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 Table of Contents  
Year : 2019  |  Volume : 32  |  Issue : 4  |  Page : 1318-1322

Short-term results of coronary artery bypass grafting for vessels with previous percutaneous coronary intervention

1 Department of Cardio-Thoracic Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Cardio-Thoracic Surgery, Alexandria Police Authority Hospital, Alexandria, Egypt

Date of Submission23-Jun-2018
Date of Decision06-Aug-2018
Date of Acceptance13-Aug-2018
Date of Web Publication31-Dec-2019

Correspondence Address:
Michael Adel Soliman Yousef
Damanhur, Al-Behera 22511
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mmj.mmj_201_18

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To determine whether previous percutaneous coronary intervention (PCI) has a prognostic impact on the outcome of subsequent coronary artery bypass grafting (CABG).
Interventional cardiologists have a growing role in the treatment of coronary artery diseases due to improvement of technology. Its 'less invasiveness' is more attractive to patients. Around one-third of patients with multivessel disease treated with bare metal stents will require reintervention within few years. CABG and PCI have a long history as invasive options for treating patients with coronary artery disease. The interventional efficacy and relative benefits have been compared in several randomized and observational studies. However, the patients who have undergone successful myocardial revascularization may subsequently require repeat invasive cardiological or surgical intervention.
Patients and methods
This was a prospective analytical study conducted on 50 consecutive patients with previous PCI indicated for CABG from Police Authority Hospitals and Nasser Institute Hospital and who have undergone CABG in the period between May 2016 and May 2018. These patients collected and were investigated by laboratory tests and radiologically to determine whether previous PCI has a prognostic impact on surgical outcome.
The mean age was 51.36 ± 8.056 years. The mean number of grafts was 2.84 ± 0.47. Inotropes was used in 13 patients. ICU stay was 72.56 ± 54.44 h, hospital stay was 10.72 ± 3.99 days, and total postoperative complication occurred in 18 (36%) patients, which was perceived as a high morbidity rate.
Previous PCI has a negative impact on the outcome of subsequent CABG regarding morbidity. However, there was no impact on the postoperative mortality.

Keywords: coronary artery bypass grafting after stent, percutaneous coronary intervention, surgical revascularization

How to cite this article:
Dokhan AL, Hafez BA, El-Hag-Aly MA, Yousef MA. Short-term results of coronary artery bypass grafting for vessels with previous percutaneous coronary intervention. Menoufia Med J 2019;32:1318-22

How to cite this URL:
Dokhan AL, Hafez BA, El-Hag-Aly MA, Yousef MA. Short-term results of coronary artery bypass grafting for vessels with previous percutaneous coronary intervention. Menoufia Med J [serial online] 2019 [cited 2020 Jun 6];32:1318-22. Available from: http://www.mmj.eg.net/text.asp?2019/32/4/1318/274232

  Introduction Top

Despite all guidelines for the treatment of chronic coronary artery disease, there has been an exponential growth in percutaneous coronary intervention (PCI); its less invasiveness is more attractive to patients [1]. Around one-third of patients treated with bare metal stents will require reintervention within few years [2]. Many studies clearly demonstrated that there was no difference between both regarding mortality, and patients treated with stenting required more often to repeat revascularization [3]. Others suggest that initial PCI may complicate the operation and may increase postoperative morbidity and mortality [4]. There remains a low but real need for emergent coronary artery bypass grafting (CABG) after PCI [5]. The aim of this work was to determine whether previous PCI has a prognostic impact on the outcome of subsequnet CABG.

