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Background: The long saphenous vein is routinely used for coronary bypass graft (CABG) surgery, and two primary techniques are commonly utilized: endoscopic vessel harvesting (EVH) and open vessel harvesting (OVH). The aim of this study was to compare the clinical outcomes of the EVH and OVH techniques used for CABG within the confines of a tertiary hospital. Methods: The clinical data of all patients subjected to either EVH or OVH for CABG surgery between 2014 and 2018 were retrospectively analyzed. Statistical analysis was performed to discern variations in the rates of postoperative complications between EVH and OVH. Results: A cohort of 1884 individuals were included in this study, 75.3% of whom underwent EVH. Notably, the incidence of postoperative leg wound complications was significantly different between the patients who underwent OVH and the patients who underwent EVH, with incidence rates of 18.6% and 32%, respectively (p < 0.001). Leg wound complications (p < 0.001; OR 1.946; 95% CI 1.528–2.477) and leg wound infections (p = 0.050, OR 1.517, 95% CI 0.999–2.303) were significantly associated with OVH. Moreover, leg wound hematoma (p = 0.039, OR = 0.402, 95% CI = 0.169–0.957) and EVH were strongly associated. Conclusions: The large sample of patients and the inclusion of a range of Asian ethnic groups provided notable insights into postoperative complications related to different modalities. EVH was associated with a lower incidence of postoperative leg wound complications, which suggests that EVH is a better modality for those undergoing CABG surgery. [ABSTRACT FROM AUTHOR]

Abstract Background Precise identification of coronary arteries and selection of anastomotic sites are critical stages of coronary bypass surgery. Visualization of coronary arteries is occasionally challenging when the heart is covered with a thick layer of fat or scar tissue. In this paper, we review the methods to localize the coronary arteries during coronary surgery. Methods Prior publications were searched to summarize all available methods for localization of coronary arteries during coronary surgery. Results Five clinically recognized and three experimental techniques from the literature review are reviewed and summarized. Conclusions Knowledge of various techniques of coronary artery identification in hard-to-see coronary arteries is an important asset in coronary surgery and especially useful during the most critical option of the most common heart surgery.

Background: Precise identification of coronary arteries and selection of anastomotic sites are critical stages of coronary bypass surgery. Visualization of coronary arteries is occasionally challenging when the heart is covered with a thick layer of fat or scar tissue. In this paper, we review the methods to localize the coronary arteries during coronary surgery. Methods: Prior publications were searched to summarize all available methods for localization of coronary arteries during coronary surgery. Results: Five clinically recognized and three experimental techniques from the literature review are reviewed and summarized. Conclusions: Knowledge of various techniques of coronary artery identification in hard-to-see coronary arteries is an important asset in coronary surgery and especially useful during the most critical option of the most common heart surgery. [ABSTRACT FROM AUTHOR]

Background: The long saphenous vein is routinely used for coronary bypass graft (CABG) surgery, and two primary techniques are commonly utilized: endoscopic vessel harvesting (EVH) and open vessel harvesting (OVH). The aim of this study was to compare the clinical outcomes of the EVH and OVH techniques used for CABG within the confines of a tertiary hospital. Methods: The clinical data of all patients subjected to either EVH or OVH for CABG surgery between 2014 and 2018 were retrospectively analyzed. Statistical analysis was performed to discern variations in the rates of postoperative complications between EVH and OVH. Results: A cohort of 1884 individuals were included in this study, 75.3% of whom underwent EVH. Notably, the incidence of postoperative leg wound complications was significantly different between the patients who underwent OVH and the patients who underwent EVH, with incidence rates of 18.6% and 32%, respectively (p < 0.001). Leg wound complications (p < 0.001; OR 1.946; 95% CI 1.528–2.477) and leg wound infections (p = 0.050, OR 1.517, 95% CI 0.999–2.303) were significantly associated with OVH. Moreover, leg wound hematoma (p = 0.039, OR = 0.402, 95% CI = 0.169–0.957) and EVH were strongly associated. Conclusions: The large sample of patients and the inclusion of a range of Asian ethnic groups provided notable insights into postoperative complications related to different modalities. EVH was associated with a lower incidence of postoperative leg wound complications, which suggests that EVH is a better modality for those undergoing CABG surgery.

Objective: This review assessed evidence on the impact of prior coronary artery bypass grafting (CABG) on outcomes of percutaneous coronary intervention (PCI) for chronic total occlusions (CTO). Methods: PubMed, CENTRAL, Embase, ScienceDirect, and Google Scholar databases were searched from 1st January 1980 up to 10th January 2022 for studies assessing outcomes of CTO-PCI in patients with and without prior-CABG. Results: Eight studies were included. The meta-analysis demonstrated significantly reduced odds of procedural success in patients with prior history of CABG (OR: 0.51 95% CI: 0.41, 0.64 I²=84% p<0.00001). There was a tendency of increased in-hospital mortality (OR: 1.72 95% CI: 0.97, 3.04 I²=26% p=0.06) and major adverse cardiac events (MACE) (OR: 1.30 95% CI: 0.99, 1.69 I²=0% p=0.05), along with a significantly increased risk of myocardial infarction (MI) (OR: 2.56 95% CI: 1.65, 3.97 I²=0% p<0.0001) and coronary perforation (OR: 1.52 95% CI: 1.03, 2.24 I²=70% p=0.04) in patients with history of CABG. There was no difference in the risk of stroke, pericardial tamponade, major bleeding, vascular access complications, and renal failure. Conclusion: Our results suggest that patients with prior history of CABG undergoing PCI for CTO have a 49% reduced chance of procedural success. Such patients are at an increased risk of in-hospital mortality, MACE, MI, and coronary perforation. [ABSTRACT FROM AUTHOR]

Symptomatic vertebrobasilar atherosclerotic disease is rarely encountered but represents a high-risk factor for recurrent transient ischemic attack or stroke. Posterior strokes are usually associated with embolism or hemodynamic impairment. Extensive disease involving the V3 and V4 segments of the vertebral artery (VA) remains infrequent, and optimal management is limited owing to the infrequency of this disease. We illustrate the case of a 65-year-old man who presented with recurrent transient episodes of dizziness with acute onset of instability, nausea, and left visual blurring. Magnetic resonance imaging findings of the head were normal, and computed tomography angiography revealed severe atherosclerotic disease of both VAs, with proximal occlusion of the right VA and multiple tight stenoses of the left VA at the V1 and V4 segments. Duplex ultrasound found markedly reduced anterograde flow in the VAs and basilar arteries and nonsignificant stenosis of the internal carotid arteries. Optimal medical treatment led to a decrease of transient symptoms. However, the patient developed a cerebellar infarction in the left posteroinferior cerebellar artery territory with left VA V4 segment occlusion. Surgical revascularization of the right VA was decided by the multidisciplinary team. Through an anterolateral approach of the right VA V3 segment, revascularization was performed using a common carotid artery-to-right VA bypass using a reversed saphenous vein graft. The patient fully recovered and was free of symptoms during the next 14 months of follow-up. In the case of extensive VA occlusive disease, surgical reconstruction of the distal VA using a bypass from the common carotid artery represents an option to improve hemodynamics and/or eliminate an embolic source of posterior stroke on a case-by-case basis.

Objectives: Coronary artery bypass grafting (CABG) is performed using anatomic guidance. Data connecting the physiologic significance of the coronary vessel stenosis to the acute physiologic response to grafting are lacking. The Collaborative Pilot Study to Determine the Correlation Between Intraoperative Observations Using Spy Near-Infrared Imaging and Cardiac Catheterization Laboratory Physiological Assessment of Lesion Severity study is the first to compare preintervention coronary physiology with the acute regional myocardial perfusion change (RMP-QC) at CABG in a per-graft analysis. Methods: Non-emergent patients undergoing diagnostic catheterization suitable for multivessel CABG were enrolled. Synergy between Percutaneous Coronary Intervention with Taxus score, fractional flow reserve (FFR), instantaneous wave free ratio (iFR), and quantitative coronary angiography was documented in 75 epicardial coronary arteries, with 62 angiographically intermediate and 13 severe stenoses. At CABG, near-infrared fluorescence analysis quantified the relative change (post- vs pregrafting, termed RMP-QC) in the grafted vessel's perfusion territory. Scatter plots were constructed for RMP-QC versus quantitative coronary angiography and RMP-QC versus FFR/iFR. Exact quadrant randomization test for randomness was used. Results: There was no relationship between RMP-QC and quantitative coronary angiography percent diameter stenosis, whether all study vessels were included (P = .949) or vessels with core-lab quantitative coronary angiography only (P = .922). A significant nonrandom association between RMP-QC and FFR (P = .025), as well as between RMP-QC and iFR (P = .008), was documented. These associations remained when excluding vessels with assigned FFR and iFR values (P = .0092 and P = .0006 for FFR and iFR, respectively). Conclusions: The Collaborative Pilot Study to Determine the Correlation Between Intraoperative Observations Using Spy Near-Infrared Imaging and Cardiac Catheterization Laboratory Physiological Assessment of Lesion Severity study demonstrates there is no association between angiographic coronary stenosis severity and the acute perfusion change after grafting; there is an association between functional stenosis severity and absolute increase in regional myocardial perfusion after CABG.

