Turkiye Klinikleri Cardiovascular Sciences

.: ORIGINAL RESEARCH
Effect of Previous Stent Implantation in Elective Coronary Artery Bypass Grafting Operation; Multivariate Analysis of 1,259 Patients: Retrospective Clinical Trial
Geçirilmiş Stent İmplantasyonunun Elektif Koroner Arter Baypas Greft Operasyonundaki Etkisi; 1.259 Hastanın Multivaryant Analizi: Retrospektif Klinik Çalışma
Mehmet Erdem TOKERa , Muharrem DAĞLIb , Cüneyt ARKANc , Ömer Faruk AKARDEREa
aDepartment of Cardiovascular Surgery, University of Health Sciences Koşuyolu Heart Training and Research Hospital, İstanbul, Türkiye
bClinic of Cardiovascular Surgery, Gebze Fatih State Hospital, İzmit, Türkiye
cClinic of Cardiovascular Surgery, Tunceli State Hospital, Tunceli, Türkiye
Turkiye Klinikleri J Cardiovasc Sci. 2023;35(2):31-7
doi: 10.5336/cardiosci.2022-95172
Article Language: EN
Full Text
ABSTRACT
 Objective: This study aims to investigate the effect of previous stent implantation on early mortality in patients undergoing elective coronary artery bypass grafting (CABG). Material and Methods: A total of 1,259 patients who underwent elective isolated CABG between January 2015 and December 2016 were included. There were 970 patients in the CABG without stent group and 289 patients in the CABG with stent group. Preoperative, intraoperative, and postoperative data of both groups were compared. Predictors of early mortality in CABG were examined using the logistic regression analysis. Results: Early mortality rates after surgery between the groups were similar (CABG without stent group vs. CABG with stent group; 2.9% vs. 3.1%, p=0.998). The length of intensive care unit stay, the use of intraaortic balloon pump, tracheotomy, new dialysis, revision and the use of extracorporeal membrane oxygenator were also comparable between the groups (p>0.05). The mean number of grafts was significantly lower in the CABG with stent group than the CABG without stent group (2.62±0.91 vs. 2.87±0.9; p<0.001 respectively). Multivariate analysis revealed that an ejection fraction of ≤40% [odds ratio (OR): 3.8; 95% confidence interval (CI): 1.9-7.7; p<0.001], preoperative renal failure (OR: 3.7; 95% CI: 1.5-8.8; p=0.003), and advanced age (OR: 1.07; 95% CI: 1.03-1.1; p<0.001) were independent predictors of early mortality. Previous stent implantation has not been found out as a risk factor for early mortality (OR: 1.08; 95% CI: 0.5-2.3; p=0.998). Conclusion: Previous stent implantation was not found to be a factor affecting early mortality in patients undergoing elective CABG operations.

Keywords: Coronary artery bypass; cardiopulmonary bypass; extracorporeal membrane oxygenation; percutaneous transluminal coronary angioplasty; stents
ÖZET
 Amaç: Bu çalışmada, koroner arter baypas greftleme (KABG) yapılan hastalarda geçirilmiş stent implantasyonunun erken dönem mortaliteye olan etkisi araştırıldı. Gereç ve Yöntemler: Ocak 2015- Aralık 2016 yılları arasında elektif izole KABG yapılan toplam 1.259 hasta çalışmaya dâhil edildi. KABG stentsiz grupta 970 hasta yer alırken, KABG stentli grupta 289 hasta vardı. Her iki grup ameliyat öncesi, ameliyat sırası ve ameliyat sonrası özellikler açısından karşılaştırıldı. Lojistik regresyon analizi ile KABG'de erken dönem mortaliteyi etkileyen faktörler araştırıldı. Bulgular: Ameliyat sonrası erken mortalite oranları her iki grupta benzerdi (KABG stentsiz gruba oranla KABG stentli grup; %2,9'a karşı %3,1, p=0,998). Yoğun bakım ünitesinde kalış süresi, intraaortik balon pompası kullanım oranı, trakeostomi, yeni diyaliz, reviyon ve ekstrakorporeal sirkülasyon kullanım oranları her iki grupta karşılaştırılabilir düzeydeydi (p>0,05). Ortalama greft sayısı, KABG stentli grupta, KABG stentsiz gruba göre anlamlı düzeyde daha düşüktü (2,62±0,91'e karşı 2,87±0,9; p<0,001). Çok değişkenli analizde ≤%40 ejeksiyon fraksiyon [göreceli olasılıklar oranı (odds ratio ''OR''): 3,8; %95 güven aralığı (confidence interval ''CI''): 1,9-7,7; p<0,001], ameliyat öncesi böbrek yetersizliği (OR: 3,7; %95 CI: 1,5-8,8; p=0,003) ve ileri yaş (OR: 1,07; %95 CI: 1,03-1,1; p<0,001) erken dönem mortaliteyi etkileyen bağımsız öngördürücüler olarak bulundu. Geçirilmiş stent implantasyonu, erken mortaliteyi etkileyen bir risk faktörü olarak saptanmadı (OR: 1,08; %95 CI: 0,5-2,3; p=0,998). Sonuç: Elektif koroner arter baypas operasyonu yapılan hastalarda, geçirilmiş stent implantasyonu erken mortaliteyi etkileyen bir faktör olarak bulunmamıştır.