  Patients and Methods Top

This was a prospective, analytical study conducted on 50 consecutive patients with previous PCI indicated for CABG from the Police Authority Hospitals and Nasser Institute who underwent CABG in the period between May 2016 and May 2018. The participants signed an informed consent after receiving full information of the study design. This study is conducted under the approval of the Human Ethics Committee of the Faculty of Medicine, Menoufia University, Egypt before starting the study. Inclusion criteria included all patients who underwent coronary artery bypass surgery and who suffered from ischemic heart disease with previous PCI. Patients who had undergone emergency CABG, candidate for redo CABG, patients with significant carotid artery stenosis with CABG, and patients associated with other cardiac operative interference (e.g. valve repair, replacement, or aortic root surgery) were excluded from this study. All patients in this study had full comprehensive clinical history. Complete clinical examination was performed for all patients. Laboratory investigations such as resting 12-lead ECG), plain chest radiography were done; each patient was examined by two-dimensional, M-mode, and Doppler echocardiography within 1 month before the surgery. Carotid Doppler and duplex were done for all patients to detect any significant carotid artery stenosis and coronary angiography (catheter was reviewed regarding: the presence or absence of left main disease, previous sites of stents and its type, and to plan the number, sites of the diseased vessels which will need to be grafted). Surgical access was through median sternotomy in all cases. All incisions and closure techniques were the same. Fine monofilament polypropylene suture (8-0 or 7-0) was used for all distal anastomoses [Figure 1].
Figure 1: Flow diagram of patients allocated in the study.

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Proximal anastomoses were performed with fine monofilament polypropylene suture (5-0 or 6-0) for venous anastomoses. Cardiopulmonary bypass was conducted using a membrane oxygenator and a nonpulsatile flow of 2.2–2.5 l/min/m 2 body surface area. Myocardial protection was through repeated infusions of antegrade warm blood cardioplegia solution every 15:20 min with potassium chloride (0.3 mEq/kg) over 3 min as initial dose and half the dose over 90 s, for every booster dose. Time of aortic cross-clamp, extra corporeal circulation operative time, and number of grafts (arterial and venous grafts) were recorded. Outcomes assessed included primary outcomes such as postoperative ECHO improvement, perioperative myocardial infarction (MI) diagnosed by ECG change plus cardiac enzyme tests with or without hemodynamic instability, and requires coronary revascularization. Secondary outcome parameters included mortality, morbidity such as the need for inotropic support (types, doses, duration), use of intra-aortic balloon pump (IABP), course in the ward regarding signs of heart failure or low cardiac output or readmission to the ICU, arrhythmias and ECG analysis, reopening for bleeding, heart failure, superficial, deep wound infection, and hospital stay duration, neurological and renal complications.

Statistical analysis

Results were collected, tabulated, and statistically analyzed by an IBM compatible personal computer with statistical package the social sciences, version 20 (SPSS Inc. released 2011, IBM SPSS statistics for windows, version 20.0; IBM Corp., Armonk, New York, USA). Data was expressed as mean, SD or median and range for continuous variables, and as frequencies (percentages) for categorical variables.

  Results Top

This study had included 50 patients with their mean age being 51.36 ± 8.056 years (range, 38–65 years). Regarding sex distribution, it was 43 men and seven women. Echocardiography was routinely performed preoperatively (within 1 month). Regarding Preoperative coronary angiography, the number of diseased vessels was (3.24 ± 0.43) [Table 1]. All patients in our group had previous stent in Left anterior descending artery (LAD), while four patients had stents in left circumflex and only two patients had stents in right coronary artery. The mean number of grafts was 2.84 ± 0.47. While the type of the conduit used was as shown in [Table 2]. The mean total operative time was 181.8 ± 33.4. The mean aortic cross-clamp time was 75.2 ± 14.46. The mean cardiopulmonary bypass time was 117.12 ± 16.14. Inotropes were used in 13 patients; however, this was not the case with IABP with only two patients requiring it [Table 3]. In fact, ICU stay was 72.56 ± 54.44 h; hospital stay was 10.72 ± 3.99 days. Total morbidity was seen in 18 patients On statistical analysis of individual morbidities the numbers are: reopening (six patients), superficial wound infection (eight patients), postoperative MI (two patients), atrial fibrillation (one patient), and respiratory complications (one patient) [Table 4]. Postoperative echo was one for all patients about 1 weak postoperatively and it showed mean End systolic diameter (ESD) 3.64 ± 0.829 cm, mean End diastolic diameter (EDD) 5.2 ± 0.88 cm, and postoperative Ejection fraction (EF%) 52.64 ± 10.65%. Regarding In-hospital mortality rate there was only one case mortality. The mortality case died during the third postoperative day due to refractory heart failure and cardiac arrest in spite of the high doses of inotropes and all the Cardiopulmonary resuscitation (CPR) trials failed.
Table 1: Demographic features of the participants in study groups

