Circulation: Clinical Summaries

Hybrid coronary revascularization versus coronary artery bypass surgery with bilateral or single internal mammary artery grafts

Bilateral Internal Mammary Artery Grafting and Risk of Sternal Wound Infection: Evidence From Observational Studies

Background— The Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST) found a higher risk of stroke after carotid artery stenting and a higher risk of myocardial infarction (MI) after carotid endarterectomy. Methods and Results— Cardiac biomarkers and ECGs were performed before and 6 to 8 hours after either procedure and if there was clinical evidence of ischemia. In CREST, MI was defined as biomarker elevation plus either chest pain or ECG evidence of ischemia. An additional category of biomarker elevation with neither chest pain nor ECG abnormality was prespecified (biomarker+ only). Crude mortality and risk-adjusted mortality for MI and biomarker+ only were assessed during follow-up. Among 2502 patients, 14 MIs occurred in carotid artery stenting and 28 MIs in carotid endarterectomy (hazard ratio, 0.50; 95% confidence interval, 0.26 to 0.94; P =0.032) with a median biomarker ratio of 40 times the upper limit of normal. An additional 8 carotid artery stenting and 12 carotid endarterectomy patients had biomarker+ only (hazard ratio, 0.66; 95% confidence interval, 0.27 to 1.61; P =0.36), and their median biomarker ratio was 14 times the upper limit of normal. Compared with patients without biomarker elevation, mortality was higher over 4 years for those with MI (hazard ratio, 3.40; 95% confidence interval, 1.67 to 6.92) or biomarker+ only (hazard ratio, 3.57; 95% confidence interval, 1.46 to 8.68). After adjustment for baseline risk factors, both MI and biomarker+ only remained independently associated with increased mortality. Conclusions— In patients randomized to carotid endarterectomy versus carotid artery stenting, both MI and biomarker+ only were more common with carotid endarterectomy. Although the levels of biomarker elevation were modest, both events were independently associated with increased future mortality and remain an important consideration in choosing the mode of carotid revascularization or medical therapy. Clinical Trial Registration— URL: http://www.ClinicalTrials.gov . Unique identifier: NCT00004732.

Objective: To analyze the 1070 catheter-based angiograms performed on patients undergoing carotid artery stenting (CAS) in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST). Background CAS may be useful as an alternative to carotid endarterectomy in selected patients with symptomatic and asymptomatic carotid artery disease. The angiographic predictors of stroke following CAS have been incompletely described. Design/Methods: Of the 1070 CAS patients, 43 (4%) experienced periprocedural stroke. Angiograms were reviewed before and after CAS. Reviews were blinded to outcomes. Strokes were adjudicated by a committee blinded to results of angiography. The view showing the most severe stenosis was selected. Extreme tortuosity was defined as 2 severe bends >90 degrees (maximum angulation/20 mm segment) beyond the target lesion, sequential lesions as lesions separated by ≥10 mm, and narrow mouth ulcer as a discrete area of contrast extension beyond the normal arterial lumen with a narrow inlet into the ulceration. Results: The internal carotid artery mean reference diameter was 4.2 ± 0.8 mm, the minimal mean lumen diameter was 1.1 ± 0.6 mm, and the baseline mean % diameter stenosis was 74.1 ± 11.6%. There were no differences in vessel size or severity of the stenosis in patients with and without stroke. Morphologic predictors significantly related to the risk of subsequent stroke were lesion length (p=0.009), sequential lesions (p=0.007), severe distal tortuosity (p=0.025), and narrow mouth ulcer (p=0.05). Calcification, lesion eccentricity, baseline flow, and distance from the bifurcation were not predictive of periprocedural stroke (p > 0.05). Conclusions: In CREST, four angiographic variables were found to increase risk for stroke during and within 30 days after CAS: severe distal tortuosity, sequential lesions, lesion length > 20 mm, and narrow mouth ulcer. Angiographic characteristics beyond percent stenosis may help in patient selection in terms of best revascularization option. Supported by: The National Institute of Neurological Disorders and Stroke (NINDS) and the NIH (R01 NS 038384) and by supplemental funding from Abbott Vascular Solutions (formerly Guidant). Disclosure: Dr.Roubin has received royalty payments from Abbott Vascular and Cook Inc. Dr. Popma has received personal compensation for activities with Boston Scientific as a consultant.Dr. Popma has received research support from Boston Scientific, Cordis, Abbott Vascular, and Medtronic. Dr. Almonacid has nothing to disclose. Dr. Morrish has nothing to disclose. Dr. Katzen has received personal compensation for activities with Boston Scientific, W.L. Gore, and Medtronic as a consultant and particpant on an advisory board. Dr. Chakhtoura has nothing to disclose. Dr. Lal has nothing to disclose. Dr. Voeks has nothing to disclose. Dr. Meschia has nothing to disclose. Dr. Brott has received personal compensation for activities with 3D Communications.