Coral reef aorta (CRA) is characterized by heavily calcified obstructive lesions in the aorta. Thoracic endovascular aortic repair (TEVAR) is an established, less invasive procedure for aortic diseases; however, aortic occlusive diseases are commonly treated with conventional open surgery, and there are no reports of TEVAR in patients with a saccular aneurysm in CRA. We present a 72-year-old frail woman with a descending thoracic saccular aneurysm in CRA; therefore, we performed TEVAR. Although we had difficulty in advancing the stent graft system because it was caught in the severely calcified aorta, we finally succeeded in excluding the aneurysm.

Purpose: To investigate the characteristics of cerebral perfusion and hemodynamics of bypass grafting in the treatment of moyamoya disease (MMD) using the iFlow color-coded flow map in comparison with magnetic resonance imaging–perfusion-weighted imaging (MRI–PWI) and computational fluid dynamic (CFD) analysis. Materials and Methods: Patients with MMD treated with bypass grafting who had undergone MRI PWI and digital subtraction angiography for iFlow color-coded map was retrospectively enrolled and CFD was performed for calculating the hemodynamic stresses around the bypass grafting. Results: Forty-five patients with unilateral MMD treated with bypass surgery were enrolled. The bypass surgery was successful in all patients, with no severe neurological complications during the periprocedural period. Followed up for 4–12 months (median 5.5), the neurological function was good in all patients. The cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT), and time to peak (TTP) were significantly (p < 0.05) improved in the middle cerebral artery distribution area on the surgical side before and after vascular bypass, and the difference of TTP (s) measured from the proximal bifurcation of common carotid artery to the confluence of sinus was also significant (p < 0.05). A significant (p < 0.05) positive correlation existed in the perfusion parameters between the iFlow blood perfusion and the MRI–PWI perfusion, with r -value for TTP of 0.765 (p < 0.01). The iFlow color-coded blood flow map showed warm color changes on the diseased side, similar to those on the contralateral side. In CFD analysis, the hemodynamic stresses were all improved, in and around the bypass grafting and distal vessels, which were beneficial to blood flow entering distal arterial branches. Conclusion: The iFlow color-coded flow map can be used to analyze cerebral perfusion after bypass grafting for MMD, similar to MRI–PWI, and CFD can be used to analyze the hemodynamics after bypass grafting, revealing improved hemodynamics to promote blood flow entering distal arteries. [ABSTRACT FROM AUTHOR]

Introduction: The COVID‐19 pandemic has had a significant impact on global surgery. In particular, deleterious effects of SARS‐CoV‐2 infection on the heart and cardiovascular system have been described. To inform surgical patients, we performed a systematic review and meta‐analysis aiming to characterize outcomes of COVID‐19 positive patients undergoing cardiac surgery. Methods: The study protocol was registered with PROSPERO (CRD42021228533) and conformed with PRISMA 2020 and MOOSE guidelines. PubMed, Ovid MEDLINE and Web of Science were searched between 1 January 2019 to 24 February 2022 for studies reporting outcomes on COVID‐19 positive patients undergoing cardiac surgery. Study screening, data extraction and risk of bias assessment were conducted in duplicate. Meta‐analysis was conducted using a random‐effects model where at least two studies had sufficient data for that variable. Results: Searches identified 4223 articles of which 18 studies were included with a total 44 patients undergoing cardiac surgery. Within these studies, 12 (66.7%) reported populations undergoing coronary artery bypass graft (CABG) surgery, three (16.7%) aortic valve replacements (AVR) and three (16.7%) aortic dissection repairs. Overall mean postoperative length of ICU stay was 3.39 (95% confidence interval (CI): 0.38, 6.39) and mean postoperative length of hospital stay was 17.88 (95% CI: 14.57, 21.19). Conclusion: This systematic review and meta‐analysis investigated studies of limited quality which characterized cardiac surgery in COVID‐19 positive patients and demonstrates that these patients have poor outcomes. Further issues to be explored are effects of COVID‐19 on decision‐making in cardiac surgery, and effects of COVID‐19 on the cardiovascular system at a cellular level. [ABSTRACT FROM AUTHOR]

Background: The failure of the saphenous vein graft (SVG) is a critical flaw in coronary artery bypass grafting (CABG) that has been associated with bad cardiac outcomes such as the necessity to repeat coronary revascularization, recurrent angina, myocardial infarction, and mortality. Objective: To compare mid-term patency of saphenous vein graft used for revascularization of the RCA when anastomosed to Distal Right Coronary Artery (DRCA) versus Right Posterior Descending Artery (RPDA) in proximal RCA lesion in patients who underwent isolated CABG. Patients and method: 80 patients who underwent isolated CABG with saphenous vein graft utilized for revascularization of RCA with proximal lesions were enrolled. Patients had been randomly allocated into 2 groups depending on the site of RCA anastomosis. In Group A (n=40), SVG was anastomosed to DRCA, while in Group B (n=40) SVG was anastomosed to RPDA. The postoperative multislice coronary angiography (MSCT) was used for evaluation of patency of the SVGs, and the presence of graft occlusion through mid-term follow ups. Results: 30 of the 80 SVGs used for RCA revascularization were found to be occluded, whereas the remaining 50 were determined to be patent. Group A had a significantly greater mean age than Group B (p<0.05); nevertheless, no statistically significant difference between the study groups was detected in terms of cardiovascular disease risk factors (p>0.05). Group A had similar patency rates (50% patent and 50% occluded), while group B had much greater patency rates (75% patent and 25% occluded, p =0.001). Moreover, the target vessel's mean diameter was substantially greater in group A (p-value=0.001). Conclusion: The findings corroborate the hypothesis that SVG anastomosed to RPDA are more patent than those anastomosed to DRCA. [ABSTRACT FROM AUTHOR]

Coronary Artery Bypass Grafting (CABG) is aimed to improve the quality of life among post-CABG patients, there exist a large number of patients having a low level of quality of life. The study aimed to analyze factors that influenced the quality of life among post-CABG patients. The descriptive study was conducted using cross-sectional analysis with a consecutive sampling of 80 post CABG patients in Hasan Sadikin Hospital from 20 May-30 June 2019. Data were analyzed using multivariate linear regression. The independent variables in this study included age, gender, education level, pain, mental health, social support, spiritual well-being, and cardiac rehabilitation. The data were collected using three questionnaires which included Short-Form 36 (SF-36) to measure patient-reported pain, mental health, and the quality of life; Multidimensional Scale of Perceived Social Support (MSPSS) to provide information about the role of social support; and Spirituality Index of Well Being (SIWB) designed to measure the spiritual well-being of the patients. The results showed four factors had significantly influenced the quality of life among patients after CABG. The factors included age (p-value0,001; r=0,521), pain level (p-value0,001; r=0,666), mental health (p-value0,001; r=0,426), and social support (p-value0,001; r=0,345). Pain factor had the most significant effect on the patients (r=0,497). Pain could cause a stress response that influenced the recovery stage which eventually impacted the quality of life. This study implies that the management of post-CABG patients could be performed by applying pain and stress management in discharge planning.

