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Ann Thorac Surg 2004;77:1245-1249
© 2004 The Society of Thoracic Surgeons

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Original article: cardiovascular

Coronary surgery in patients with peripheral vascular disease: effect of avoiding cardiopulmonary bypass

^a Department of Cardiothoracic Surgery, The Cardiothoracic Centre, Liverpool, United Kingdom
^b Department of Research and Development, The Cardiothoracic Centre, Liverpool, United Kingdom
^c Department of Cardiothoracic Surgery, Manchester Royal Infirmary, Manchester, United Kingdom

Accepted for publication September 10, 2003.

^* Address reprint requests to Dr Fabri, The Cardiothoracic Centre-Liverpool, Thomas Dr, Liverpool, L14 3PE UK
e-mail: brian.fabri{at}ctc.nhs.uk

BACKGROUND: An increasing number of patients with peripheral vascular disease are undergoing coronary artery bypass grafting. Such patients have an increased risk of adverse outcomes. Our aim was to quantify the effect of avoiding cardiopulmonary bypass in this group of patients.

METHODS: Between April 1997 and March 2002, 3,771 consecutive patients underwent coronary artery bypass grafting performed by five surgeons. Four hundred and twenty-two (11.2%) had peripheral vascular disease and of these, 211 (50%) received off-pump surgery. We used multivariate logistic regression analysis to assess the effect of off-pump surgery on in-hospital mortality and morbidity, while adjusting for treatment selection bias. Treatment selection bias was controlled for by constructing a propensity score, which was the probability of receiving off-pump surgery and included core patient characteristics. The C statistic for this model was 0.8.

RESULTS: Off-pump patients were more likely to have preoperative renal dysfunction, previous gastrointestinal surgery, and less extensive disease. The left internal mammary artery was used more in off-pump compared to on-pump cases (90.1% vs 82.9%; p = 0.033). In the univariate analyses, off-pump patients were less likely to have a postoperative stroke (p = 0.007), and had shorter postoperative hospital stays (p < 0.001). However, the incidence of new atrial arrhythmia was higher (p = 0.028). After adjustment for differences in case-mix (propensity score), avoidance of cardiopulmonary bypass was still associated with a significant reduction in postoperative stroke (adjusted odds ratio 0.09 [95% confidence interval 0.02 to 0.50]; p = 0.005), and shorter postoperative hospital stay (p = 0.001).

CONCLUSIONS: Off-pump coronary surgery is safe in patients with peripheral vascular disease, with acceptable results. The incidence of postoperative stroke is substantially reduced when avoiding cardiopulmonary bypass in patients with peripheral vascular disease.

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