Several randomized trials have emerged with conflicting data on the overall safety of carotid artery stenting (CAS) in comparison with carotid endarterectomy (CEA). The authors hypothesize that changes in national trends correspond to publication of randomized trials, including an increase in utilization of CAS after publication of trials favorable to CAS (for example, Carotid and Vertebral Artery Transluminal Angioplasty Study [CAVATAS] and Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy [SAPPHIRE]) and decrease in utilization of CAS after publication of trials favorable to CEA (for example, Endarterectomy versus Stenting in Patients with Symptomatic Severe Carotid Stenosis [EVA3-S] and Stent-Supported Percutaneous Angioplasty of the Carotid Artery versus Endarterectomy [SPACE]). The Nationwide Inpatient Sample was obtained for the years 1998-2008. Individual cases were isolated for principal diagnosis of unilateral or bilateral carotid artery stenosis or occlusion undergoing CEA or CAS. The percentage of CAS for all carotid revascularization procedures was calculated for each year. Perioperative inpatient morbidity, including stroke or death, were calculated and compared. The percentage of patients undergoing CAS increased yearly from the start of the observed period to the end, with the exception of a decrease in 2007. The peak utilization of CAS for carotid artery revascularization procedures was 15% of all cases in 2006. The stroke or death rate was consistent at 5% among all patients undergoing CEA for all years, while the incidence of stroke or death decreased among patients undergoing CAS from 9% in 1998 to 5% in 2008. The practice of CAS in the US is expanding, from less than 3% of all carotid artery revascularization procedures to 13% in 2008. The utilization of CAS was seen to correlate with publication of randomized trials. Utilization nearly doubled in 2005 after publication of the CAS-favorable SAPPHIRE in 2004, and decreased by 22% after publication of the CEA-favorable EVA-3S and SPACE in 2007. With the publication of Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST), the authors predict a resultant increase in the rate of CAS for carotid artery disease in the upcoming years.

Determinants of operative mortality in elderly patients undergoing coronary artery bypass grafting: Emphasis on the influence of internal mammary artery grafting on mortality and morbidity

Invited commentary

Background: Bilateral internal mammary artery (BIMA) grafting is largely underutilized in patients undergoing coronary artery bypass grafting (CABG), partly because of the perceived increased complexity of the procedure. In this study we evaluated whether BIMA grafting can be safely performed also in centers in which this revascularization strategy is infrequently adopted. Methods: Out of 6783 patients from the prospective multicenter E-CABG study, who underwent isolated non-emergent CABG from January 2015 to December 2016, 2457 underwent BIMA grafting and their outcome was evaluated in this analysis. Results: The mean number of BIMA grafting per center was 82 cases/year and hospitals were defined as high- or low-volume according to this cutoff value. Six hospitals were considered as centers with high-volume of BIMA grafting (no. of procedures ranging from 120 to 267/year; overall: 2156; prevalence: 62.2%) and nine hospitals as centers with low-volume of BIMA grafting (no. of procedures ranging from 2 to 39/year; overall: 301; prevalence: 9.1%). Multilevel mixed-effects regression analysis showed that the low- and high-volume cohorts had similar outcomes. Propensity score one-to-one matching analysis of 292 pairs showed that the low-volume cohort had a significantly shorter intensive care unit stay (2.2 ± 2.3 vs. 2.9 ± 4.8 days, p = 0.020). The rates of in-hospital death (1.0% vs. 0.3%, p = 0.625), deep sternal wound infection/mediastinits (3.8% vs. 3.1%, p = 0.824) and 1-year survival (98.1% vs. 99.7%, p = 0.180) as well as other outcomes were similar between the high- and low-volume cohorts. Conclusions: BIMA grafting can be safely performed also in centers in which this revascularization strategy is infrequently performed.