PurposeTo investigate the characteristics of cerebral perfusion and hemodynamics of bypass grafting in the treatment of moyamoya disease (MMD) using the iFlow color-coded flow map in comparison with magnetic resonance imaging–perfusion-weighted imaging (MRI–PWI) and computational fluid dynamic (CFD) analysis.Materials and MethodsPatients with MMD treated with bypass grafting who had undergone MRI PWI and digital subtraction angiography for iFlow color-coded map was retrospectively enrolled and CFD was performed for calculating the hemodynamic stresses around the bypass grafting.ResultsForty-five patients with unilateral MMD treated with bypass surgery were enrolled. The bypass surgery was successful in all patients, with no severe neurological complications during the periprocedural period. Followed up for 4–12 months (median 5.5), the neurological function was good in all patients. The cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT), and time to peak (TTP) were significantly (p < 0.05) improved in the middle cerebral artery distribution area on the surgical side before and after vascular bypass, and the difference of TTP (s) measured from the proximal bifurcation of common carotid artery to the confluence of sinus was also significant (p < 0.05). A significant (p < 0.05) positive correlation existed in the perfusion parameters between the iFlow blood perfusion and the MRI–PWI perfusion, with r-value for TTP of 0.765 (p < 0.01). The iFlow color-coded blood flow map showed warm color changes on the diseased side, similar to those on the contralateral side. In CFD analysis, the hemodynamic stresses were all improved, in and around the bypass grafting and distal vessels, which were beneficial to blood flow entering distal arterial branches.ConclusionThe iFlow color-coded flow map can be used to analyze cerebral perfusion after bypass grafting for MMD, similar to MRI–PWI, and CFD can be used to analyze the hemodynamics after bypass grafting, revealing improved hemodynamics to promote blood flow entering distal arteries.

Background Pseudoaneurysms (PSAs) of native coronary arteries are rare but potentially lethal complications occurring after coronary artery graft anastomosis mainly secondary to median sternotomy. Case summary A 61-year-old man underwent coronary artery bypass grafting because of stable angina. After the surgery, the patient was asymptomatic. A routine pre-discharge transthoracic echocardiogram was performed showing a haematoma of the apex partially involving the right ventricle with systolic colour Doppler flow going from the left ventricle to the pericardium. A coronary computed tomography scan was ordered and it revealed the presence of a PSA of the left anterior descending (LAD) artery distal to the graft anastomosis with the left internal mammary artery. An off-pump direct suture of the LAD injury through a redo sternotomy was successfully performed. Discussion The development of a PSA of a native coronary artery after bypass grafting is a very rare and potentially fatal condition. A correct and prompt diagnosis is crucial to avoid lethal complication. [ABSTRACT FROM AUTHOR]

Purpose: The study aimed to share the short-term mortality rates of coronary artery bypass grafting (CABG) experience in a private hospital and to evaluate parameters affecting the clinical outputs following the CABG who were divided according to the number of vessel graft. Materials and Methods: The study is a longitudinal-term observational clinical study, with a patient follow-up period of 7 years in Turkey. We analyzed 3027 cases with outcomes and short-term mortality according to the number of vessel grafts that we used as 1 (n:608), 2-3 (n:1359), and four or more (n:1060) grafts. Results: The short-term mortality was found as 1.1% (36/3027) in all the patients. The male population was the highest in the group with the highest number of vascular grafts and its percentage to females was correlated with vessel grafts that we performed. Mean aortic cross-clamp time was 36.6±17.2 minutes, while bypass time was 66.4±21 minutes. The mean number of vessels revascularized was 3.17±0.9 (1-7). The amount of drainage was 419±286 ml. The period of intensive care was 1.2±1.1 days, while the hospital period was 5.2±1.5days. In comparison according to the number of vascular grafts, positive inotrope agent, drainage, blood supply, cross-clamp and pump period showed significant difference. Conclusion: The number of vessel grafts was related to clinical outputs of CABG operations and Our CABG in the private hospital reached the short-term mortality rates that were below the averages of Turkey and international operations.

Background Patients undergoing on-pump coronary artery bypass grafting (CABG) are at increased risk of perioperative bleeding and morbidity associated with transfu- sion as a result of acquired and pharmacologically induced impaired platelet function. Settings and Design In this a prospective observational study where 52 patients underwent on-pump CABG were analyzed with ROTEM platelet aggregometry. Materials and Methods Patients were assigned to the “nonexcessive” and “exces- sive” postoperative bleeding groups according to the postoperative chest tube drainage over 24 hours. Platelet function was assessed by ROTEM platelet using three different activators (arachidonic acid, adenosine diphosphate, and thrombin receptor- activating peptide), at two perioperative time points (T1, before heparinization and T2, 5–10 minutes after protamine administration). Results There were no differences regarding demographic, pre–cardiopulmonary bypass (CPB) platelet count and antiplatelet therapy. Platelet function was impaired over the time course in all parameters with three different activators. At T2 point, area under the curve (AUC) of all the three platelet indices, that is, TRAPTEM, ARATEM, and ADPTEM, showed significant difference between excessive and nonexcessive groups. At both T1 and T2 points, the amplitude after 6 minutes (A6) and maximum slope (MS) parameters of TRAPTEM, ARATEM, and ADPTEM tests were not significantly different in excessive and nonexcessive groups. At T1 point, AUC was also not significantly different in all three ROTEM platelet tests. Results after protamine administration showed correlation with postoperative chest tube drainage. Cut-off values, as determined by receiver operating characteristics (ROC) analyses, had a consistently weak positive predictive value for all tests at T2 time point, whereas negative predictive values were higher. Conclusion Platelet function analysis using ROTEM platelet can help to exclude platelet dysfunction as the reason for bleeding after cardiac surgery. Point-of-care platelet function analysis, particularly in combination with viscoelastic testing can reduce perioperative bleeding and transfusion requirements, as well as improve patient outcomes in cardiac surgery. [ABSTRACT FROM AUTHOR]

Objectives: To assess the improvement in left ventricular ejection fraction (LVEF) after Coronary artery bypass grafting (CABG) among patients with severe LV dysfunction. Methodology: This Quasi experimental study was conducted at Punjab Institute of Cardiology from January to June 2021. One hundred and thirty four patients of severe LV dysfunction with coronary anatomy suitable for CABG were included in the study. Assessment of LVEF was carried out with echocardiography at baseline. All patients underwent CABG under general anaesthesia and were followed-up on 15th day with repeat echocardiography. Pre-CABG and post-CABG EFs were compared and mean changes in EFs were checked for potential effect modifications with gender, diabetes, CAD duration, age and body weight. Results: The mean LVEFs before and after surgery were 23.63 ± 1.17% and 32.11 ± 1.98% respectively. Mean improvement in LVEF after CABG was 8.5 ± 2.7 % (p < 0.001, 95% CI for difference 8.0 - 8.9) and did not different significantly according to gender, diabetes, CAD duration, age and body weight (P = 0.592, 0.167, 0.506, 0.138 and 0.458 respectively). Conclusion: Patients of CAD who underwent CABG had improved post-operative LVEFs independent of evaluated potential effect modifiers. [ABSTRACT FROM AUTHOR]

Objective To compare the efficacy and outcomes of surgical operations (myotomy and bypass surgery) and coronary stenting for treatment of coronary myocardial bridge. Methods We searched PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure and Wanfang database for studies of treatment of coronary artery myocardial bridge with coronary stenting, myotomy or coronary artery bypass grafting. The data were extracted from the eligible studies, and regression analysis was performed to explore the sources of heterogeneity in the sample size, surgical methods, nations (Asian and others), and year of publication. Results There were 3 584 English articles and 1 678 Chinese articles reviewed in this study, and finially 4 019 articles were recruited after removing duplicate ones. Thirty-three eligible studies involving a total of 1 286 patients were included in the qualitative analysis. A total of 572 patients from 26 studies were included in the quantitative analysis. Analyses of the single rates showed that the overall symptom remission rate of myocardial bridge was 88.00% (95% CI: 81.31%-93.56%) following surgical interventions, which were associated with an overall postoperative coronary artery restenosis rate of 9.09% (95% CI: 4.30%-15.05%) and overall rates of intraoperative complications and postoperative cardiovascular events of 0.59% (95% CI: 0.00%-1.83%) and 0.46% (95% CI: 0.00%-1.63%), respectively. Regression analysis showed that postoperative symptom relief and coronary artery restenosis rates were significantly correlated with the surgical methods used (P < 0.001) but not with the sample size, year of publication, or nationalities of the patients (P > 0.1). Subgroup analysis showed that compared with interventional treatment, surgical treatments resulted in a significantly higher rate of postoperative symptom relief (95.45% vs 68.82%, P < 0.001) and lower rates of coronary artery restenosis (3.89% vs 21.78%, P < 0.001) and postoperative cardiovascular events (0.01% vs 2.91%, P < 0.001). The incidence of intraoperative complications did not differ significantly between surgical and interventional treatments (1.65% vs 0.00%, P=0.1405). Conclusion Surgical treatments result in a higher rate of postoperative symptom relief and a lower postoperative restenosis rate than interventional treatment, but high-quality randomized controlled trials with a large sample size are still needed to verify this conclusion.