Anahtar Kelimeler: Koroner arter baypas; kardiyopulmoner baypas; yapay dolaşım membran oksijenasyonu; perkütan translüminal koroner anjiyoplasti; stentler
REFERENCES:
  1. O'Brien SM, Shahian DM, Filardo G, Ferraris VA, Haan CK, Rich JB, et al; Society of thoracic surgeons quality measurement task force. The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 2--isolated valve surgery. Ann Thorac Surg. 2009;88(1 Suppl):S23-42. [Crossref]  [PubMed] 
  2. ElBardissi AW, Aranki SF, Sheng S, O'Brien SM, Greenberg CC, Gammie JS. Trends in isolated coronary artery bypass grafting: an analysis of the Society of Thoracic Surgeons adult cardiac surgery database. J Thorac Cardiovasc Surg. 2012;143(2):273-81. [Crossref]  [PubMed] 
  3. Kötting J, Beckmann A, Döbler K, Schäfer E, Veit C, Welz A, et al. German CABG score: a specific risk model for patients undergoing isolated coronary artery bypass grafting. Thorac Cardiovasc Surg. 2014;62(4):276-87. [Crossref]  [PubMed] 
  4. Kindo M, Hoang Minh T, Perrier S, Bentz J, Mommerot A, Billaud P, et al. Trends in isolated coronary artery bypass grafting over the last decade. Interact Cardiovasc Thorac Surg. 2017;24(1):71-6. [Crossref]  [PubMed] 
  5. Movahed MR, Ramaraj R, Jamal MM, Hashemzadeh M. Nationwide trends in the utilization of multivessel percutaneous coronary intervention (MVPCI) in the United States across different gender and ethnicities. J Interv Cardiol. 2009;22(3):247-51. [Crossref]  [PubMed] 
  6. Hakamada K, Sakaguchi G, Marui A, Arai Y, Nagasawa A, Tsumaru S, et al. Effect of multiple prior percutaneous coronary interventions on outcomes after coronary artery bypass grafting. Circ J. 2021;85(6):850-6. [Crossref]  [PubMed] 
  7. Lisboa LA, Mejia OA, Dallan LA, Moreira LF, Puig LB, Jatene FB, et al. Previous percutaneous coronary intervention as risk factor for coronary artery bypass grafting. Arq Bras Cardiol. 2012;99(1):586-95. English, Portuguese. [Crossref]  [PubMed] 
  8. Thielmann M, Leyh R, Massoudy P, Neuhäuser M, Aleksic I, Kamler M, et al. Prognostic significance of multiple previous percutaneous coronary interventions in patients undergoing elective coronary artery bypass surgery. Circulation. 2006;114(1 Suppl):I441-7. [Crossref]  [PubMed] 
  9. Tran HA, Barnett SD, Hunt SL, Chon A, Ad N. The effect of previous coronary artery stenting on short- and intermediate-term outcome after surgical revascularization in patients with diabetes mellitus. J Thorac Cardiovasc Surg. 2009;138(2):316-23. [Crossref]  [PubMed] 
  10. Thielmann M, Neuhäuser M, Knipp S, Kottenberg-Assenmacher E, Marr A, Pizanis N, et al. 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(2):470-6. [Crossref]  [PubMed] 
  11. Nakazawa G, Otsuka F, Nakano M, Vorpahl M, Yazdani SK, Ladich E, et al. The pathology of neoatherosclerosis in human coronary implants bare-metal and drug-eluting stents. J Am Coll Cardiol. 2011;57(11):1314-22. [Crossref]  [PubMed]  [PMC] 
  12. Yoneda S, Abe S, Kanaya T, Oda K, Nishino S, Kageyama M, et al. Late-phase inflammatory response as a feature of in-stent restenosis after drug-eluting stent implantation. Coron Artery Dis. 2013;24(5):368-73. [Crossref]  [PubMed] 
  13. Mitsutake Y, Ueno T, Yokoyama S, Sasaki K, Sugi Y, Toyama Y, et al. Coronary endothelial dysfunction distal to stent of first-generation drug-eluting stents. JACC Cardiovasc Interv. 2012;5(9):966-73. [Crossref]  [PubMed] 
