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Ann Thorac Surg 1996;61:1793-1796
© 1996 The Society of Thoracic Surgeons
Departments of Cardiovascular Surgery and Cardiology, The Heart Institute of Japan, Tokyo Women's Medical College, Tokyo, Japan
Accepted for publication February 16, 1996.
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Abstract |
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 TopFootnotes Abstract IntroductionMaterial and MethodsResultsCommentReferences |
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Methods. A retrospective analysis was performed of the short- and long-term clinical results in 23 coronary artery bypass grafting patients and 20 coronary angioplasty patients undergoing chronic renal dialysis.
Results. Among coronary bypass grafting patients, there were no hospital deaths. The graft patency rate was 100% for arterial grafts. There were four late deaths and four cardiac events. In coronary angioplasty patients, the lesion success rate was 76%. There were no hospital deaths and three major complications. The restenosis rate was 70%. There were two late deaths and 14 cardiac events. The 5-year cardiac event-free rate was 70% in coronary bypass grafting patients, significantly better than 18% in coronary angioplasty patients (p < 0.001).
Conclusions. Coronary artery bypass grafting in chronic renal dialysis patients can be accomplished with a better short- and long-term outcome than coronary angioplasty, through an intensive perioperative dialysis program and extensive use of arterial grafts.
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Introduction |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Material and Methods |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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The main causes of renal failure were chronic glomerulonephritis in 10 coronary bypass grafting patients (43%) and in 10 coronary angioplasty patients (50%), and diabetic nephropathy in 8 (35%) and 3 (15%), respectively.
Coronary Artery Bypass Grafting
Six patients underwent emergent coronary artery bypass grafting, and 1 patient underwent graft replacement simultaneously for concomitant impending rupture of an abdominal aortic aneurysm. Coronary bypass grafting was performed using total cardiopulmonary bypass, moderate systemic hypothermia, cold crystalloid cardioplegia, and topical cooling. Distal and proximal anastomoses of vein grafts were performed during aortic cross-clamping. The number of revascularized vessels was 2.2 ± 0.8. Graft materials consisted of 21 left internal thoracic arteries, seven right internal thoracic arteries, seven right gastroepiploic arteries, and 15 saphenous veins. The use index of arterial grafts (percentage of patients with at least one arterial graft) was 95.7%.
Percutaneous Transluminal Coronary Angioplasty
Coronary angioplasty was performed on the target lesion primarily in 18 left anterior descending arteries and 13 right coronary arteries. The number of vessels dilated was one in 15 patients and two in 5 patients. Lesion success was defined as angiographic improvement of the vascular occlusion to less than 50% stenosis (percent diameter). Patient success was defined as the relief of anginal pain or increase of exercise capacity as a consequence of lesion success, without major complications such as hospital death, emergent coronary bypass operation, or myocardial infarction. Restenosis was defined as angiographic return of the same lesion to more than 50% stenosis.
Renal Dialysis
All the coronary bypass grafting patients underwent intraoperative hemodialysis during cardiopulmonary bypass. In 17 of the patients having hemodialysis preoperatively, peritoneal dialysis was initiated immediately after the operation and was maintained until the hemodynamic indices stabilized sufficiently to resume hemodialysis (mean, 5.7 ± 3.4 days after the operation). In 1 patient who underwent graft replacement for concomitant impending rupture of an abdominal aortic aneurysm, it was necessary to initiate hemodialysis immediately after the operation (Fig 1
). In all 7 patients whose right gastroepiploic artery was used, peritoneal dialysis was also initiated immediately after the operation. Although 2 early patients had leakage of dialysis fluid into the pericardial cavity after weaning from positive-pressure ventilation to spontaneous breathing, peritoneal dialysis could be established in the remaining 5 patients by making a smaller hole in the diaphragm, passing the skeletonized portion of the graft through the hole, and sealing the hole in the diaphragm using fibrin glue. The coronary angioplasty patients received hemodialysis the day before the procedure and immediately after the procedure.
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Results |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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). The number of diseased arteries was 2.5 ± 0.7 in coronary bypass grafting patients and 1.7 ± 0.7 in coronary angioplasty patients (p < 0.01).
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After coronary angioplasty, the lesion success rate was 76% (29 of 38) and the patient success rate was 65% (13 of 20). The cause of unsuccessful coronary angioplasty was insufficient dilation in 3 patients, inability to cross the lesion with a balloon catheter in 3, and inability to cross the lesion with a guidewire in 1. The presence of a calcified lesion in the target coronary artery was significantly more frequent in unsuccessful coronary angioplasty procedures than in successful ones (100% versus 46%; p < 0.05). There were no hospital deaths and three major complications, consisting of two cases of emergent coronary bypass operation and one myocardial infarction. There were two late deaths due to acute myocardial infarction and pneumonia, respectively. There were 16 cardiac events, consisting of 14 cases of repeat coronary angioplasty, one coronary bypass grafting, and one myocardial infarction. The restenosis rate was 70% (7 of 10).
