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Coronary surgery in patients with peripheral vascular disease: effect of avoiding cardiopulmonary bypass
Shishir Karthik1, Ghassan Musleh, Antony D Grayson
1Department of Cardiothoracic Surgery, The Cardiothoracic Centre, Liverpool, United Kingdom.
Insights
Off-pump coronary artery bypass grafting significantly reduces stroke incidence and hospital stays for patients with peripheral vascular disease. This approach is safe and yields acceptable outcomes in this high-risk group.
Area of Science:
- Cardiovascular Surgery
- Vascular Surgery
- Anesthesiology
Background:
- Increasing number of patients with peripheral vascular disease (PVD) undergo coronary artery bypass grafting (CABG).
- PVD patients face higher risks of adverse outcomes during CABG.
- Need to evaluate strategies to mitigate these risks.
Purpose of the Study:
- Quantify the effect of avoiding cardiopulmonary bypass (off-pump surgery) in PVD patients undergoing CABG.
- Assess the impact on in-hospital mortality and morbidity.
- Determine safety and efficacy of off-pump CABG in this population.
Main Methods:
- Retrospective analysis of 3,771 consecutive CABG patients (April 1997-March 2002).
- Identified 422 patients (11.2%) with PVD, 211 of whom received off-pump surgery.
- Multivariate logistic regression and propensity score analysis to adjust for treatment selection bias.
Main Results:
- Off-pump surgery associated with lower postoperative stroke rates (adjusted OR 0.09; p=0.005).
- Off-pump patients experienced shorter postoperative hospital stays (p=0.001).
- Higher incidence of new atrial arrhythmia observed in off-pump group (p=0.028).
Conclusions:
- Off-pump coronary surgery is a safe and effective option for patients with PVD.
- Avoiding cardiopulmonary bypass substantially reduces postoperative stroke incidence.
- Acceptable outcomes achieved, with significant benefits in stroke reduction and length of stay.
Background:
An increasing number of patients with peripheral vascular disease are undergoing coronary artery bypass grafting. Such patients have an increased risk of adverse outcomes. Our aim was to quantify the effect of avoiding cardiopulmonary bypass in this group of patients.
Methods:
Between April 1997 and March 2002, 3,771 consecutive patients underwent coronary artery bypass grafting performed by five surgeons. Four hundred and twenty-two (11.2%) had peripheral vascular disease and of these, 211 (50%) received off-pump surgery. We used multivariate logistic regression analysis to assess the effect of off-pump surgery on in-hospital mortality and morbidity, while adjusting for treatment selection bias. Treatment selection bias was controlled for by constructing a propensity score, which was the probability of receiving off-pump surgery and included core patient characteristics. The C statistic for this model was 0.8.
Results:
Off-pump patients were more likely to have preoperative renal dysfunction, previous gastrointestinal surgery, and less extensive disease. The left internal mammary artery was used more in off-pump compared to on-pump cases (90.1% vs 82.9%; p = 0.033). In the univariate analyses, off-pump patients were less likely to have a postoperative stroke (p = 0.007), and had shorter postoperative hospital stays (p < 0.001). However, the incidence of new atrial arrhythmia was higher (p = 0.028). After adjustment for differences in case-mix (propensity score), avoidance of cardiopulmonary bypass was still associated with a significant reduction in postoperative stroke (adjusted odds ratio 0.09 [95% confidence interval 0.02 to 0.50]; p = 0.005), and shorter postoperative hospital stay (p = 0.001).
Conclusions:
Off-pump coronary surgery is safe in patients with peripheral vascular disease, with acceptable results. The incidence of postoperative stroke is substantially reduced when avoiding cardiopulmonary bypass in patients with peripheral vascular disease.
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