The effectiveness of bilateral internal mammary artery (BIMA) grafting during multivessel coronary artery bypass grafting (CABG) is uncertain in patients with mildly decreased renal function (glomerular filtration rate 60-89ml/min/1.73m2). We compared outcomes of bilateral versus single IMA (SIMA) grafting in this population. We analyzed 933 patients with mildly decreased renal function who underwent isolated primary CABG using BIMA (n = 454) or SIMA (n = 479) at our center. Patients receiving radial artery grafts or no IMA grafts were excluded. Inverse probability treatment weighting was used to create a well-balanced cohort. 6-year survival and the cumulative incidence of major adverse cardiac or cerebrovascular events (MACCE)-including death, stroke, myocardial infarction, revascularization, and rehospitalization-were assessed. The median age of the entire cohort was 68.0years (IQR 61.5-74.0). Median follow-up time was 4.63years (IQR 4.46-4.82). In well-balanced cohort, BIMA group had a higher number of total distal anastomoses (P < 0.001), with similar rate of complete revascularization (P = 0.101). BIMA group had significantly higher 6-year survival compared to SIMA group (91.9% [87.7-96.3%]; 85.9% [81.7-90.2%]; P = 0.046), which was reconfirmed on multivariable Cox regression analysis (Hazard ratio: 0.505 [0.268-0.953], P = 0.035). MACCE incidence was significantly lower with BIMA (23.5% vs. 40.5%, P < 0.001). Among patients with mildly decreased renal function, the BIMA group was associated with longer survival and lower major adverse cardiac or cerebrovascular events after multivessel CABG.

Scoring system to guide decision making for the use of bilateral internal mammary arteries: The BIMA score

Distal Protection Device-Induced Slow- or Stop-Flow Phenomenon During Carotid Stenting and the Use of Aspiration to Decrease Periprocedural Events

Influence of multiple stents on periprocedural stroke after carotid artery stenting in the Carotid Revascularization Endarterectomy versus Stent Trial (CREST)

Effect of CREST Findings on Carotid Revascularization Practice in the United States

Management of Carotid Artery Stenosis: Endarterectomy or Stenting?

The purpose is to determine whether patching during carotid endarterectomy (CEA) affects the perioperative and long-term risks of restenosis, stroke, death, and myocardial infarction as compared with primary closure. We identified all patients who were randomized and underwent CEA in Carotid Revascularization Endarterectomy versus Stenting Trial. CEA patients who received a patch were compared with patients who underwent CEA with primary closure without a patch. We compared periprocedural and 4-year event rates, 2-year restenosis rates, and rates of reoperation between the 2 groups. We further analyzed results by surgeon specialty. There were 1151 patients who underwent CEA (753 [65%] with patch and 329 [29%] with primary closure). We excluded 44 patients who underwent eversion CEA and 25 patients missing CEA data (5%). Patch use differed by surgeon specialty: 89% of vascular surgeons, 6% of neurosurgeons, and 76% of thoracic surgeons patched. Comparing patients who received a patch versus those who did not, there was a significant reduction in the 2-year risk of restenosis, and this persisted after adjustment by surgeon specialty (hazard ratio, 0.35; 95% confidence interval, 0.16-0.74; P=0.006). There were no significant differences in the rates of periprocedural stroke and death (hazard ratio, 1.58; 95% confidence interval, 0.33-7.58; P=0.57), in immediate reoperation (hazard ratio, 0.6; 95% confidence interval, 0.16-2.27; P=0.45), or in the 4-year risk of ipsilateral stroke (hazard ratio, 1.23; 95% confidence interval, 0.42-3.63; P=0.71). Patch closure in CEA is associated with reduction in restenosis although it is not associated with improved clinical outcomes. Thus, more widespread use of patching should be considered to improve long-term durability. http://www.clinicaltrials.gov. Unique identifier: NCT00004732.