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Ann Thorac Surg 1999;68:1257-1261
© 1999 The Society of Thoracic Surgeons

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Original Articles

Coronary artery bypass grafting in dialysis patients

^a Department of Cardiovascular Surgery, Kumamoto Central Hospital, Kumamotoshi, Japan

Address reprint requests to Dr Sakata, 96 Tainoshima, Tamukaemachi, Kumamotoshi, Japan, 862-0965

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. To analyze the characteristic problems of coronary artery bypass grafting in patients with chronic renal failure.

Methods. Fifty-one consecutive dialysis patients who required isolated coronary bypass grafting over a 9-year period were studied retrospectively.

Results. Nine patients (18%) had emergent operation, 4 of whom had intraaortic balloon counterpulsation instituted preoperatively. A mean of 3.3 ± 1.0 bypasses per patient were grafted; 14 patients (27%) had bypass with two arterial grafts, 13 (25%) of which used left internal mammary artery and gastroepiploic artery and one of which used bilateral internal mammary artery grafts. A mean of 4.2 ± 2.6 coronary artery segments were calcific according to American Heart Association classification. Eight patients (16%) required operative modifications to avoid manipulating calcific plaques on the ascending aorta. Four patients (7.8%) died, and 15 had nonlethal complications. The actuarial survival rates in 47 hospital survivors at 1, 3, and 5 years were overall 89%, 84%, and 71%, respectively, and estimates for cardiac deaths 93%, 93%, and 82%, respectively. Cardiac event-free rates after coronary artery bypass grafting were 83% and 65% for 3- and 5-year periods, respectively.

Conclusions. Calcification of coronary arteries and the ascending aorta is a serious problem in long-term dialysis patients. However using arterial grafts, preferentially, in situ, seems to provide a practical alternative to minimize manipulating the ascending aorta during coronary artery bypass grafting, with acceptable perioperative morbidity and mortality rates and long-term survival.

	Introduction

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Lansing and coworkers [1] first reported a series of patients with chronic renal failure undergoing successful cardiovascular operation in 1968. The first report of coronary artery bypass grafting (CABG) in a patient with end-stage renal disease was published by Menzoian and associates in 1974 [2], and although a number of authors have reported acceptable acute mortality subsequently [3–8], only a few long-term studies are available [6–9]. In this study we analyzed the peculiarities posed by 51 patients on maintenance dialysis who had isolated CABG, and particularly its impact on the selection of operative procedures to the calcified lesions of coronary artery or ascending aorta and long-term results.

	Material and methods

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Fifty-one patients with chronic renal failure on maintenance dialysis who required isolated CABG between July 1988 and July 1997 at Kumamo Central Hospital were studied retrospectively. There were 41 (80%) male patients, and the mean age was 64 ± 9.9 years (range, 37 to 83 years). The causes of chronic renal failure are summarized in Table 1. Patients had been on dialysis at least 1 month, with a mean duration of 6.1 ± 5.6 years (0.1 to 20 years) before the CABG. Associated conditions were present in most patients. Peripheral vascular disease (PVD) of the lower extremities often complicated diabetic nephropathy. With the exception of 1 patient who was maintained on long-term ambulatory peritoneal dialysis, all were on hemodialysis (HD).

The need for technical modifications to minimize atheroembolization was determined by preoperative computed tomography and intraoperative epiaortic ultrasonography of the ascending aorta (thickness, irregularity, ulceration of intima, mobile plaque, and calcification). The surgical technique was similar to that used in normal patients. Cardiopulmonary bypass (CPB) induced mild hypothermia to 32°C–34°C at flow indexes of 2.2 to 2.4 L/m² per minute to maintain perfusion pressure above 70 mm Hg. Cardioprotection was accomplished using the following techniques similar to those of nondialysis cases: initial crystalloid cardioplegia was followed by subsequent cold blood cardioplegia every 30 minutes, with topical cooling. Techniques differed from those of ordinary cases by diverting the coronary sinus effluent into a hemofilter connected in parallel to the extracorporeal circuit, for large volume hemofiltration with K⁺ free replacement solution during CPB. Patients were weaned off CPB with a hematocrit level greater than 30% by packed red blood cell transfusion and return of the mediastinal blood drainage after cell washing and packing, and serum K⁺ less than 4.0 mEq/L.

Except for patients who needed to be put on CPB in a hurry, the left internal mammary artery (IMA) was used whenever possible and often combined with simultaneous use of the gastroepiploic artery if it was more than 1.5 mm in diameter in patients younger than 75 years old, except for patients on long-term ambulatory peritoneal dialysis or with previous laparotomy.

Calcification score was represented by the sum of all involved coronary artery segments following the American Heart Association classification, which was confirmed by fluoroscopy during preoperative coronary angiography. For comparison, 30 CABG counterparts without chronic renal failure were selected at random.

