The Unplanned Postoperative Coronary Angiogram after CABG: Identifying the Patients at Risk
15 June 2015
02 September 2015
30 October 2015 (online)
Objectives Coronary artery bypass grafting (CABG) is the “gold standard” for patients with multiple vessel coronary artery disease (CAD). However, there is no “gold standard” to control bypass patency immediately postoperatively. “Post-completion” control angiogram (CA) is not routinely performed. We retrospectively analyzed the data of all patients undergoing urgent coronary angiogram post-CABG at our center.
Methods Between January 2005 and June 2011, a total of 6,025 patients underwent CABG (isolated or combined) for CAD in our hospital. In patients who underwent urgent postoperative CA, high serum cardiac enzymes (>100 CK-MB), severe new ECG changes, or unexpected low left ventricular function were present.
Results A total of 106 patients (1.8%) underwent post-CABG urgent coronary angiogram. Overall 30-day mortality in this cohort was 8.5%. The average time between the cardiac operation and the coronary angiogram in these patients was 3.41 ± 5.68 days. The rates for an urgent coronary angiogram were 1.3% (n = 25), 2% (n = 65), and 1.8% (n = 16) for total arterial, combined arterial, and venous and solely venous CABG, respectively. Twenty-four percent of patients underwent CABG bypass revision, while 32% of the patients underwent PTCA, stenting, or both. Younger patients, female patients, smaller patients, and patients receiving a combined arterial and venous revascularization were at a higher risk for an unplanned postoperative CA in the multivariate risk analysis.
Conclusion This study shows that the necessity for urgent post-CABG coronary angiogram is low (1.8%). However, more than half of the patients undergoing postoperative coronary angiogram needed reintervention, and, in spite of it, had high mortality. “Completion” control angiogram is not always feasible, patients at higher risk (e.g., female patients) should be identified and post-CABG coronary angiogram performed as soon as possible without undue delay, or a primary hybrid approach with an intraoperative CA should be applied.
The data from this manuscript were presented at the Annual Meeting of the European Society for Cardio-Thoracic Surgery in Barcelona (invited talk, Session: Controversies and catastrophes in adult cardiac surgery).
- 1 Mohr FW, Morice MC, Kappetein AP , et al. Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial. Lancet 2013; 381 (9867): 629-638
- 2 Kappetein AP, Feldman TE, Mack MJ , et al. Comparison of coronary bypass surgery with drug-eluting stenting for the treatment of left main and/or three-vessel disease: 3-year follow-up of the SYNTAX trial. Eur Heart J 2011; 32 (17) 2125-2134
- 3 Collins P, Webb CM, Chong CF, Moat NE ; Radial Artery Versus Saphenous Vein Patency (RSVP) Trial Investigators. Radial artery versus saphenous vein patency randomized trial: five-year angiographic follow-up. Circulation 2008; 117 (22) 2859-2864
- 4 Halabi AR, Alexander JH, Shaw LK , et al. Relation of early saphenous vein graft failure to outcomes following coronary artery bypass surgery. Am J Cardiol 2005; 96 (9) 1254-1259
- 5 Zhao DX, Leacche M, Balaguer JM , et al; Writing Group of the Cardiac Surgery, Cardiac Anesthesiology, and Interventional Cardiology Groups at the Vanderbilt Heart and Vascular Institute. Routine intraoperative completion angiography after coronary artery bypass grafting and 1-stop hybrid revascularization results from a fully integrated hybrid catheterization laboratory/operating room. J Am Coll Cardiol 2009; 53 (3) 232-241
- 6 Raabe Jr DS, Morise A, Sbarbaro JA, Gundel WD. Diagnostic criteria for acute myocardial infarction in patients undergoing coronary artery bypass surgery. Circulation 1980; 62 (4) 869-878
- 7 Lorusso R, Crudeli E, Lucà F , et al. Refractory spasm of coronary arteries and grafted conduits after isolated coronary artery bypass surgery. Ann Thorac Surg 2012; 93 (2) 545-551
- 8 Locker C, Schaff HV, Dearani JA , et al. Multiple arterial grafts improve late survival of patients undergoing coronary artery bypass graft surgery: analysis of 8622 patients with multivessel disease. Circulation 2012; 126 (9) 1023-1030
- 9 Fleissner F, Ius F, Haverich A, Ismail I. Extension of the right internal thoracic artery with the radial artery in extensive re-do coronary artery bypass grafting. J Cardiothorac Surg 2013; 8: 173
- 10 Hayward PA, Buxton BF. Contemporary coronary graft patency: 5-year observational data from a randomized trial of conduits. Ann Thorac Surg 2007; 84 (3) 795-799
- 11 Epstein AJ, Polsky D, Yang F, Yang L, Groeneveld PW. Coronary revascularization trends in the United States, 2001-2008. JAMA 2011; 305 (17) 1769-1776