Surgery in a patient with hepatic cirrhosis entails risk of complications and of death. Association of end stage renal disease (ESRD) along with cirrhosis further increases perioperative risk of morbidity and mortality. There are no reports in the literature of patients with liver cirrhosis and ESRD having undergone cardiac surgery. We present a report of a successfully operated case of ESRD with compensated hepatic cirrhosis posted for coronary artery bypass grafting.

Concomitant carotid endarterectomy (CEA; for severe internal carotid artery stenosis) with carotid-subclavian bypass grafting (CSBG; for proximal common carotid artery or subclavian artery occlusion) is rarely used. Only a few studies have been reported. This report analyzed early and late clinical outcomes of the largest study to date of the combined procedures in our institution. Electronic medical records of patients who had concomitant CEA with CSBG during three decades were analyzed. Indications for surgery were arm ischemia, neurologic events, and clinical subclavian steal. Early (30 days) perioperative complications (stroke, death, and others) and late complications (stroke, death) were recorded. Kaplan-Meier analysis was used to estimate late graft/CEA primary patency, freedom from stroke, and stroke-free survival rates. Graft patency was determined clinically and confirmed using duplex ultrasound. Outcomes were compared with previously published data on isolated CSBG by the same group. There were 37 combined procedures analyzed. Mean age was 64 years (range, 45-81 years). Indications for surgery were arm ischemia in 12 (32%), hemispheric transient ischemic attack or stroke in 15 (41%), vertebrobasilar insufficiency in 4 (11%), symptomatic subclavian steal in 10 (27%), and asymptomatic common carotid artery occlusion with severe internal carotid artery stenosis in 6 (16%). The 30-day perioperative (stroke and death) rate was 5.4% (one stroke and one death). Immediate symptom relief was noted in 100%, with 2.7% (transient ischemic attack) symptom recurrence. The crude patency rate of both CEA and CSBG was 92%. At 1 year, 2 years, 3 years, 4 years, and 5 years, respectively, primary patency rates were 100%, 96%, 96%, 96%, and 85%; freedom from stroke rates were 97%, 97%, 97%, 97%, and 97%; and stroke-free survival rates were 94%, 94%, 87%, 82%, and 78%. When these outcomes were compared with the isolated CSBG group alone (28 patients), there was no difference in perioperative stroke (2.7% for concomitant CEA/CSBG vs 0% for isolated CSBG), perioperative death (2.7% vs 2.8%), or late patency rates (92% vs 96%). Concomitant CEA/CSBG is safe and durable. There was no significant difference in perioperative stroke/death or late patency rates compared with isolated CSBG. [ABSTRACT FROM AUTHOR]

The great saphenous vein (GSV) has served as a coronary artery bypass graft (CABG) conduit for over 50 years. Despite prevalent use, first-year failure rates remain high compared to arterial autograft options. Amongst other factors, vein graft failure can be attributed to material and mechanical mismatching that lead to apoptosis, inflammation, and intimal-medial hyperplasia. Through the implementation of the continuum mechanical-based theory of "stress-mediated growth and remodeling," we hypothesize that the mechanical properties of porcine GSV grafts can be favorably tuned for CABG applications prior to implantation using a prolonged but gradual transition from venous to arterial loading conditions in an inflammatory and thrombogenic deficient environment. To test this hypothesis, we used a hemodynamic-mimetic perfusion bioreactor to guide remodeling through stepwise incremental changes in pressure and flow over the course of 21-day cultures. Biaxial mechanical testing of vessels pre- and post-remodeling was performed, with results fit to structurally-motivated constitutive models using non-parametric bootstrapping. The theory of "small-on-large" was used to describe appropriate stiffness moduli, while histology and viability assays confirmed microstructural adaptations and vessel viability. Results suggest that stepwise transition from venous-to-arterial conditions results in a partial restoration of circumferential stretch and circumferential, but not axial, stress through vessel dilation and wall thickening in a primarily outward remodeling process. These remodeled tissues also exhibited decreased mechanical isotropy and circumferential, but not axial, stiffening. In contrast, only increases in axial stiffness were observed using culture under venous perfusion conditions and those tissues experienced moderate intimal resorption. [ABSTRACT FROM AUTHOR]

We describe a 54-year-old man with neurofibromatosis type 1 who presented with a left-sided neck mass. Computed tomography demonstrated a left common carotid artery aneurysm (51 × 33 mm). Surgery was performed because of the risk of rupture. The left common carotid artery was found to be a huge aneurysmal dilatation, and the arterial wall partially collapsed and extensively adherent to the surrounding tissues. Left common carotid artery to internal carotid artery bypass grafting was performed with a reversed saphenous vein graft. Histopathological examination revealed vascular fragility of the left carotid arterial wall. [ABSTRACT FROM AUTHOR]

Purpose: To report the outcomes of bypass grafting (BG) vs endovascular therapy (EVT) in patients with non-dialysis-dependent chronic kidney disease (CKD) and chronic limb-threatening ischemia (CLTI). Materials and Methods: The CRITISCH Registry is a prospective, national, interdisciplinary, multicenter registry evaluating the current practice of all available treatment options in 1200 consecutive CLTI patients. For the purposes of this analysis, only the 337 patients with non-dialysis-dependent CKD treated by either BG (n=86; median 78 years, 48 men) or EVT (n=251; median age 80 years, 135 men) were analyzed. The primary composite outcome was amputation-free survival (AFS); secondary outcomes were overall survival (OS) and amputation-free time (AFT). All outcomes were evaluated in Cox proportional hazards models; the results are reported as the hazard ratio (HR) and 95% confidence interval (CI). Results: The Cox regression analysis revealed a significantly greater hazard of amputation or death after BG (HR 1.78, 95% CI 1.05 to 3.03, p=0.028). The models for AFT and overall survival also suggested a higher hazard for BG, but the differences were not significant (AFT: HR 1.66, 95% CI 0.78 to 3.53, p=0.188; OS: HR 1.41, 95% CI 0.80 to 2.47, p=0.348). The absence of runoff vessels (HR 1.73, 95% CI 1.15 to 2.60, p=0.008) was associated with a decreased AFS. The likelihood of amputation was higher in male patients (HR 2.21, 95% CI 1.10 to 4.45, p=0.027) and was associated with a lack of runoff vessels (HR 1.95, 95% CI 0.96 to 3.95, p=0.065) and myocardial infarction (HR 3.74, 95% CI 1.23 to 11.35, p=0.020). Death was more likely in patients without runoff vessels (HR 1.76, 95% CI 1.11 to 2.80, p=0.016) and those with a higher risk score (HR 1.73, 95% CI 1.03 to 2.91, p=0.038). Conclusion: This analysis suggested that BG was associated with poorer AFS than EVT in patients with non-dialysis-dependent CKD and CLTI. Male sex, previous myocardial infarction, and the absence of runoff vessels were additionally identified as predictors of poorer outcomes. [ABSTRACT FROM AUTHOR]

OBJECTIVE. The authors developed a low invasive method of bimammary coronary artery bypass grafting (CABG) of minimum two arteries through left-sided thoracotomy. MATERIAL AND METHODS. The left internal thoracic artery was used for bypass grafting of anterior interventricular artery according to V.I. Kolesov method. Anastomosis of the right interventricular artery with conduit (from autoartery or autovein) was performed by using extrapleural way in the second intercostal space from the right of the breast. Conduit was lengthened behind the sternum to pericardium cavity in order to create the second distal anastomosis with branch of coronary artery. RESULTS. The operations (10 cases) were conducted at the period from October 2015 to December 2016. The second distal anastomosis between conduit and coronary artery was performed with diagonal artery in 1 case, with branch of blunt edge in 5 cases and with posterior interventricular branch in 4 cases. Tolerance of operation and early postoperative period were satisfactory. CONCLUSIONS. New method of bimammary coronary artery bypass allowed doctors to perform revascularization minimum of two coronary vessels on working heart by avoiding manipulations on aorta and the sternum.

