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Ann Thorac Surg 2001;72:S1033-S1037
© 2001 The Society of Thoracic Surgeons

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Supplement: Cardiothoracic techniques and technologies

Off-pump coronary artery bypass may decrease the patency of saphenous vein grafts

^a Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul, South Korea
^b Department of Internal Medicine, Clinical Research Institute, Seoul National University Hospital, Seoul, South Korea

Address reprint requests to Dr Kim, Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, 28 Yeun-Kun Dong, Chong-Ro Ku, Seoul 110-744, Korea
e-mail: kimkb{at}snu.ac.kr

Presented at the Seventh Annual Cardiothoracic Techniques and Technologies Meeting 2001, New Orleans, LA, Jan 24–27, 2001.

	Abstract

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Background. There is concern that a hypercoagulable status is caused after coronary artery bypass grafting without cardiopulmonary bypass (off-pump coronary artery bypass grafting, or OPCAB) and may potentially endanger the patency of the anastomosis. The aims of this study were: (1) to compare 1-year graft patency after OPCAB with that of conventional coronary artery bypass grafting (CABG) and that of on-pump beating CABG; and (2) to demonstrate any differences in patency of various conduits among the three groups.

Methods. We analyzed the results of 122 consecutive OPCAB cases (group I) compared with those of 65 consecutive conventional CABG cases (group II) and those of 19 consecutive on-pump beating CABG cases (group III). In group I, coronary angiography (CAG) was performed immediately postoperatively and 1 year after surgery. In groups II and III, CAG was performed 1 year after surgery. Graft patency was graded as grade A (excellent), grade B (fair), or grade O (occluded).

Results. The average number of distal anastomoses in groups I, II, and III were 3.1 ± 1.1, 3.7 ± 0.9, and 3.6 ± 0.9, respectively. In group I, postoperative CAG was performed in 92% of patients (112/122) before discharge. The patency rate (grade A + B) was 96.4% (162/168) for arterial grafts, and 85.6% (160/187) for saphenous vein grafts (SVG). One-year follow-up CAG was performed in 74% of patients (90/122). The patency rate was 97.8% (132/135) for arterial grafts and 67.9% (106/156) for SVG. In group II, 1-year follow-up CAG was performed in 65% of patients (42/65). The patency rate (grade A + B) was 93.5% (43/46) for arterial grafts and 88.3% (98/111) for SVG. In group III, 1-year follow-up CAG was performed in 89% of patients (17/19). The patency rate (grade A + B) was 100% (19/19) for arterial grafts and 86.8% (33/38) for SVG.

Conclusions. Our results demonstrate that the patency rate of SVG after OPCAB was significantly lower than that of arterial grafts in the early postoperative CAG (p < 0.001), and was also significantly lower than those of SVG of group II (p < 0.001) and group III (p < 0.01) in the postoperative 1-year CAG, although there was no significant difference in 1-year patency of arterial grafts among the three groups. Our data suggest that a specific perioperative anticoagulant therapy may be advisable in patients undergoing OPCAB with SVG.

	Introduction

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
The surgical results of coronary artery bypass grafting without cardiopulmonary bypass (off-pump coronary artery bypass grafting, or OPCAB) have demonstrated several advantages by avoiding the potentially detrimental effects of cardiopulmonary bypass (CPB) and eliminating intraoperative global myocardial ischemia [1–5]. However, there are concerns about the accuracy and patency of the anastomosis, as well as the long-term outcome after OPCAB. Midterm angiographic assessment of OPCAB demonstrated a significantly lower patency rate of saphenous vein grafts (SVG) compared with that of conventional coronary artery bypass grafting (CABG) or that of arterial grafts [6, 7]. The aims of this study were: 1) to compare 1-year graft patency after OPCAB with that of conventional CABG and on-pump beating CABG, and 2) to demonstrate any difference in patency of various conduits among the three groups.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
A total of 122 consecutive patients who underwent OPCAB between January 1998 and June 1999 were studied in a prospective, nonrandomized manner (group I). We compared these results with those of 65 consecutive patients who underwent conventional CABG performed in 1997 (group II) and those of 19 consecutive patients who underwent on-pump beating CABG performed in late 1997, during the time the surgeon was learning to perform OPCAB. Those who required concomitant valvular or Maze operations in group II were excluded from this study. All the operations were performed by a single surgeon (K.-B. K.).