The operation was considered emergent when it was done nonelectively within 24 hours of the decision to proceed with CABG regardless of the patient’s hemodynamic status. The hospital mortality rate included deaths within 30 days of CABG or during the same hospitalization. Long-term follow-up data were collected from patients’ medical records or telephone interviews. Cardiac events included recurrent angina, myocardial infarction, percutaneous transluminal coronary angioplasty, reoperation, and cardiac death. Angina was rated according to the Canadian Cardiovascular Society and symptoms of congestive heart failure according to the New York Heart Association classification.

Fisher’s exact test was used for the nonparametric variables, and unpaired t test for continuous variables; a p value less than 0.05 was considered to be statistically significant. Long-term survival rates were calculated using the Kaplan-Meier method. All data are presented as mean ± standard deviation unless stated otherwise.

	Results

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Tables 2 and 3 summarize the clinical, angiographic, and operative characteristics of patients. In all patients myocardial ischemia was severe enough to interfere with maintenance dialysis. The mean hemofiltered and replaced volumes of hemofiltration during CPB were 6,809 ± 2,610 mL and 7,953 ± 2,442 mL, respectively; the levels of K⁺ and hematocrit at discontinuation of CPB were 3.8 ± 0.5 mEq/L and 28% ± 3.3%, respectively. No patient required emergency HD before the resumption of maintenance dialysis on the first postoperative day, and no HD sessions (mean, 4.5 ± 0.8 hours) were interrupted because of hemodynamic instability; the mean diafiltrate volume of the first HD was 2,108 ± 693 mL.

Calcification score was significantly higher in dialysis patients compared with the counterparts (4.2 ± 2.6 versus 1.5 ± 2.1, p < 0.05) which mandated implementation of technical modifications to minimize atheroembolization in a significantly higher proportion of dialysis patients compared with ordinary patients (8 of 51 [16%] versus 38 of 979 [3.9%] p < 0.01) (Table 4).

The mean blood loss from drainage tubes and the mean administered blood products (packed red blood cells, platelets, or fresh frozen plasma) were not significantly different compared with the counterparts (847 ± 568 mL versus 827 ± 498 mL and 564 ± 618 mL versus 542 ± 586 mL, respectively).

Fifteen complications were observed. Two patients required reoperation for mediastinal bleeding; 1 nondiabetic patient who had emergent CABG with saphenous vein graft had perioperative low output syndrome and eventually mediastinitis. None of the 8 patients who had technical modifications developed cerebrovascular accidents, but 2 who did not have a modification had a stroke, although 1 recovered completely. Three patients in whom the left IMA was used developed left pleural effusion that had to be tapped; 4 patients had secondary closure of leg incisions. Life-threatening arrhythmia (ventricular tachycardia or fibrillation) attributable to hypokalemia occurred in 3 patients.

Four patients died, for a hospital mortality rate of 7.8% (4 of 51). One 59-year-old man who had CABG with circulatory arrest to remove mobile plaque in the ascending aorta died 10 days postoperatively of multiple organ failure caused by intestinal necrosis. Two patients died of ventricular fibrillation, 1 on the 14th postoperative day from hypokalemia, and the other patient on the 7th postoperative day of unknown cause. The fourth death was a 68-year-old man who had emergent CABG using only a saphenous vein graft and who died of postoperative low output syndrome, mediastinitis, and multiple other infectious complications on the 52nd postoperative day.

The mean follow-up time of the 47 hospital survivors was 32 months (range, 7 to 89 months). Actuarial survival rates at 1, 3, and 5 years including all deaths were 89%, 84%, and 71%, and estimated by cardiac deaths were 93%, 93%, and 82%, respectively (Fig 1). Five of the 11 late deaths were from cardiac causes (two congestive heart failure, two with obvious ischemic events, and one arrhythmia), and six from other causes (three chronic renal failure, one cerebral hemorrhage, one pneumonia, and one accident of HD). Cardiac event-free rates were 83% and 65% at 3 and 5 years after CABG (Fig 2). Three patients with severe three-vessel disease had recurrent angina, in two from new left anterior descending or circumflex coronary artery lesions and occlusion of the saphenous vein graft to right coronary artery in the third.

View larger version (10K): [in this window] [in a new window]   Fig 1. (A) Actuarial survival rates including all deaths. (B) Actuarial survival rates estimated by cardiac deaths. (CABG = coronary artery bypass grafting.)

View larger version (8K): [in this window] [in a new window]   Fig 2. Cardiac-event-free rates of the 47 hospital survivors. (CABG = coronary artery bypass grafting.)

	Comment

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Some authors recommend dialysis more than 24 hours before the CPB procedure [11], but we believe it is best to use dialysis as close to the procedure as possible. Whereas some surgeons advocate the use of intraoperative HD [12], we chose intraoperative hemofiltration for the simplicity in achieving control of water and electrolyte (mainly K⁺) balance until maintenance HD could be resumed on the first postoperative day, which was possible in all patients without untoward hemodynamic sequelae, but for logistic and safety reasons patients were usually kept in the intensive care unit slightly longer than the ordinary patients and likewise were transferred back to the referring dialysis service at a later period than the ordinary patients would be discharged.