The 5-year event-free rate was 70% in coronary bypass grafting patients, significantly better than 18% in coronary angioplasty patients (p < 0.001) (Fig 2).
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Comment |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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At the introduction of coronary angioplasty, our early and long-term outcomes were relatively poor. The existence of calcified lesions in the target coronary artery resulted in poorer lesion success. Moreover, restenosis requiring repeat coronary angioplasty occurred frequently. Kahn and co-workers [6] studied 17 chronic dialysis patients requiring coronary angioplasty. Procedures were successful in 47 of 49 stenoses (96%) attempted, but 11 patients with recurrent angina had angiographically demonstrated restenosis in 26 of 32 dilated sites (81%). It is evident that the restenosis rate is higher in dialysis patients than in the routine population undergoing coronary angioplasty. Although the precise mechanisms initiating and maintaining restenosis are unknown, possibilities include abnormalities of platelet function, with hyperaggregability and decreased responsiveness to prostacyclin, and activation of plasma coagulation systems after contact with the hemodialysis membrane. Kahn and co-workers [6] concluded that although coronary angioplasty in chronic dialysis patients is technically feasible and provides relief of angina, aggressive restenosis limits the long-term benefit, and thus coronary bypass grafting may be the preferred treatment in this patient population. Coronary bypass grafting in this population has been considered to carry a high risk; however, recently it has been performed safely. Many studies [7–13] of patients having dialysis and undergoing coronary bypass grafting have been reported. Crawford and associates [14] predicted that coronary bypass grafting would not affect the aggressive atherosclerosis in dialysis patients and that long-term graft patency might be decreased in dialysis patients as compared with other groups. In other studies, the early mortality rate ranged from 2.6% to 20%, and the actuarial survival rate ranged from 83% to 95% at 1 year, but decreased to 48% to 60% at 5 years [15]. The overall operative mortality rate for the 296 cases reported in the English-language literature [15] thus far is 9%. Our early mortality rate was 0% and the 5-year survival rate was 83%. We believe that these excellent outcomes are attributable to the intensive perioperative dialysis and extensive use of arterial grafts [12].
The perioperative dialysis program consisted of hemodialysis the day before the operation, hemodialysis during the operation, and peritoneal dialysis immediately after the operation. Peritoneal dialysis after the operation could prevent fluid overload and hyperkalemia. The advantage of peritoneal dialysis is that it is simple to perform and does not require any special apparatus or technicians. Moreover, peritoneal dialysis has little influence on hemodynamic indices. McNamee and coauthors [16] also suggested that peritoneal dialysis avoids heparin administration, large swings in blood pressure, and the risk of infective endocarditis associated with hemodialysis. On the other hand, disadvantages of peritoneal dialysis include protein loss, risk of peritonitis, respiratory disturbance, and pericardial or pleural effusions due to diaphragmatic leakage.
In the present series of patients, the use index of arterial grafts was 95.7%, and all arterial grafts remained patent. There was no increased risk associated with usage of arterial grafts, such as poor wound healing or increased bleeding. Two of four cardiac events-cases of coronary angioplasty and myocardial infarction after operation-were due to occlusion of saphenous vein grafts. Most patients on chronic hemodialysis are known to have extensive coronary disease. As well as having a large number of lesions in each vessel, such patients show extensive disease with diffuse and calcified lesions and poor distal runoff. Therefore, we were obliged to perform less revascularization (mean 2.2 revascularized vessels versus 2.5 diseased vessels). Nevertheless, because we were able to perform bypass to five vessels with three arterial grafts and a vein graft in one case, we are confident that it is possible to achieve complete revascularization with extensive usage of arterial grafts, even in chronic dialysis patients. Owen and colleagues [17] suggested that future studies need to clarify whether internal mammary artery grafting is possible. Our data in this study demonstrated favorable answers to these questions.
The 3 patients with late death due to cerebral hemorrhage had hypertension, and 2 of them had a history of cerebrovascular disease, consisting of aneurysm of the middle cerebral artery and reversible ischemic neurologic deficit, respectively. Because cerebrovascular disease is the second greatest cause of death among dialysis patients, it is necessary to control blood pressure precisely and to give a minimum dosage of anticoagulant drugs after the operation.
The 5-year event-free rate was 70% after coronary bypass grafting, significantly better than 18% after coronary angioplasty. Although coronary angioplasty is generally preferable for one-vessel or two-vessel coronary disease, we propose that coronary bypass grafting is recommended for coronary disease in which the target lesion exhibits severe calcification.
In conclusion, coronary artery bypass grafting in chronic renal dialysis patients can be accomplished with better short- and long-term outcomes than percutaneous transluminal coronary angioplasty, through an intensive perioperative dialysis program and extensive use of arterial grafts.
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Footnotes |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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References |
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