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Correspondence

Coronary Artery Bypass Grafting After Previous Stenting is Associated With Compromised Long-Term Efficacy

Mayo Clinic Jacksonville, Division of Cardiovascular & Thoracic Surgery, 4500 San Pablo Rd, Jacksonville, FL 32224

(Email: odell.john{at}mayo.edu).

To the Editor:

The article by Rao and colleagues [1] is another supporting argument that coronary artery bypass grafting is the better option for management of coronary artery disease. I have a poor understanding of the statistical model myself, but I do understand the hypotheses that have been proposed that may play a role. The authors mention that in-stent stenosis is associated with a higher risk of early venous graft failure: the grafts are performed more distally, the discontinuation of antiplatelet medication may result in an in-stent stenosis, and there may be pathophysiologic changes associated with an intravascular foreign body.

There may also be another factor playing a role (ie, intraoperative deformation of the pre-existing stent). This issue has been alluded to by Tovar and colleagues [2] who described a case in which manipulation at surgery deformed a patent vein graft containing stents. As a follow-up to this case, the authors developed an experimental model in pigs [3]. The authors found that pressure over the stented coronary arteries, sufficient to retract the heart, resulted in angioscopic and explant obstruction of the stent, whereas angiographic and radiographic analysis failed to reveal the obstruction. The authors calculated that a force of 4 oz is all that is needed to crush a 4-mm stent, and they suggested that lifting the heart, which usually weighs 11 oz, could result in obliteration of the stents. For this reason, the authors suggested revascularization of all stented vessels, even if they are patent.

I am not aware of any other study that has looked at the fate of the stented and patent vessels which have not been grafted when coronary artery bypass grafting (CABG) is later undertaken. I raise this issue to offer another hypothesis for poor survival in patients having CABG after stenting, and hope that this issue will be further studied.

	References

Top References

 

1. Rao C, Stanbridge RL, Chikwe J, et al. Does previous percutaneous coronary stenting compromise the long-term efficacy of subsequent coronary artery bypass surgery?. A microsimulation study. Ann Thorac Surg 2008;85:501-507.[Abstract/Free Full Text]
2. Tovar EA, Blau N, Borsari A, Landa DW, Packer JM. Severe deformity of a Palmaz-Schatz stent after normal surgical manipulation Ann Thorac Surg 1997;63:220-221.[Abstract/Free Full Text]
3. Tovar EA, Borsari A. Effects of surgical manipulation on coronary stents: should surgical strategy be altered? Ann Thorac Surg 1997;63:37-40.[Abstract/Free Full Text]

This article has been cited by other articles:

				C. Rao, T. Athanasiou, and J. Chikwe Reply Ann. Thorac. Surg., September 1, 2008; 86(3): 1052 - 1053. [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted 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): John A. Odell Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Odell, J. A. Search for Related Content PubMed PubMed Citation Articles by Odell, J. A. Related Collections Coronary disease Related Article