Influence of Prior Coronary Stenting on the Immediate and Mid-term Outcome of Isolated Coronary Artery Bypass Surgery

Abstract

Background

There has been little emphasis on the possible consequences of prior stent placement on the outcome of coronary bypass surgery (CABG). We compared the results of isolated CABG patients who had prior stents with those who had not with respect to preoperative status, operative procedure, and postoperative immediate and long-term outcome.

Methods

Records of 1471 patients undergoing isolated CABG at our institution between January 1, 2000, and March 31, 2005, were reviewed. Patients were divided into three groups. Group I had no stents (n = 1317). Group II had one to three stents (n = 137). Group III had more than three stents (n = 17). Groups were compared with respect to preoperative risk factors, operative procedures, and postoperative results. Long-term survival data were obtained on 97.6% of patients with a mean follow-up, 4.1 ± 2.3 years.

Results

Stented patients were younger (66.1 ± 10.8 vs. 69.1 ± 10.8 years, P = 0.006), had more unstable angina (68.2% vs. 58.9%, P = 0.02), hypercholesterolemia (83.8% vs. 61.2%, P = 0.00), chronic obstructive pulmonary disease (13.6% vs. 8.4%, P = 0.03), peripheral vascular disease (15.2% vs. 8.4%, P = 0.00), and previous CABG (10.1% vs. 4.2%, P = 0.00), fewer low ejection fractions (1.3% vs. 5.2%, P = 0.02), left main disease (25.3% vs. 32.6%, P = 0.04), diabetes (31.2% vs. 40.8%, P = 0.01), or diffuse disease (19.5 ± 10.5 vs. 22.5 ± 10.9, P = 0.00), had more off pump procedures (53.2% vs. 45.3%, P = 0.03), fewer internal thoracic artery grafts (80.5% vs. 86.6%, P = 0.03), fewer grafts placed (>3: 52.6% vs. 61.8%, P = 0.02), more complications (76.5% vs. 42.6%, P = 0.005), atrial fibrillation (47.1% vs. 19.7%, P = 0.011), longer hospital stays (12.2 vs. 8.3 days, P = 0.019). Percentage survival for groups I, II, and III at 60 months was 82.1%, 84.7%, and 72.6%, respectively.

Conclusions

Stents placed before surgery in isolated CABG patients may be associated with higher preoperative risk, altered operative procedures, more postoperative complications, longer hospitalizations, and more readmissions. Overall, stented patients experienced more preoperative hospitalizations, catheterizations, and percutaneous coronary interventions (PCIs) than nonstented patients. Survival for those with more than three stents may be diminished.

Keywords

Coronary bypass surgery Percutaneous catheter intervention Stents Immediate and mid-term follow-up Multiple coronary stents Risk of repeated PCI

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References

Ferreira

A.C.

, Peter

A.A.

, Salerno

T.A.

Clinical impact of drug-eluting stents in changing referral practices for coronary surgical revascularization in a tertiary care center. Ann Thorac Surg. 2003; 75: 485–489.

Liddicoat

J.R.

, De La Torre

, Ho

K.K.L.

Initial impact of drug-eluting stents on coronary artery bypass graft surgery. Ann Thorac Surg. 2006; 81: 1239–1242.

Locker

, Mohr

, Lev-Ran

Comparison of bilateral thoracic artery grafting with percutaneous coronary interventions in diabetic patients. Ann Thorac Surg. 2004; 78: 471–475.

Rihal

C.S.

, Raco

D.L.

, Gersh

B.J.

, Yusuf

Indications for coronary artery bypass surgery and percutaneous coronary intervention in chronic stable angina: review of the evidence and methodological considerations. Circulation. 2003; 108): 2439–2445.

Berger

P.B.

, Sketch

M.H.

Jr. , Califf

R.M.

Choosing between percutaneous coronary intervention and coronary artery bypass grafting for patients with multivessel disease: what can we learn from the Arterial Revascularization Therapy Study (ARTS)?

Circulation. 2004; 109: 1079–1081.

Cutlip

D.E.

, Chhabra

A.G.