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Table 2: Operative data according to the grafts used

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Table 3: Total operative time, aortic cross-clamp, cardiopulmonary bypass time, inotropes, and intra-aortic balloon pump usage in the study groups

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Table 4: Postoperative morbidity in the study group

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  Discussion Top

When a patient is eligible for both procedures, PCI is often preferred than surgery. The initial choice of PCI is reinforced by the perception that patients can safely be referred to surgery after PCI. However, depending on the studies on bare metal stents, from 6 to 13% of patients will undergo CABG within 1 year after PCI, and from 13 to 26% within 10 years, which was perceived as a high recurrence rate [6]. Comparison was made between patients who used Drug eluted stents (DES) and those who used Bare metal stents (BMS), over 3 years. Patients with DES underwent total target revascularization more than those who used BMS, although the clinical syndromes at the time of presentation, resulting in the need for total target revascularization, for the two stents type were similar. This made clinical presentation poststent insertion, which was not always benign with an MI including stent thrombosis occurring in up to one-third of the patients, regardless of the stent type. Over the course of 3 years, the patients with total vascular revascularization (most of them used DES) had a threefold increase in the hazard of nonfatal MI or death compared with those without total target revascularization, independent of the stent type. These findings suggest that total target revascularization is often accompanied by an MI and make its patients at particularly high risk for subsequent nonfatal MI death [7]. Patients with prior PCI presented for CABG with more advanced symptoms and greater urgency; Moreover, prior PC was an independent risk factor for in-hospital mortality and worse outcome after CABG. Eifert's group stated that morbidity, mortality, and reoperation rate was higher among the patients who did previous PCI prior to CABG [8]. Previous PCI before CABG in patients with diabetes mellitus and triple-vessel disease independently increases the risk for in-hospital mortality and major adverse cardiac events [9]. Hayes et al. [7] focused on the preoperative EF% of the patients and stated that patients with left ventricular ejection fraction less than 40% having a history of PCI prior to surgery had a worse outcome post-CABG than those without prior PCI. On the other hand, Van den Brule et al. [2] stated that successful PCI independently has no role in affecting short-term and mid-term outcomes of subsequent CABG. The mean age was 51.36 ± 8.056 years (range, 38–65), Van den Brule et al. [2], Eifert et al. [8], and Kalaycioǧlu et al. [10] studies showed a difference in age between their PCI group and the non-PCI group. This was also found with Loponen and colleagues when the non-PCI group age was 66.3 ± 9.0 and the PCI group was 64.5 ± 10.1, so he statistically analyzed the age groups. He found no difference between the two randomized groups in age group from 65 to 74 years and above 75 years, but the younger age group (<65 years) was more in the PCI group. He stated that the younger age group in the post-PCI group was not coinciding with the severity of the disease such as the number of diseased vessels or dyslipidemia as there was no difference between both groups in these parameters or with arteriopathy which was higher in the non-PCI group in his study [11]. The choice of the surgical technique was not affected by the presence of previous stent. On-pump coronary artery bypass grafting (OPCAB) was used in 13 patients in our group, this coincides with Chocron et al.'s [6] study. In Van den Brule et al. [2] and Eifert et al. [8] study all patients underwent cardiopulmonary bypass, while with Chocron et al. [6] team all patients underwent OPCAB. The mean number of grafts was significantly less than the average in our group. Eifert and colleagues found a higher number of distal anastomosis (2.43 ± 1.08 for non-PCI group vs. 2.08 ± 1.08). He attributed this higher number of distal anastomosis in the non-PCI group to the higher