Complete Arterial Revascularisation in Patients Older than 70 Years[1]

Background: Coronary artery bypass grafting (CABG) using left internal thoracic artery and vein grafts is standard in patients of advanced age. A number of these patients, however, present without suitable vein grafting material and thus require the use of arterial conduits. In order to investigate the safety and efficacy of complete arterial revascularisation, we have compared the perioperative results of patients older than 70 years with conventional CABG and complete arterial revascularisation. Patients and Methods: Group I (n = 172) with conventional CABG in 1999 was compared with 152 patients (group II) with complete arterial CABG between 1996 and July 2000. There were no significant differences regarding age, gender, left ventricular ejection fraction or incidence of three-vessel disease or left main stenosis. The proportion of reoperations was significantly higher in group II (16 %) vs. group I (4 %). Results: A mean of 3.7 ± 0.7 anastomoses (I) versus 4.0 ± 0.9 (II) were performed per patient (p = n. s.). Mean operating time (I: 210 ± 46 min; II: 194 ± 46 min) and bypass time (I: 87 ± 25 min; II: 78 ± 29 min) were significantly lower in group II. Ischemic time (I: 46 ± 22 min; II: 49 ± 21 min) was not significantly different. The incidence of sternal dehiscence was 2.9 % (I: n = 5) vs. 1.3 % (II: n = 2). Hospital mortality was 4.6 % in group I vs. 3.9 % (II). Conclusion: Complete arterial revascularisation is a safe option in patients aged over 70. It remains to be shown whether it may also have advantage in the long term.

Key words:

Coronary surgery - Elderly patient - Arterial grafts - T-grafts - Radial artery

1 Presented at the 30th Annual Meeting of the German Society of Thoracic and Cardiovascular Surgery, February 2001

References

• 1 Edwards F H, Clark R E, Schwartz M. Impact of internal mammary artery conduits on operative mortality in coronary revascularization.  Ann Thorac Surg. 1994;  57 27-32
• 2 Gardner T J, Greene P S, Rykiel M F. et al . Routine use of the left internal mammary artery graft in the elderly.  Ann Thorac Surg. 1990;  49 188-194
• 3 Aades M, Fessler F H, Starr A. Five-year result of coronary bypass graft in patients older than 70 years: role of internal mammary artery.  Ann Thorac Surg. 1990;  50 940
• 4 Loop F D, Lytle B W, Cosgrove D M. et al . Influence of the internal mammary artery graft on 10-year survival and other cardiac events.  N Engl J Med. 1986;  314 1-6
• 5 Bergsma T M, Grandjean J G, Voors A V. et al . Low recurrence of angina pectoris after coronary artery bypass surgery with bilateral internal thoracic and right gastroepiploic arteries.  Circulation. 1998;  97 2402-2405
• 6 Gurevitch J, Paz Y, Shapira I, Matsa M, Kramer A, Pevni D. et al . Routine use of bilateral skeletonized internal mammary arteries for myocardial revascularization.  Ann Thorac Surg. 1999;  68 406-412
• 7 Wendler O, Hennen B, Markwirth T, Langer F, Graeter T h, Schäfers H J. Complete arterial revascularization in the diabetic patient - early postoperative results. Thorac Cardiovasc Surg 2001:
• 8 Bamer H B, Sundt T M. Multiple arterial grafts and survival.  Curr Opin Cardiol. 1999;  14 501-505
• 9 Acar C, Jebara V A, Porthoghese M. et al. Revival of the radial artery for coronary artery bypass grafting.  Ann Thorac Surg. 1992;  54 652-660
• 10 Lytle B W, Blackstone E H, Loop F D. et al . Two internal thoracic artery grafts are better than one.  J Thorac Cardiovasc Surg. 1999;  117 855-872
• 11 Jones J W, Schmidt S E, Miller 111 C C, Beall A C, Baldwin J C. Bilateral internal thoracic artery operations in the elderly.  J Cardiovasc Surg. 2000;  41 165-170
• 12 Wendler O, Hennen B, Demertzis S. et al . Complete arterial revascularization in multivessel coronary artery disease with two conduits (skeletonized grafts/T-grafts).  Circulation. 2000;  102 (suppl Ill) lll-79-lll-83
• 13 Parisian Mediastinitis Study G roup. Risk factors for deep sternal wound infection after stemotomy: a prospective, multicenter study.  J Thorac Cardiovasc Surg. 1996;  111 1200-1207
• 14 Wendler O, Tscholl D, Huang Q, Schäfers H J. Free flow capacity of skeletonized versus pedicled internal thoracic artery grafts in CABG.  Eur J Cardio Thorac Surg. 1999;  15 247-250
• 15 Calafiore A M, Vitolla G, laco A L. et al . Bilateral internal mammary artery grafting: Midterm results of pedicled versus skeletonized conduits.  Ann Thorac Surg. 1999;  67 1637-1642
• 16 Gaudino M, Toesca A, Nori S L, Glieca F, Possati G. Effect of skeletonization of the internal thoracic artery on vessel wall integrity.  Ann Thorac Surg. 1999;  68 1623-1627
• 17 Huddleston C B, Stoney W S, Alford W C. et al . Internal mammary artery grafts: Technical factors influencing patency.  Ann Thorac Surg. 1986;  42 543-549
• 18 Markwirth T, Hennen B, Scheller B, Schäfers H J, Wendler O. Flow wire measurements after complete arterial coronary revascularization with T-grafts: quantitative blood flow in the grafts is dependent in competing flow from native coronary arteries. Ann Thorac Surg 2001:

1 Presented at the 30th Annual Meeting of the German Society of Thoracic and Cardiovascular Surgery, February 2001