Background: An anomalous origin of the right coronary artery (RCA) from the left sinus of Valsalva with an interarterial course is a rare congenital anomaly. We aimed to assess midterm results after coronary artery bypass grafting (CABG) for the treatment of anomalous RCA arising from the left sinus of Valsalva.Methods: From 2008 to 2012, 16 patients underwent CABG for treatment of an anomalous origin of the RCA from the left sinus of Valsalva. Details such as risk factors, operative details, and results of multislice coronary angiography follow-up were assessed.Results: The mean age of the patients was 34.8 ± 4.68 years, and most of them were male (15 out of 16, 93.75%). They received a mean of 1.5 ± 0.87 grafts. Closure of the RCA was completed in all patients except one (15 out of 16), who developed ischemic symptoms upon closing the proximal part of the RCA. One in-hospital death occurred. Among the remaining patients, symptoms persisted in 2 out of 15. The mean follow-up time was 63.4 ± 28.6 months. All patients had patent vessels on 5-year follow-up multislice computed tomography scans, except one patient who showed RCA graft occlusion on the 1-year follow-up scan.Conclusion: The CABG of the RCA with anomalous origin can be done safely with excellent early and midterm results. Proximal RCA ligation is an essential step to the success of CABG, but intraoperative challenge testing is required to confirm the sufficiency of the internal thoracic artery graft to reperfuse the supplied territory. [ABSTRACT FROM AUTHOR]

The purpose of this study was to compare the renal function in patients undergoing coronary artery bypass grafting in off-pump and on-pump having pre-operative impaired renal function. In the on-pump, the serum creatinine and urea levels were significantly increased on post-operative day 1, 3 and 7. On day 1, it was maximum, then gradually decreased but not reached to pre-operative level. In case of off-pump, serum creatinine and urea levels were significantly increased on post-operative day 1 and 3. On day 1, it was maximum. Then decreased and the serum creatinine reached below pre-operative level on day 7. In case of on-pump, the creatinine clearance rate was significantly decreased on post-operative day 1, 3 and 7. On day 1, it was minimum. Then gradually increased but not reached the pre-operative level. In case off-pump, the creatinine clearance rate was significantly decreased on day 1 and 3. On day 1, it was minimum, then gradually increased and reached above the pre-operative level. A significant low level creatinine clearance rate was observed in on-pump group. Renal function was better preserved in patients undergoing off-pump in comparison to on-pump coronary artery bypass grafting.

Aim To evaluate the usefulness of echocardiography in the diagnosis of complete rupture of papillary muscle. Methods Transthoracic (TTE) and transesophageal echocardiography (TEE) was performed with the ATL 3000 HDI Ultrasound Inc (Bothell, WA, USA) with a 2.5 MHz transducer and 5-7 MHz multiplane phased array transducer. We are reporting about two patients (a 45 and a 51-year old male) with complete ruptures of papillary muscle following acute myocardial infarction (AMI). Results Both patients were previously treated with fibrinolysis in their local hospitals, 400 and 300 km, respectively, away from our hospital. Massive mitral regurgitation developed in both followed by rapid deterioration of hemodynamic state and severe heart failure, because of which both were transferred by helicopter to the Coronary Care Unit of our clinic. The diagnosis of complete papillary muscle rupture was confirmed in both patients by TTE and TEE. Due to the significant deterioration in their hemodynamic state, vasoactive drugs and intra-aortic balloon pump support were applied. Both patients then underwent mitral valve replacement, accompanied by concomitant coronary artery bypass grafting in one case. Conclusion Transesophageal echocardiography is a more accurate and rapid diagnostic method in patients with mechanical complications of AMI than TTE.

Stroke and other ischemic neurological events are among the most dreaded adverse events following cardiac surgery. The stroke risk in patients undergoing coronary artery bypass graft surgery (CABG) is estimated at 2%. We performed a retrospective analysis of patients with and without severe carotid artery disease who were scheduled for CABG to determine what variables were associated with severe carotid artery stenosis. This is a case control study. 49 patients with carotid stenosis =70% identified by duplex ultrasound and coronary artery disease (CAD) scheduled for CABG at the University Hospital Centre "Mother Theresa" were matched by age and gender with 49 patients with carotid stenosis <50%. In univariate analysis, a statistically significant difference was found between cases and controls regarding the CAD extent (p=0.03), hypertriglyceridemia (p<0.001) and carotid bruit (p<0.001). In multivariate analysis by logistic regression, independent risk factors associated with stenosis were smoking (p=0.03) and carotid bruit (p<0.001). All patients with CAS should have medical management that includes control of hypertension, cholesterol levels, and diabetes, administration of antiplatelet agents, and smoking cessation. [ABSTRACT FROM AUTHOR]

Purpose: To examine the outcomes of all first-line strategies for the treatment of critical limb ischemia (CLI), identify factors that influenced the treatment choice, and determine the risk of amputation or death after each treatment. Methods: CRITISCH (ClinicalTrials.gov identifier NCT01877252) is a multicenter, national, prospective registry evaluating all available treatment strategies applied in 1200 consecutive CLI patients in 27 vascular centers in Germany. The recruitment started in January 2013 and was completed in September 2014. Treatment options were endovascular revascularization (642, 53.5%), bypass surgery (284, 23.7%), femoral artery patchplasty (126, 10.5%) with or without concomitant peripheral intervention, conservative treatment (118, 9.8%), and primary major amputation (30, 2.5%). The primary endpoint of this study was amputation-free survival (AFS). The Society of Vascular Surgery's suggested objective performance goal (OPG) for AFS (71%) was used as the effectiveness criterion. Multivariable regression methods were employed to identify variables that influenced the treatment selection and AFS after each treatment; results are presented as the hazard ratio (HR) and 95% confidence interval (CI). Results: The 12-month AFS estimates following endovascular therapy, bypass grafting, femoral patchplasty, and conservative treatment were 75%, 72%, 73%, and 72%, respectively. Factors influencing treatment choice were age, chronic kidney disease (CKD), diabetes, smoking, prior vascular procedures in the index leg, TransAtlantic Inter- Society Consensus II C/D lesions, and absence of runoff vessels. Cox regression analysis identified CKD (HR 2.07, 95% CI 1.26 to 3.41, p=0.004), the use of a prosthetic bypass conduit (HR 1.97, 95% CI 1.23 to 3.14, p=0.004), and previous vascular intervention in the index limb (HR 1.52, 95% CI 0.94 to 2.43, p=0.085) as independent risk factors for diminished AFS after bypass surgery. CKD (HR 1.47, 95% CI 1.09 to 1.99, p=0.012) and Rutherford category 6 (HR 1.81, 95% CI 1.30 to 2.52, p<0.001) compromised the performance of endovascular revascularization. Conclusion: CRITISCH registry data revealed that all first-line treatment strategies selected and indicated by the treating physicians met the suggested OPGs. CKD was an important determinant of patient prognosis after treatment regardless of the revascularization method. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Our goal was to compare the rates of in-hospital and 30-day major adverse cardiac and cerebrovascular events (MACCE) including death, stroke, myocardial infarction and repeat revascularization in patients with multivessel disease undergoing multiarterial (MultArt) coronary artery bypass grafting (CABG) with the left internal mammary artery/saphenous vein (LIMA/SV) CABG or percutaneous coronary intervention (PCI). METHODS: From 1 January 1993 to 31 December 2009, 12 615 consecutive patients underwent isolated primary CABG (n = 6667) with LIMA/SV (n = 5712) or MultArt (n = 955) or were treated by PCI (n = 5948) with balloon angioplasty (n = 1020), bare metal stent (n = 3242), and drug-eluting stent (n = 1686). We excluded patients with acute myocardial infarction. We matched the CABG group with the 3 PCI subgroups, and the PCI group with the 2 CABG subgroups. Multivariable analyses were used to evaluate the impact of CABG versus PCI and their subgroups on early MACCE. RESULTS: Unadjusted early MACCE were lower for MultArt (1.5%) than for LIMA/SV (4.5%, P < 0.001) and PCI (8.5%, P < 0.001). In matched analysis, CABG had lower early MACCE versus balloon angioplasty (4.7% vs 13.2%, P < 0.001), bare metal stent (4.3% vs 8.3%, P < 0.001), and drug-eluting stent (2.9% vs 5.5%, P = 0.008), as well as LIMA/SV versus PCI (4.6% vs 9.2%, P < 0.001) and MultArt versus PCI (1.8% vs 7.8%, P < 0.001). Stroke rate was similar in MultArt versus PCI (0.8% vs 0.3%, P = 0.18) but higher with LIMA/SV versus PCI (2.3% vs 0.4%, P < 0.001). In multivariable analysis, PCI (odds ratio 4.53, 95% confidence interval: 2.62-7.83; P < 0.001) and LIMA/SV (odds ratio 2.04, 95% confidence interval: 1.18-3.53; P < 0.011) were strong predictors of early MACCE compared with MultArt. [ABSTRACT FROM AUTHOR]