, Baim

D.S.

Beyond restenosis: five-year clinical outcomes from second-generation coronary stent trials. Circulation. 2004; 110: 1226–1230.

Drenth

D.J.

, Veeger

NJGM

, Grandjean

J.G.

Isolated high-grade lesion of the proximal LAD: a stent or off-pump LIMA?

Eur J Cardiothorac Surg. 2004; 25: 567–571.

Legrand

V.M.G.

, Serruys

P.W.

, Unger

F.B.

Three-year outcome after coronary stenting versus bypass surgery for the treatment of multivessel disease. Circulation. 2004; 109: 1114–1120.

Lytle

B.W.

, Block

P.C.

PCI or CABG—which is better for the patient?

Cardiovasc Rev J. 2006; 15: 16–19.

10.

Moses

J.W.

, Leon

M.B.

, Fitzgerald

P.J.

Sirolimus-eluting stents versus standard stents in patients with stenosis in native coronary artery. N Engl J Med. 2004; 349: 1315–1323.

11.

Rodriguez

, Bernardi

, Navia

Argentine Randomized Study: coronary angioplasty with stenting versus coronary bypass surgery in patients with multiple-vessel disease (ERACI II): 30-day and one-year follow-up results. ERACI II Investigators. JACC. 2001; 37: 51–58.

12.

Sedlis

S.P.

, Morrison

D.A.

, Lorin

J.D.

Percutaneous coronary intervention versus coronary bypass graft surgery for diabetic patients with unstable angina and risk factors for adverse outcomes with bypass: outcome of diabetic patients in the AWESOME randomized trial and registry. JACC. 2002; 40: 1555–1566.

13.

Thielmann

, Leyh

, Massoudy

Prognostic significance of multiple previous percutaneous coronary interventions in patients undergoing elective coronary artery bypass surgery. Circulation. 2006; 114: 441–447.

14.

Thielmann

, Neuhauser

, Knipp

Prognostic impact of previous percutaneous coronary intervention in patients with diabetes mellitus and triple-vessel disease undergoing coronary artery bypass surgery. J Thorac Cardiovasc Surg. 2007; 134: 470–476.

15.

Shroyer

A.L.W.

, Coombs

L.P.

, Peterson

E.D.

The Society of Thoracic Surgeons: 30-day operative mortality and morbidity risk models. Ann Thorac Surg. 2003; 75: 1856–1865.

16.

Nashef

S.A.M.

, Roques

, Hammill

B.G.

Validation of European System for Cardiac Operative Risk Evaluation (EuroSCORE) in North American cardiac surgery. Eur J Cardiothorac Surg. 2002; 22: 101–105.

17.

Nashef

S.A.M.

, Roques

, Michel

European system for cardiac operative risk evaluation (EuroSCORE). Eur J Cardiothorac Surg. 1999; 16: 9–13.

18.

Roques

, Nashef

S.A.M.

, Michael

Risk factors and outcome in European cardiac surgery: analysis of the EuroSCORE multinational database of 19030 patients. Eur J Cardiothorac Surg. 1999; 15: 816–823.

19.

Roques

, Michel

, Goldstone

The logistic EuroSCORE. Eur Heart J. 2003; 24: 1–2.

20.

Shaw

R.E.

, Anderson

H.V.

, Brindis

Updated risk adjustment mortality model using the complete 1.1 dataset from the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR). J Invasive Cardiol. 2003; 25: 578–580.

21.

Brener

S.J.

, Lytle

B.W.

, Casserly

I.P.

Propensity analysis of long-term survival after surgical or percutaneous revascularization in patients with multivessel coronary artery disease and high-risk features. Circulation. 2004; 109: 2290–2295.

22.

Mark

D.B.

, Nelson

C.L.

, Califf

R.M.

Continuing evolution of therapy for coronary artery disease. Initial results from the era of coronary angioplasty. Circulation. 1994; 89: 2015–2025.

23.

Smith

L.R.

, Harrell

F.E.

, Rankin

J.S.

Determinants of early versus late cardiac death in patients undergoing coronary artery bypass graft surgery. Circulation. 1991; 84(suppl III): III-245–III-253.