number of nongraftable vessels in the PCI group [7]. Also, total revascularization was less than average for our group. This was expected because the number of graftable vessels were lower in our group. These nongraftable vessels are due to either propagation of poststent thrombosis that occlude the vessel totally, which is more common, or due to the propagation of atherosclerosis in previously diseased vessel left without intervention (less common). This made the anastomosis more challenging and risky for the surgeon [8]. Inotropes were used postoperatively in 13 patients; however, this was not the case with IABP which only two patients requiring it. The higher usage of inotropic support may be related to the lower incidence of total revascularization and higher incidence of preoperative MI. Thielmann and colleagues showed no difference in the usage of IABP between the PCI group and the non-PCI group; however, other groups have shown a higher incidence of the use of IABP in the PCI group [6],[8],[9]. Overall morbidity was high in the study group [11]. Although it is difficult to attribute the higher morbidity rate to a specific cause, some possible explanations are: (a) PCI-induced inflammation of the coronary intima with subsequent poor graft flow; (b) prevention of adequate collateral formation around the coronary stenosis; (c) diffuse coronary disease with poor distal target for revascularization and higher chances of incomplete revascularization; and (d) patients referred for CABG after PCI may have more aggressive atherosclerosis, which may have resulted in de-novo lesions or in-stent stenosis. Surgical revascularization in these patients may be technically challenging because the distal targets are small and of poor quality [8],[9]. On further analysis of morbidity, the PCI group showed higher incidence of reexploration and superficial wound infection. Other postoperative parameters were the same. Reopening for bleeding was due to the continuous use of clopidogrel for long-time preoperative management (and till the operation in case of emergency operation). In the PCI group, aspirin was not discontinued until the morning of the operation as a precaution against total stent occlusion and perioperative MI. Some authors stated that previous PCI has no role in postoperative morbidity; Eifert and colleagues results were so interesting, as it showed no difference in reopening but the PCI group received more units of packed red blood cells. There was no difference in postoperative acute renal failure but the highest creatinine level was higher in the PCI group (1.9 ± 1.6 vs. 1.61 ± l. 4); no difference in postoperative MI but the highest troponin level was in the PCI group. Mack et al.'s [12] results were the same but also showed that the morbidity increases when the number of previous interventions increases. Eifert et al. [8] also showed a high incidence of reopening in the PCI group. The ICU stay was long (72.56 ± 54.44 h) but the hospital stay was not. Also, Kalaycioglu et al. [10] stated that the ICU stay was longer in the PCI group, although both groups had the same hospital stay. But others showed no difference in both ICU or hospital stay [2],[8]. The long ICU stay in this study was due to the difference of the morbidity specially reopening and wound infection which prolong the ICU stay. There was only one case of in-hospital mortality. Yap and colleagues and Kanemitsu group had found no difference in mortality, but the Kanemitsu group monitored the patients for the first 30 days only, while Van den Brule and colleagues had equal hospital mortality as well as 1-year postoperatively [2],[6],[13]. On the contrary, Thielmann et al. [9] and Mack [12] stated that patients with prior PCI had higher in-hospital mortality. Eifert et al. [8] showed higher mortality in the first 30 days postoperatively in the PCI group, which decreases after that to become nonsignificant between the two groups during the first 5 years postoperatively. Before discharge, a postoperative echo was done for all patients. In this echo, the mean ESD was 3.64 ± 0.829 cm, the mean EDD 5.2 ± 0.88 cm, and the postoperative EF% was 52.64 ± 10.65%. The number of enrolled patients limits the explanatory power of our study. It is plausible to study the long-term outcome to complete the results of short-term outcome.

