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Published on: September 15, 2023
Intraoperative surgical strategy changes in patients with chronic and end-stage renal disease undergoing coronary
Ethan S Rosenfeld1,2, Gregory D Trachiotis1,2, Andrew D Sparks2
1Division of Cardiothoracic Surgery and Heart Center, Washington DC Veterans Affairs Medical Center, Washington, DC, USA.
Insights
Patients with chronic and end-stage renal disease (ESRD) undergoing coronary artery bypass grafting (CABG) require more surgical strategy changes. However, high-frequency ultrasound and transit-time flow measurement (TTFM) ensure comparable graft flow in ESRD patients.
Area of Science:
- Cardiovascular Surgery
- Nephrology
- Medical Imaging
Background:
- Patients with chronic and end-stage renal disease (ESRD) present unique challenges during coronary artery bypass grafting (CABG) due to diffuse atherosclerosis, plaque instability, and vascular calcification.
- Intraoperative assessment tools like high-frequency ultrasound and transit-time flow measurement (TTFM) are crucial for optimizing CABG outcomes.
Purpose of the Study:
- To evaluate if patients with chronic and ESRD experience more intraoperative surgical strategy changes or graft revisions during CABG compared to patients with normal renal function.
- To assess the effectiveness of a protocol utilizing intraoperative high-frequency ultrasound and TTFM in managing CABG procedures for ESRD patients.
Main Methods:
- A retrospective analysis of the multicentre prospective REQUEST study comparing outcomes of CABG in patients with and without chronic/ESRD.
- Primary endpoint: frequency of intraoperative surgical strategy changes. Secondary endpoint: post-protamine TTFM parameters.
- Utilized high-frequency ultrasound and TTFM during CABG procedures.
Main Results:
- Patients with chronic and ESRD (n=95) showed a significantly higher rate of strategy changes (33.7% vs. 24.3%) and greater graft revisions per graft (7.0% vs. 3.4%) compared to patients with normal renal function (n=921).
- Despite increased surgical adjustments, final post-protamine graft TTFM parameters were comparable between the two cohorts.
- Odds ratios indicated a 1.58-fold increased likelihood of strategy changes and a 2.14-fold increased likelihood of graft revisions in the ESRD group.
Conclusions:
- The use of high-frequency ultrasound and TTFM in CABG procedures for patients with chronic and ESRD leads to a higher frequency of surgical strategy changes.
- These interventions, however, result in comparable graft flow, suggesting the protocol effectively manages the complexities associated with renal disease in CABG.
- The findings highlight the utility of advanced intraoperative monitoring in complex cardiac surgeries involving patients with renal impairment.
Objectives:
Factors such as more diffuse atherosclerosis, plaque instability and accelerated vascular calcification in patients with chronic and end-stage renal disease (ESRD) can potentially present intraoperative challenges in coronary artery bypass grafting (CABG) procedures. We evaluated whether patients with chronic and ESRD experienced more surgical strategy changes and/or graft revisions than patients with normal renal function when undergoing CABG procedures according to a protocol for intraoperative high-frequency ultrasound and transit-time flow measurement (TTFM).
Methods:
Outcomes of CABG for patients with chronic and ESRD and patients with normal renal function enrolled in the multicentre prospective REQUEST (REgistry for QUality assESsmenT with Ultrasound Imaging and TTFM in Cardiac Bypass Surgery) study were compared retrospectively. The primary end point was frequency of intraoperative surgical strategy changes. The secondary end point was post-protamine TTFM parameters.
Results:
There were 95 patients with chronic and ESRD and 921 patients with normal renal function. Patients with chronic and ESRD undergoing CABG according to a protocol for intraoperative high-frequency ultrasound and TTFM had a higher rate of strategy changes overall [33.7% vs 24.3%; odds ratio (OR) = 1.58; 95% confidence interval (CI) = 1.01-2.48; P = 0.047] and greater revisions per graft (7.0% vs 3.4%; odds ratio = 2.14; 95% CI = 1.17-3.71; P = 0.008) compared to patients with normal renal function. Final post-protamine graft TTFM parameters were comparable between cohorts.
Conclusions:
Patients with chronic and ESRD undergoing CABG procedures with high-frequency ultrasound and TTFM experience more surgical strategy changes than patients with normal renal function while achieving comparable graft flow.
Clinical Trial Registration Number:
ClinicalTrials.gov NCT02385344.
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