Peritoneal dialysis offers the advantages of avoiding hemodynamic instability and the risks of bleeding associated with the use of heparin for HD, as well as the logistic advantage of not requiring a specialized technician [13], but it precludes the use of gastroepiploic artery as a secondary arterial graft. In our experience, except for patients with severely depressed cardiac function, with careful observation HD could be done safely in most patients, but frequent arteriovenous access could cause endocarditis [10, 14].

In general, the results of CPB in patients with chronic renal failure on maintenance dialysis tend to be worse than in patients with normal renal function. Our mortality rate of 7.8% for CABG in patients on maintenance dialysis is similar to the 9% (27 of 296 patients) reported by Ko and associates [13] in a diverse group of dialysis patients. Several factors contributed to this high mortality rate. Fatal mediastinitis occurred in 1 patient in whom arterial conduits were not used. The propensity to infection is attributed to decreased leukocyte chemotaxis and leukopenia [15]. The accelerated atherosclerosis [14], often involving vessels of the neck, is manifested by cerebrovascular or other visceral vessel complications, including lower extremities, ascending aorta, and coronary artery. Although the incidence of post-CPB gastrointestinal complications is small, when it occurs the mortality is considerable [13, 16].

The presence of congestive heart failure (New York Heart Association class 4) [8] and older age [5] are the most important single predictors of hospital death. New York Heart Association class 4 congestive heart failure [13] and cerebrovascular disease [8] are also strong predictors of diminished long-term survival, which is better when the duration of maintenance dialysis is shorter [7].

The significantly higher coronary calcification score and more frequent need of modifications of the operative procedure than their counterparts to avoid calcifications of the ascending aorta confirm the reported higher incidence of coronary and extracoronary calcific arterial lesions [14], as well as other less frequent cardiac lesions such as valvular [17] and conduction system calcifications [18] in patients on dialysis. Although our purpose was not to compare two arterial grafts to one or no arterial grafts, the use of in-situ arterial conduits facilitated the revascularization without requiring manipulation of the ascending aorta, during induced ventricular fibrillation, but saphenous vein CABG required circulatory arrest. However, none of the patients with operative technique modifications had cerebrovascular complications.

Long-term dialysis patients with symptomatic coronary disease who had percutaneous transluminal coronary angioplasty have a higher risk of subsequent cardiac events (angina recurrence, myocardial infarction, cardiac death, or CABG) than those who had CABG [19]. Two-thirds of our patients were event free 5 years after CABG and compare favorably to reported results with percutaneous transluminal coronary angioplasty.

Kahn and associates [20] studied 17 chronic dialysis patients who had percutaneous transluminal coronary angioplasty: 47 of 49 vessels were successfully dilated, but angina recurred within 6 months in 12 of 15 patients. Angiographic restenosis was evident in 26 (81%) of 32 dilated vessels. Reusser and colleagues [21] studied a cohort of 13 HD patients matched with 13 non-HD patients treated by percutaneous transluminal coronary angioplasty and found that 50% of the HD group had cardiac events compared with 15% of the counterparts over a 2-year follow-up period. In situ arterial grafts for CABG patients on dialysis have two advantages. The thickness better matches the more distal thin coronary arteries, where patients with chronic renal failure must frequently have the anastomosis done, and eliminates the need to manipulate the calcified ascending aorta.

There are two main reasons for the reluctance to use bilateral IMA grafts in dialysis patients: impaired wound healing and the less effective clotting mechanisms caused by the deficiency of platelet adhesion-aggregation as well as factor III [15]. However, Blakeman and colleagues [22] reported using unilateral or bilateral IMA in patients on chronic renal dialysis and found that it did not affect wound healing or increase blood loss. We try to preserve the tissue blood flow as much as possible by avoiding electrocautery and by dissecting the IMA without injuring the periostium and maintaining a high perioperative cardiac output. Thus far, mediastinal complications have not developed in any patients who had the IMA dissected.

Crawford and colleagues [23] stated that CABG would not affect the aggressive nature of atherosclerosis in dialysis patients, implying that long-term graft patency can be expected to be lower than in nondialysis patients. Nevertheless, because the IMA offers the best patency at 10 years [24, 25] we prefer arterial grafts, including the gastroepiploic artery, based on the predicted superior long-term patency over the saphenous vein graft.

Although 30% to 53% of patients with chronic renal failure die of cardiac causes despite coronary revascularization [6–9], our results, which confirm the reported dramatic early New York Heart Association functional class [4, 6] as well as improvement in late cardiac symptoms in most patients after CABG, are encouraging. Whether proper selection of conduits could improve long-term mortality rates in dialysis patients is not known yet, but CABG using arterial in situ conduits with the no-touch technique of the ascending aorta, could offer the easiest and most suitable solution for patients in whom angina precludes dialysis.

	References

Top Abstract Introduction Material and methods Results Comment References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Ryuzo Sakata Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Nakayama, Y. Articles by Miyamoto, T.-A. Search for Related Content PubMed PubMed Citation Articles by Nakayama, Y. Articles by Miyamoto, T.-A.