  Conclusion Top

Previous PCI has a negative impact on the outcome of subsequent CABG regarding morbidity. However, there was no difference in the postoperative mortality.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Hannan EL, Racz MJ, Walford G, Jones RH, Ryan TJ, Bennett E, Rose EA. Long-term outcomes of coronary-artery bypass grafting versus stent implantation. N Engl J Med 2005; 352:2174–2183.  Back to cited text no. 1
Van den Brule JM, Noyez L, Verheugt FW. Risk of coronary surgery for hospital and early morbidity and mortality after initially successful percutaneous intervention. Interact Cardiovasc Thorac Surg 2005; 4:96–100.  Back to cited text no. 2
Hoffman SN, TenBrook JA, Wolf MP, Wong JB, Pauker SG, Salem DN. A meta-analysis of randomized controlled trials comparing coronary artery bypass graft with percutaneous transluminal coronary angioplasty: one-to eight-year outcomes. J Am Coll Cardiol 2003; 41:1293–1304.  Back to cited text no. 3
Haan CK, O'Brien S, Edwards FH, Peterson ED, Ferguson TB. Trends in emergency coronary artery bypass grafting after percutaneous coronary intervention, 1994–2003. Ann Thorac Surg 2006; 81:1658–1665.  Back to cited text no. 4
Kanemitsu S, Tanaka K, Tanaka J, Suzuki H, Kinoshita T. Initial clinical impact of drug eluting stents on coronary artery bypass graft surgery. Interact Cardiovasc Thorac Surg 2007; 6:632–635.  Back to cited text no. 5
Chocron S, Baillot R, Rouleau JL, Warnica WJ, Block P, Johnstone D, et al. Impact of previous percutaneous transluminal coronary angioplasty and/or stenting revascularization on outcomes after surgical revascularization: insights from the imagine study. Eur Heart J 2008; 29:673–679.  Back to cited text no. 6
Hayes KR, Applegate RJ, Sacrinty MT, Kutcher MA, Gandhi SK, Santos RM, Little WC. Target lesion revascularization after bare-metal or drug-eluting stents: clinical presentations and outcomes. J Invasive Cardiol 2010; 22:266–270.  Back to cited text no. 7
Eifert S, Mair H, Boulesteix AL, Kilian E, Adamczak M, Reichart B, Lamm P. Mid-term outcomes of patients with PCI prior to CABG in comparison to patients with primary CABG. Vasc Health Risk Manag 2010; 6:495–501.  Back to cited text no. 8
Thielmann M, Neuhäuser M, Knipp S, Kottenberg-Assenmacher E, Marr A, Pizanis N, Jakob H. Prognostic impact of previous percutaneous coronary intervention in patients with diabetes mellitus and triple-vessel disease undergoing coronary artery bypass surgery. J Thorac Cardiovasc Surg 2007; 134:470–476.  Back to cited text no. 9
Kalaycioǧlu S, Sinci V, Oktar L. Coronary artery bypass grafting (CABG) after successful percutaneous transluminal coronary angioplasty (PTCA): is PTCA a risk for CABG? Int Surg 1998; 83:190–193.  Back to cited text no. 10
Loponen P, Korpilahti K, Luther M, Huhtala H, Tarkka MR. Repeat intervention after invasive treatment of coronary arteries. Eur J Cardiothorac Surg 2009; 35:43–47.  Back to cited text no. 11
Mack, M. Does percutaneous coronary intervention compromise the outcome of subsequent coronary artery bypass grafting?. 2009: 765–766.  Back to cited text no. 12
Yap CH, Yan BP, Akowuah E, Dinh DT, Smith JA, Shardey GC, Pick A. Does prior percutaneous coronary intervention adversely affect early and mid-term survival after coronary artery surgery? JACC Cardiovasc Interv 2009; 2:758–764.  Back to cited text no. 13


  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]


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