteries limiting the possibility to perform a successful and complete revascularization, but this has not been examined in prediabetics. To evaluate whether there is an association between prediabetes and the coronary arterial size. We prospectively studied 168 consecutive patients with CAD and 172 patients with normal coronary artery anatomy (NCA). Patients were divided into three groups according to hemoglobin (Hb) A1c levels as "normal," "prediabetic," and "diabetic" groups, and the coronary artery sizes and Gensini scores were analyzed. There were 78 female patients and 90 male patients in the CAD group, and 87 female patients and 85 male patients in the NCA group. There was a statistically significant difference in distal and proximal total coronary arterial size among the CAD and NCA groups for both genders. There was a positive correlation between the HbA1c subgroups and Gensini score (Spearman's ρ: 0.489, p<0.001 in female group; Spearman's ρ: 0.252 p=0.016 in male group). We found that prediabetic patients have a smaller coronary size and diffuse coronary narrowing for both genders, particularly in distal coronary arterial tree of left anterior descending coronary artery. The early detection of prediabetes in daily cardiology practice may provide more appropriate coronary lesion for percutaneous or surgical revascularization.Journal of Cardiology 09/2013; · 2.57 Impact Factor