24.

Davis

K.B.

, Fisher

, Gillespie

M.J.

, Pettinger

A test of the National Death Index using the Coronary Artery Surgery Study (CASS). Controlled Clin Trials. 1985; 6: 179–191.

25.

Williams

B.C.

, Demitrack

L.B.

, Fries

B.E.

The accuracy of the National Death Index when personal identifiers other than Social Security number are used. Am J Public Health. 1992; 82: 1145–1147.

26.

Eberli

F.R.

, Meier

Coronary bypass surgery vs coronary angioplasty: a look to the past for new insights into the future. Eur Heart J. 2002; 23: 511–514.

27.

Flaherty

J.D.

, Davidson

C.J.

Diabetes and coronary revascularization. JAMA. 2005; 293: 1501–1508.

28.

Hannan

E.L.

, Racz

M.J.

, Walford

Long-term outcomes of coronary-artery bypass grafting versus stent implantation. N Engl J Med. 2005; 352: 2174–2183.

29.

Herzog

C.A.

, Ma

J.Z.

, Collins

A.J.

Comparative survival of dialysis patients in the United States after coronary angioplasty, coronary artery stenting, and coronary artery bypass surgery and impact of diabetes. Circulation. 2002; 106: 2207.

30.

Mak

K.H.

, Faxon

D.P.

Clinical studies on coronary revascularization in patients with type 2 diabetes. Eur Heart J. 2003; 24: 1087–1103.

31.

Mikhail

, Airoldi

, Tavano

The use of drug eluting stents in single and multivessel disease: results from a single centre experience. Heart. 2004; 90: 990–994.

32.

Beohar

, Davidson

C.J.

, Kip

K.F.

Outcomes and complications associated with off-label and untested use of drug-eluting stents. JAMA. 2007; 297: 1992–2000.

33.

Win

H.K.

, Caldera

A.E.

, Maresh

Clinical outcomes and stent thrombosis following off-label use of drug-eluting stents. JAMA. 2007; 297: 2001–2009.

34.

King

III , Dangas

, Moses

J.W.

Surgery is preferred for the diabetic with multivessel disease. Circulation. 2005; 112: 1500–1515.

35.

Abizaid

, Costa

M.A.

, Centemero

Clinical and economic impact of diabetes mellitus on percutaneous and surgical treatment of multivessel coronary disease patients. Insights from the Arterial Revascularization Therapy Study (ARTS) Trial. Circulation. 2001; 104: 533–538.

36.

Briguori

, Condorelli

, Airoldi

Impact of microvascular complications on outcome after coronary stent implantations in patients with diabetes. JACC. 2005; 45: 464–466.

37.

Sobel

A.E.

, Frye

, Detre

K.M.

Burgeoning dilemmas in the management of diabetes and cardiovascular disease: rationale for the bypass angioplasty revascularization. Investigation 2 Diabetes (BARI 2D) Trial. Circulation. 2003; 107: 636–642.

38.

Smith

S.C.J.

, Feldman

T.E.

, Hirshfeld

J.W.J.

ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to update the 2001 guidelines for percutaneous coronary intervention). JACC. 2006; 47: e1–e121.

39.

Weintraub

W.S.

, Mahoney

E.M.

, Zhang

One year comparison of costs of coronary surgery versus percutaneous coronary intervention in the stent or surgery trial. Heart. 2004; 90: 782–788.

40.

Griffin

S.C.

, Barber

J.A.

, Manca

Cost effectiveness of clinically appropriate decisions on alternative treatments for angina pectoris: prospective observational study. BMJ. 2007; 334: 624–632.

41.

Rao

, Aziz

, Panesar

S.S.

Cost effectiveness analysis of minimally invasive internal thoracic artery bypass versus percutaneous revascularisation for isolated lesions of the left anterior descending artery. BMJ. 2007; 334: 621–628.

42.

Taggart

D.P.

Coronary artery bypass grafting is still the best treatment for multivessel and left main disease, but patients need to know. Ann Thorac Surg. 2006; 82: 1966–1975.