Stroke is a major adverse event in patients developing atrial fibrillation (AF) after cardiac surgery. Surgical left atrial appendage amputation/ligation (LAA-A/L) during off-pump coronary artery bypass grafting (OPCAB) is routinely performed in our institution. We analyzed 578 consecutive patients (mean age 69 years, male 82%) undergoing OPCAB with or without concomitant LAA-A/L from 2011 to 2014 at our institution in a prospective observational manner. The safety and efficacy of the concomitant LAA-A/L on preventing early (<30 days) and overall postoperative stroke were examined. A total of 193 patients (33.4%) underwent LAA-A/L, consisting of amputation in 154 and ligation in 39 patients (80 and 20% of the cases, respectively). Preoperative characteristics, operative time, requirement of blood transfusion, and 30-day mortality were not significantly different between those with and without LAA-A/L. The incidences of postoperative AF and early and overall stroke were not significantly different between the groups in the analysis based on a total cohort. In a subanalysis of patients without LAA-A/L, early and overall stroke occurred more frequently in those developing postoperative AF than those without AF (2.8 vs. 0%; p = 0.005, 6.2 vs. 1.5%; p = 0.017, respectively), while in patients receiving LAA-A/L, stroke incidences did not differ between those with and without AF. Multivariate logistic regression showed postoperative AF without LAA-A/L as the only independent positive predictor of overall stroke (OR 3.69, p = 0.03). Concomitant LAA-A/L with OPCAB can safely prevent postoperative stroke occurrence in case patients develop AF, the most common arrhythmia associated with stroke. [ABSTRACT FROM AUTHOR]

Background: There is an ongoing debate on the benefits and risks of off-pump coronary artery bypass grafting (CABG) surgery. The fate of patients who start with their procedure being an off-pump one and then have to undergo conversion to an onpump procedure is debated with regard to in-hospital mortality and unknown with regard to long-term survival. We investigated the in-hospital mortality and long-term survival of patients who underwent conversion from off- to on-pump surgery. Methods: We performed a multivariate and propensity analysis on in-hospital mortality and long-term survival of postisolated CABG patients in a single institution having 15,704 patients of which 5,353 who underwent off-pump CABG were analyzed. Results: In-hospital mortality was 2.15% for the study cohort, and 73 (1.4%) off-pump cases were converted. Univariate analysis demonstrated that patients undergoing conversion had a significantly increased in-hospital mortality (p < 0.001) and reduced long-term survival (p = 0.002). Logistic regression (receiver operating curve 0.77, Hosmer-Lemeshow test 0.46) and Cox analysis demonstrated that in-hospital mortality and long-term survival were not significantly affected by conversion. Propensity analysis (one:many match) demonstrated that in-hospital mortality was not significantly affected (p = 0.7), and long-term survival - univariate, and multivariate were also not significantly reduced in patients undergoing conversion. Conclusion: Conversion from off- to on-pump by a team of surgeons and anesthetists who are dedicated off-pump specialists does not have an impact on in-hospitalmortality or long-term survival. [ABSTRACT FROM AUTHOR]

Objective: The aim of the study was to investigate health-related quality of life (QOL) an the impact of demographic factors after bypass grafting (BG) in patients with critical limb ischemia (CLI). Material and Method: A total of 33 patients with CLI underwent BG over a period of 18 months. Quality of life data were collected before and three months after BG with the Short-Form 36 (SF-36) questionnaire. Demographic data and information about the disease presentation were evaluated with another form. Results: There were 32 male patients and one female patient. The SF-36 questionnaire was completed by all patients before and after BG. There was an improvement in all categories of QOL, and statistically significant changes were observed in the pain and physical role restriction subdomains after the operation (p=0.020 and p=0.012, respectively). Education level was found to be associated with post-operative pain. The attitude of the patient after diagnosis (quitting smoking, obeying diet and regularly taking medicine) affected post-operative physical function, energy, general health and emotional role restriction. Proximal artery interventions (aorto-femoral, ilio-femoraland cross-femoral) resulted in more improvements in pain and mental health subdomains than distal interventions (femoropopliteal and crural) (p=0.027 and p=0.017, respectively). Conclusion: Most patients with CLI smoked and had low or intermediate income. Pain and physical role restriction, which are subdomains of QOL, were improved by BG, and post-operative pain was affected by the education level of the patient. Proximal interventions were related with better QOL. [ABSTRACT FROM AUTHOR]

Both open surgery and endovascular peripheral interventions have been shown to effectively improve outcomes in patients with peripheral artery disease, but minimal data exist comparing outcomes performed at and below the knee. The purpose of this study was to compare outcomes following infrageniculate lower extremity open bypass (LEB) versus peripheral vascular intervention (PVI) in patients with critical limb ischemia. Using data from the 2008–2014 Vascular Quality Initiative, 1-year primary patency, major amputation, and mortality were compared among all patients undergoing LEB versus PVI at or below the knee for rest pain or tissue loss. Overall, 2566 patients were included (LEB=500, PVI=2066). One-year primary patency was significantly worse following LEB (73% vs 81%; p<0.001). One-year major amputation (14% vs 12%; p=0.18) and mortality (4% vs 6%; p=0.15) were similar regardless of revascularization approach. Multivariable analysis adjusting for baseline differences between groups confirmed inferior primary patency following LEB versus PVI (HR 0.74; 95% CI, 0.60–0.90; p=0.004), but no significant differences in 1-year major amputation (HR 1.06; 95% CI, 0.80–1.40; p=0.67) or mortality (HR 0.71; 95% CI, 0.44–1.14; p=0.16). Based on these data, we conclude that endovascular revascularization is a viable treatment approach for critical limb ischemia resulting from infrageniculate arterial occlusive disease. [ABSTRACT FROM AUTHOR]

We investigate the dynamics of a bypass in terms of determining the optimal parameters of shunt operation. The equations that describe the propagation of pressure pulse waves in blood vessels are presented in differential form and in approximate form for the averaged values based on the conservation laws. The correspondence of these forms is shown from the solution of the initial-boundary-value problem for vascular junction. The influence of the parameters such as various diameters, wall thicknesses, and elastic properties of blood vessels on the shunt effectiveness is investigated. In particular, we investigate the influence of the shunt form and junction area, as well as the angle of the shunt connection with the vessel, on the passage of the coronary vessels and blood coagulation. On the basis of the calculations, conclusions about the influence of various parameters on the dynamics of bypass are made. [ABSTRACT FROM AUTHOR]

The internal thoracic artery is often used for reconstruction of coronary arteries. In a proportion of cases the reasonfor bypass failure (internal thoracic artery – coronary artery) is abnormal blood flow in the subclavian artery resultingfrom its stenosis. The stricture can result from post-surgery progression of atherosclerosis or could have been presentand undiagnosed already when cardiac surgery was performed. This may result in exercise angina or even acute coronarysyndrome. Interventional intervention is inevitable in these cases. An 84-year-old man was admitted for unstableangina 7 years after coronary artery bypass grafting (CABG) from the internal thoracic artery to the left anteriordescending branch of the left coronary artery. In spite of medical treatment the symptoms did not recede and coronaryand bypass angiography was performed on the 4th day of hospitalization, revealing multiple stenoses of thecoronary arteries and severe stenosis of the left subclavian artery. Moreover, the symptoms subsided only slightlyafter angioplasty of the circumflex branch of the left coronary artery. For this reason, angioplasty of the left subclavianartery with stent implantation, widening of the right coronary artery aortic opening, and angioplasty of the leftcoronary artery trunk and of the circumflex branch at its origin were performed. These procedures resulted in completecessation of angina, while the patient also observed significant improvement of his left upper limb performance.The coronary-subclavian steal syndrome is defined as reduced flow through the bypass (internal thoracic artery –coronary artery) or reversed flow through the bypass, as a result of the narrowing of the proximal part of the left subclavianartery. In most cases the symptoms are stable and chronic, but in some patients an acute coronary syndromecan develop. Additionally, there are usually disturbances of the left upper limb perfusion. Routine blood pressuremeasurement on both arms is believed to identify a group of patients with high probability of subclavian artery stenosis,who may benefit from supplementation of coronary angiography with aortic arch imaging. Traditional surgicalmethods of treatment for subclavian-coronary steal syndrome include bypass between the left common carotid andleft subclavian artery. However, intravascular angioplasty with stent implantation is a contemporary method of choice.Intravascular methods allow simultaneous correction of coronary vessels when there is a recurrent stenosis.