There were no differences in sex, age, preoperative risk factors except hypertension, ratio of unstable to stable angina, left ventricular ejection fraction measured by transthoracic echocardiography, and urgent or emergent operations, among the three groups. The incidence of hypertension was higher in group I than in groups II and III (p < 0.05). The number of cases with single-vessel disease has increased in group I since the introduction of OPCAB (p < 0.05, group I vs group II), as shown in Table 1.

Temperature was maintained at normothermia using adequate room temperature, warm circulating water blankets, and warm infusion solutions. After the pericardium was opened, deep pericardial sutures were placed to facilitate pericardial retraction for cardiac elevation and exposure. To reduce the heart rate to less than 70 to 80 beats per minute and to minimize myocardial oxygen consumption, most of the patients were given boluses or continuous infusion of ß-blockers such as esmolol, or adenosine. Ischemic preconditioning was not performed in most cases. Anesthetic management, including volume loading and placing the patient in the Trendelenburg position, controlled hemodynamic derangement during displacement or manipulation of the heart. After exposure of the coronary artery, vascular control was performed with elastic vessel loops (Retract-O-Tape, Quest Medical Inc, Allen, TX) placed around the proximal artery and distal to the site of the anastomosis. These two sutures were carefully retracted during the anastomosis to occlude and immobilize the coronary artery. When a bloodless operative field was not maintained due to profuse collaterals, internal vascular control was achieved with a flow occluder (Florester, Bio-Vascular Inc, St. Paul, MN) or intracoronary shunt (FloCoil Shunt, CardioThoracic Systems Inc, Cupertino, CA). To reduce the amplitude of ventricular wall movement, a compression-type mechanical stabilizer (CardioThoracic Systems) or suction-type mechanical stabilizer (Octopus, Medtronic, Minneapolis, MN) was used. A Blower/Mister (Visuflo, Baxter Healthcare, Midvale, UT) using carbon dioxide gas (flow rate, < 5 L/min) or a micro-sucker system with a rubber tip was also used to obtain a bloodless surgical field. The distal anastomosis was constructed using a continuous technique with 8-0 polypropylene sutures for arterial grafts or 7-0 polypropylene sutures for SVG. The proximal anastomosis on the ascending aorta was constructed using a partial occlusion clamp with 6-0 polypropylene continuous sutures. During this study period, 0.5 mg of protamine was administered for each 100 U of heparin given at the end of the OPCAB procedure to normalize the prolonged activated clotting time.

Group II (conventional CABG)
Conventional CABG was performed with single-stage venous cannula drainage, moderate systemic hypothermia, and antegrade or retrograde cold blood cardioplegia solution. The patients were heparinized with an initial dose of 3 mg/kg of heparin and periodically supplemented with additional doses to maintain an activated clotting time of more than 480 seconds. At the end of the procedure, 1 mg of protamine per each 100 U of heparin was given.

Group III (on-pump beating CABG)
On-pump beating CABG was performed with single stage venous cannula drainage, systemic normothermia, and without cardioplegic arrest. To reduce the amplitude of ventricular wall movement, a mechanical stabilizer either a compression or suction type was used during on-pump beating CABG. The patients were heparinized with an initial dose of 3 mg/kg of heparin and periodically supplemented with additional doses to maintain an activated clotting time of more than 480 seconds. A quantity of 1 mg of protamine per each 100 U of heparin was given at the end of the procedure.