  14. Yap CH, Yan BP, Akowuah E, Dinh DT, Smith JA, Shardey GC, et al. Does prior percutaneous coronary intervention adversely affect early and mid-term survival after coronary artery surgery? JACC Cardiovasc Interv. 2009;2(8):758-64. [Crossref]  [PubMed] 
  15. Ueki C, Miyata H, Motomura N, Sakaguchi G, Akimoto T, Takamoto S. Previous percutaneous coronary intervention does not increase adverse events after coronary artery bypass surgery. Ann Thorac Surg. 2017;104(1):56-61. [Crossref]  [PubMed] 
  16. Massoudy P, Thielmann M, Lehmann N, Marr A, Kleikamp G, Maleszka A, et al. Impact of prior percutaneous coronary intervention on the outcome of coronary artery bypass surgery: a multicenter analysis. J Thorac Cardiovasc Surg. 2009;137(4):840-5. [Crossref]  [PubMed] 
  17. Stevens LM, Khairy P, Agnihotri AK. Coronary artery bypass grafting after recent or remote percutaneous coronary intervention in the Commonwealth of Massachusetts. Circ Cardiovasc Interv. 2010;3(5):460-7. [Crossref]  [PubMed] 
  18. Mariscalco G, Rosato S, Serraino GF, Maselli D, Dalén M, Airaksinen JKE, et al. Prior percutaneous coronary intervention and mortality in patients undergoing surgical myocardial revascularization: results from the E-CABG (European Multicenter Study on Coronary Artery Bypass Grafting) with a systematic review and meta-analysis. Circ Cardiovasc Interv. 2018;11(2):e005650. [Crossref]  [PubMed] 
  19. Luthra S, Leiva Juárez MM, Senanayake E, Luckraz H, Billing JS, Cotton J, et al. Percutaneous intervention before coronary artery bypass surgery does not unfavorably impact survival: a single-center propensity-matched analysis. Ann Thorac Surg. 2016;102(6):1911-8. [Crossref]  [PubMed] 
  20. Biancari F, Dalén M, Ruggieri VG, Demal T, Gatti G, Onorati F, et al. Prognostic impact of multiple prior percutaneous coronary interventions in patients undergoing coronary artery bypass grafting. J Am Heart Assoc. 2018;7(20):e010089. [Crossref]  [PubMed]  [PMC] 
  21. Bugajski P, Greberski K, Kuzemczak M, Kalawski R, Jarząbek R, Siminiak T. Impact of previous percutaneous coronary interventions on the course and clinical outcomes of coronary artery bypass grafting. Kardiol Pol. 2018;76(6):953-9. [Crossref]  [PubMed] 
  22. Toker ME, Arkan C, Akardere ÖF. Right coronary endarterectomy with stent removal before right coronary artery bypass during coronary artery bypass grafting surgery. Koşuyolu Heart J. 2021;24(1):63. [Crossref] 
  23. Grieshaber P, Oswald I, Albert M, Reents W, Zacher M, Roth P, et al. Risk of perioperative coronary stent stenosis or occlusion in patients with previous percutaneous coronary intervention undergoing coronary artery bypass grafting surgery. Eur J Cardiothorac Surg. 2020;57(6):1122-9. [Crossref]  [PubMed] 
  24. Mannacio V, Di Tommaso L, De Amicis V, Lucchetti V, Pepino P, Musumeci F, et al. Previous percutaneous coronary interventions increase mortality and morbidity after coronary surgery. Ann Thorac Surg. 2012;93(6):1956-62. [Crossref]  [PubMed] 
  25. Nauffal V, Schwann TA, Yammine MB, El-Hage-Sleiman AK, El Zein MH, Kabour A, et al. Impact of prior intracoronary stenting on late outcomes of coronary artery bypass surgery in diabetics with triple-vessel disease. J Thorac Cardiovasc Surg. 2015;149(5):1302-9. [Crossref]  [PubMed]  [PMC] 

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