Objectives: First external validation of a preoperative scoring system (Guy's) in patient selection for femoro-distal bypass grafting to single calf or pedal artery in critical limb ischemia (Fontaine III & IV/Rutherford grade IV, V & VI).Material and Methods: A prospective study of 76 (n = 76) consecutive femoro-crural/pedal bypass grafts on 72 individuals (n = 72) from 2008 to 2011 with 36 months mean follow-up was performed. All cases were scored against a previously designed and published scoring system (ranging from 0 to 10) based on: inflow, outflow, graft material, flow type, patent pedal vessels and diabetes mellitus.Results: Preoperative score of 0-4 (n = 37) demonstrated the primary patency of 27% at 10.3 months. This value for intermediate group 5-7 (n = 34) was 70.6% at 18.9 months. The high-score group 8-10 (n = 4) showed the longest primary patency (80%) at 27.3 months. Kaplan-Meier survival analysis exhibited a consistent and significant difference in primary assisted, secondary patency and overall limb/foot salvage amongst all individual scoring groups (p < 0.001).Conclusion: This study validates and complements the Guy's scoring system and provides a platform for the identification of critical limb ischemia patients in whom the result of femoro-crural/distal bypass grafting is so poor that primary amputation may be both clinically and economically more justified. [ABSTRACT FROM AUTHOR]

Objective: To determine the frequency of increased fibrinolysis after coronary artery bypass grafting (CABG). Study Design: Descriptive study. Place and Duration of Study: One year duration conducted in the Department of Pathology, Army Medical College in collaboration with Armed Forces Institute of Cardiology (AFIC) from December 2013 to November 2014. Material and Methods: Sixty patients were selected who were admitted to AFIC for CABG surgery. Venous samples were drawn from the patients immediately after surgery when the patients were shifted to post operative ward. Patients were selected by non probability purposive sampling technique. D-dimers were analysed by rapid agglutination assay. Results: Out of 60 patients included in the study, 50 (83.3%) were males and 10 (16.7%) were females. Ddimers level more than 200ng/ml were considered to show increased fibrinolysis. Raised D-dimers were present in 40 (66.6 %) patients while they were normal in 20 (33.3 %) patients.Twenty (33.3%) patients had Ddimers< 200ng/ml, 27 (45%) patients had D-dimers between 200-400ng/ml, 7 (11.7%) patients had D-dimers between 400-800ng/ml and 6 (10%) had D-dimers between 800-1600ng/ml. Conclusion: Increased fibrinolysis was present in 40 (66.7%) patients. It is more common in older age than younger ones. [ABSTRACT FROM AUTHOR]

Aim To evaluate the usefulness of echocardiography in the diagnosis of complete rupture of papillary muscle. Methods Transthoracic (TTE) and transesophageal echocardiography (TEE) was performed with the ATL 3000 HDI Ultrasound Inc (Bothell, WA, USA) with a 2.5 MHz transducer and 5-7 MHz multiplane phased array transducer. We are reporting about two patients (a 45 and a 51-year old male) with complete ruptures of papillary muscle following acute myocardial infarction (AMI). Results Both patients were previously treated with fibrinolysis in their local hospitals, 400 and 300 km, respectively, away from our hospital. Massive mitral regurgitation developed in both followed by rapid deterioration of hemodynamic state and severe heart failure, because of which both were transferred by helicopter to the Coronary Care Unit of our clinic. The diagnosis of complete papillary muscle rupture was confirmed in both patients by TTE and TEE. Due to the significant deterioration in their hemodynamic state, vasoactive drugs and intra-aortic balloon pump support were applied. Both patients then underwent mitral valve replacement, accompanied by concomitant coronary artery bypass grafting in one case. Conclusion Transesophageal echocardiography is a more accurate and rapid diagnostic method in patients with mechanical complications of AMI than TTE. Cilj Procijeniti korisnost ehokardiografije u dijagnostici kompletne rupture papilarnog mišića. Metode Za transtorakalnu (TTE) i transezofagusnu ehokardiografiju (TEE) korišten je aparat ATL 3000 HDI Ultrasound Inc. (Bothell, WA, USA), sondama od 2,5 MHz i od 5 do 7 MHz. Opisana su dva muška bolesnika u dobi 45 i 51 godine s kompletnom rupturom papilarnog mišića u akutnom infarktu miokarda (AIM). Rezultati Oba bolesnika liječena su trombolitičkom terapijom zbog AIM-a u dvije lokalne bolnice udaljene 400, odnosno 300 km. Zbog masivne mitralne regurgitacije koja je uzrokovala hemodinamsku nestabilnost i zatajivanje srca teškog stupnja bolesnici su helikopterom transportirani u koronarnu jedinicu naše Klinike. Dijagnozu kompletne rupture papilarnog mišića potvrdili smo u oba bolesnika pomoću TTE-a i TEE-a. Zbog teškog općeg stanja i hemodinamske nestabilnosti bolesnici su primali vazoaktivu terapiju i priključeni su na intraaortalnu balon-crpku. U oba bolesnika implantirana je umjetna mitralna valvula, a aortokoronarno premoštenje učinjeno je u jednog bolesnika. Zaključak Transezofagusna ehokardiografija u odnosu na TTE je točna i brza dijagnostička metoda u bolesnika s mehaničkim komplikacijama u akutnom infarktu miokarda. [ABSTRACT FROM AUTHOR]

Coronary artery ectasia ( CAE) or aneurysm is usually defined as dilation ≥1.5-fold the normal vessel diameter. It has an incidence of 1.4-5.3% and is associated with a wide variety of etiologies-mainly congenital, atherosclerotic, and inflammatory ones. CAE is very common in sickle cell disease, and possibly sickle cell trait, with an incidence of 17.7%. It is likely related to the inflammatory process associated with hemoglobin S. Prognosis depends mainly on the underlying etiology. Atherosclerotic CAE does not carry additional risks compared to atherosclerotic coronary artery disease ( ACAD) without ectasia. However, isolated CAE in the absence of ACAD carries an increased risk of myocardial infarction ( MI) due to vasospasm, slower coronary blood flow, and thrombosis, typically within the dilated segments. Due to lack of studies and guidelines, management recommendations are based on personal experiences. Therapy should be tailored to each individual case after assessment of severity, history of complications, underlying etiology, and comorbidities. Treatment of underlying condition and avoidance of exacerbating factors are essential. Medical therapy in general may include antiplatelets, β-blockers, angiotensin-converting enzyme inhibitors statins, and dihydropyridine calcium channel blockers. In severe CAE or history of MI, the addition of anticoagulation therapy after assessing bleeding risk may be warranted. In acute MI, the large thrombus burden in the dilated segment makes the percutaneous approach very challenging. Aspiration attempts can result in distal thromboembolization. Survival is better in bypass grafting than with medical therapy. Nonetheless, bypass grafting does not improve survival in atherosclerotic CAE. Depending on the physical characteristics of aneurysm, different surgical approaches can be sought; however, the ideal one is unclear. [ABSTRACT FROM AUTHOR]