Postoperative follow-up
All the patients received aspirin (300 mg/d) postoperatively. In group I, postoperative coronary angiography (CAG) was performed in 92% of patients (112/122) 2.4 ± 2.3 days postoperatively. After discharge all patients received follow-up examination at 3-month intervals. At the 1-year follow-up CAG was performed (12.6 ± 2.1 months, 13.8 ± 4.7 months, and 12.3 ± 1.0 months postoperatively, in groups I, II, and III, respectively). The 1-year follow-up CAG was performed in 74% (90/122), 65% (42/65), and 89% (17/19) of patients, in groups I, II, and III, respectively. The 1-year follow-up CAG was performed irrespective of any anginal symptoms of the patients, and was not performed in the case of mortalities, in patients with renal dysfunction, or patients who refused the procedure. Follow-up CAG included left ventriculography and four-plane selective coronary and bypass graft angiography. One physician initially reviewed all the coronary angiograms and consensus was reached after review.

Grading of anastomoses
All of the anastomoses were reviewed and graded as described by FitzGibbon and associates [8]: Grade A was defined as an excellent graft with unimpaired run-off. Grade B was defined as stenosis reducing caliber of proximal, distal anastomosis, or trunk to less than 50% of the grafted coronary artery; or a graft that was functionally impaired by new stenosis of the grafted coronary artery, more than 50% of what it was before operation, proximal or distal, as relevant, to the anastomosis site. Overall graft B grade was determined by the lowest of the three specific site grades. Grade O was defined as occlusion.

Statistical analysis
Statistical analysis was performed with the Statistical Analysis System software package (version 6.12; SAS Institute, Cary, NC). The significance of differences among three groups was assessed by analysis of variance or RIDIT test. All results were expressed as mean ± standard deviation, and a value of p less than 0.05 was considered statistically significant.

	Results

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
There were no differences among the three groups in arterial grafts used. In group I, SVG was used less frequently than in groups II and III (p < 0.05) (Table 2). The number of anastomosis was lower in group I than in group II (p < 0.05). The average number of distal anastomoses in groups I, II, and III were 3.1 ± 1.1, 3.7 ± 0.9, and 3.6 ± 0.9, respectively. When the coronary arteries were classified as anterior (left anterior descending artery, diagonal branches, ramus intermedius, and right coronary artery) and posteroinferior (posterior descending artery, posterolateral branches, and obtuse marginal branches) vessels, there were no differences among the three groups in coronary arteries grafted except for the posterolateral branch. The posterolateral branch was less frequently revascularized in group I than in groups II and III (p < 0.05) (Table 3).

Group II (conventional CABG)
The 1-year patency rate (grade A + B) was 93.2% (41/44) for ITA, 88.3% (98/111) for SVG, and 100% (2/2) for RA; the perfect patency rate (grade A) was 81.8% (36/44) for ITA, 82.9% (92/111) for SVG, and 100% (2/2) for RA.

Group III (on-pump beating CABG)
The 1-year patency rate (grade A + B) was 100% (19/19) for ITA, 86.8% (33/38) for SVG, and 100% (2/2) for RA; the perfect patency rate (grade A) was 78.9% (15/19) for ITA, 71.1% (27/38) for SVG, and 50% (1/2) for RA.

Comparison of graft patency among the three groups
The patency rate of SVG after OPCAB was significantly lower than that of arterial grafts examined in the early postoperative CAG (p < 0.001), and was also significantly lower than group II (p < 0.001) and group III (p < 0.01) SVG in the postoperative 1-year CAG, although there were no significant differences in the 1-year patency of arterial grafts among the three groups (Table 5).

	Comment

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

The long-term patency of grafts is one of the major factors in determining the late results of CABG. Although the long-term patency of SVG has been known to be lower than that of ITA [9, 10], the SVG is still the most widely used graft because of its accessibility and ease of use. The patency of SVG after CABG is influenced by three processes that cause SVG failure, such as thrombosis, fibrointimal hyperplasia, and vein graft arteriosclerosis [11]. Among these three processes, thrombosis accounts for most graft failures within the first month but continues to occur as long as 1 year after CABG. Fibrointimal hyperplasia occurs predominantly after 1 month to 5 years, and SVG arteriosclerosis may begin as early as the first year but is fully developed only after about 5 years.

With resurgent interest in OPCAB, there have been concerns about accuracy and patency of the grafts and the long-term outcome. Gundry and colleagues [6] showed lower patency rates for OPCAB grafts than grafts implanted by conventional techniques and limited revascularization, which resulted in more frequent reinterventions. The 7-year patency rates of LAD grafts were 47% and 92% in the OPCAB group and conventional CABG group, respectively, and those of RCA or PDA grafts were 23% and 54% in the OPCAB group and conventional CABG group, respectively. Ömeroglu and associates [7] demonstrated a significantly lower patency rate for SVG (47.1%) than for ITA (95.7%) in 3-year follow-up results after OPCAB. They suggested that the decreased patency rate for SVG may result from the type of graft, presence of hyperlipidemia, and the exposure and quality of stabilization during OPCAB. Regional cardiac wall immobilization with specially designed stabilizer systems provides excellent stabilization of the target area and enables surgeons to perform coronary anastomoses safely without CPB, and greatly enhances the graft patency in a predictable manner [12]. Mariani and associates [13] demonstrated that procoagulant activity was increased in the first 24 hours after OPCAB. Procoagulant activity is a well-known phenomenon in major general surgery and is also a phenomenon to be expected after major surgical procedures such as OPCAB. Procoagulant activity may increase the risk of venous thrombosis and potentially endanger the patency of coronary anastomoses. They suggested not antagonizing the heparin with protamine at the end of the procedure. They also suggested that perioperative anticoagulation policy for patients undergoing OPCAB should be more aggressive than that for patients undergoing conventional CABG with CPB.

Our results demonstrated that the patency rate of SVG after OPCAB was significantly lower than that of arterial grafts in the early postoperative CAG, and was also significantly lower than the SVG patency rates of groups II and III in the 1-year postoperative CAG. Our data suggested that the decreased patency rate of SVG after OPCAB might be related to CPB because all the operations were performed by a single surgeon and the patency rate of SVG after on-pump beating CABG performed while the surgeon was learning OPCAB demonstrated comparable patency with conventional CABG patency rates. During this study period, 0.5 mg of protamine per 100 U of heparin was given at the end of the OPCAB procedure. We expect that the increased procoagulant activity associated with protamine administration, and other factors that promote early SVG closure, such as endothelial injury, low SVG flow, etc., may have influenced the increased thrombosis and decreased early SVG patency rate in our study. We currently do not antagonize the heparin with protamine at the end of the OPCAB procedure.

The development of a lower SVG patency rate compared with that of arterial grafts after OPCAB encouraged us to pay attention to off-pump total arterial revascularization, in order to improve the midterm outcome of myocardial revascularization. Enhanced long-term survival has been shown when the left ITA is grafted to the left anterior descending artery rather than SVG, or bilateral ITAs are used rather than single ITA in patients with triple-vessel disease [14–16]. However, technical difficulties and lack of angiographic results make surgeon hesitate to perform off-pump total arterial revascularization. Mack and associates [17] reviewed the publications that examined outcomes of left ITA grafting in conventional CABG and minimally invasive direct CABG (MIDCAB). The early (1 month or less postoperatively) and 1-year patency rates of left ITA in conventional CABG have been reported to be between 94% and 99% and between 88% and 93%, respectively. The left ITA graft patency data after MIDCAB showed early graft patency rates between 91% and 99%. They suggested that early graft patency by both techniques could confidently be stated as being 90% or greater, although meaningful comparison of left ITA graft patency between the two techniques is difficult. Calafiore and associates [18] demonstrated the feasibility of arterial revascularization without CPB, with results similar to those obtained with CPB. They showed a 98.9% patency rate of arterial grafts at about 1 month after OPCAB. Our data showed that the 1-year patency for arterial grafts after OPCAB was 97.8%, demonstrating results comparable to those of conventional CABG or on-pump beating CABG. In addition, our data demonstrated an excellent midterm patency rate for arterial grafts, and suggests the feasibility of total arterial revascularization without CPB.

In conclusion, we suggest not antagonizing the heparin with protamine at the end of the OPCAB procedure, especially in cases using SVG, and performing the OPCAB using exclusively arterial grafts to avoid the low patency rate and sequelae of SVG occlusion.

	Acknowledgments

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
We appreciate Dawn Schuessler for preparation of the manuscript.

	References

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 

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