Cystic adventitial disease (CAD) of the popliteal artery is a rare vascular disorder in which a mucin-containing cyst develops in the adventitial layer of the artery. We report two such cases, each of which was treated differently. The first case was of a 49-year-old man, treated by excision of the involved arterial segment and interposition of an autologous saphenous vein graft. The second case was of a 36-year-old man, treated by local excision of the affected arterial segment and interposition with prosthetic bypass grafting. Both patients presented with rapidly progressing intermittent claudication of the lower extremities, but without remarkable evidence of atherosclerotic disease. Physical examination revealed diminished or absent popliteal, posterior tibial and dorsalis pedis pulses in the lower extremities. Color Doppler ultrasound of the popliteal artery revealed hypoechoic cystic lesions surrounding the vessel, and popliteal arterial stenosis, in both patients. Surgery resulted in immediate improvement of the arterial pulse distal to the lesion. Both patients recovered uneventfully. Thus, resection of the involved artery segment and interposition bypass grafting, using either patient or prosthetic veins, offers favorable results for CAD of the popliteal artery. [ABSTRACT FROM AUTHOR]

We report a case of axillary artery aneurysm with brachial artery embolism in a 60-year-old man who had walked with the assistance of axillary crutches all of his life since poliomyelitis during infancy had left him with lower limb paralysis. We performed bypass grafting from the axillary to brachial artery with exclusion of the aneurysm. An axillary artery aneurysm is rare, but potentially lethal for the upper extremity; therefore, surgical treatment should be considered. [ABSTRACT FROM AUTHOR]

We briefly and comprehensively present some of the novel findings in the field of revascularization therapy and management of ST-segment-elevation myocardial infarction (STEMI). We highlight the latest evidence-based advancements in the pharmacological and mechanical treatment of patients who presented with STEMI. Since the last updates to the international guidelines (American College of Cardiology/American Heart Association and the European Society of Cardiology) were published in 2011 and 2012, there have been changes and several important studies have presented their final outcomes. We also highlight some controversial approaches as part of the current debates in the cardiology community. In addition, we share our recent experience in the field of biodegradable scaffold stents as a treatment strategy in STEMI. [ABSTRACT FROM AUTHOR]

Purpose: In this study we evaluated the diagnostic performance of Tc-HMPAO-leucocyte (Tc-HMPAO-WBC) scintigraphy in a consecutive series of 55 patients (46 men and 9 women, mean age 71 ± 9 years, range 50 - 88 years) with a suspected late or a low-grade late vascular prosthesis infection (VPI), also comparing the diagnostic accuracy of WBC with that of other radiological imaging methods. Methods: All patients suspected of having VPI underwent clinical examination, blood tests, microbiology, US and CT, and were classified according to the Fitzgerald criteria. A final diagnosis of VPI was established in 47 of the 55 patients, with microbiological confirmation after surgical removal of the prosthesis in 36 of the 47. In the 11 patients with major contraindications to surgery, the final diagnosis was based on microbiology and clinical follow-up of at least 18 months. Results: Tc-HMPAO-WBC planar, SPECT and SPECT/CT imaging identified VPI in 43 of 47 patients (20 of these also showed infection at extra-prosthetic sites). In the remaining eight patients without VPI, different sites of infections were found. The use of SPECT/CT images led to a significant reduction in the number of false-positive findings in 37 % of patients (sensitivity and specificity 100 %, versus 85.1 % and 62.5 % for stand-alone SPECT). Sensitivity and specificity were 34 % and 75 % for US, 48.9 % and 83.3 % for CT, and 68.1 % and 62.5 % for the FitzGerald classification. Perioperative mortality was 5.5 %, mid-term mortality 12 %, and long-term mortality 27 %. Survival rates were similar in patients treated with surgery and antimicrobial therapy compared to patients treated with antimicrobial therapy alone (61 % versus 63 %, respectively), while infection eradication at 12 months was significantly higher following surgery (83.3 % versus 45.5 %). Conclusion: Tc-HMPAO-WBC SPECT/CT is useful for detecting, localizing and defining the extent of graft infection in patients with late and low-grade late VPI with inconclusive radiological findings. Tc-HMPAO-WBC SPECT/CT might be used to optimize patient management. [ABSTRACT FROM AUTHOR]

BACKGROUND: Atrial fibrillation occurs after approximately 25% to 45% of coronary artery bypass graft (CABG) surgeries. Oxidative stress and related electrophysiological remodeling has been proposed as a potential cause of this atrial fibrillation. Perioperative supplementation of the antioxidant ascorbic acid has been evaluated as a preventive agent. The current investigation was conducted to evaluate the efficacy of ascorbic acid in reducing atrial fibrillation in CABG patients. METHODS: A prospective, randomized, placebo-controlled, triple-blind, single-institution study was conducted in nonemergency CABG patients. Subjects were monitored for episodes of arrhythmia and other complications. RESULTS: Eighty-nine treatment and 96 control subjects completed the study protocol. Demograph-ics, comorbidities, and preoperative drugs were similar between groups. Surgical characteristics and postoperative medication use also were similar. The incidence of atrial fibrillation was 30.3% in the treatment group and 30.2% in the control group (P = .985). No difference was found in postoperative complications or mortality. CONCLUSIONS: Our data indicate that supplementation of ascorbic acid in addition to routine postoperative care does not reduce atrial fibrillation after coronary artery bypass grafting. [ABSTRACT FROM AUTHOR]

True aneurysm formation in arterialized autologous veins is an unusual complication. A saccular aneurysmal degeneration of 53 mm (maximal diameter) of a saphenous vein graft inserted for repair of a popliteal aneurysm, four years after implantation, is reported. The patient (with prior history of abdominal aortic aneurysm) had been initially treated through a posterior approach. A new saphenous vein bypass grafting (medial approach) was performed. Histological examination revealed myointimal fibrosis, medial degeneration and inflammation. In spite of the widespread use of the autologous saphenous vein as an arterial substitute, this complication is extremely rare and its etiology remains unclear. Atherosclerosis is considered to be the main cause of aneurysm formation in vein grafts, but current data suggest that additional etiopathogenic factors should be further investigated. We note the rarity of this finding and review the literature for true aneurysm formation within vein grafts used for bypass procedures. True aneurysm formation in arterialized autologous veins is an unusual complication. A saccular aneurysmal degeneration of 53 mm (maximal diameter) of a saphenous vein graft inserted for repair of a popliteal aneurysm, four years after implantation, is reported. The patient (with prior history of abdominal aortic aneurysm) had been initially treated through a posterior approach. A new saphenous vein bypass grafting (medial approach) was performed. Histological examination revealed myointimal fibrosis, medial degeneration and inflammation. In spite of the widespread use of the autologous saphenous vein as an arterial substitute, this complication is extremely rare and its etiology remains unclear. Atherosclerosis is considered to be the main cause of aneurysm formation in vein grafts, but current data suggest that additional etiopathogenic factors should be further investigated. We note the rarity of this finding and review the literature for true aneurysm formation within vein grafts used for bypass procedures. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: To compare practice in lower limb bypass surgery in nine countries. Design: A prospective study amalgamating and analysing data from national and regional vascular registries. Methods: A table of data fields and definitions was agreed by all member countries of the Vascunet Collaboration. Data from January 2005 to December 2009 was submitted to a central database. Results: 32,084 cases of infrainguinal bypass (IIB) in nine countries were analysed. Procedures per 100,000 population varied between 2.3 in the UK and 24.6 in Finland. The proportion of women varied from 25% to 43.5%. The median age for all countries was 70 for men and 76 for women. Hungary treated the youngest patients. IIB was performed for claudication for between 15.7% and 40.8% of all procedures. Vein grafts were used in patients operated on for claudication (52.9%), for rest pain (66.7%) and tissue loss (74.1%). Italy had the highest use of synthetic grafts. Among claudicants 45% of bypasses were performed to the below knee popliteal artery or more distally. Graft patency at 30 days varied between 86% and 99%. Conclusions: Significant variations in practice between countries were demonstrated. These results should be interpreted alongside the known limitations of such registry data with respect to quality and completeness of the data. Variation in data completeness and data validation between countries needs to be improved for useful international comparison of outcomes. [Copyright &y& Elsevier]

Abstract: Objectives: The aim of the study is to study contemporary presentation patterns and clinical results in patients undergoing aortofemoral bypass (AFB) surgery. Design: This was a retrospective comparative study. Material and methods: During a 14-year period, 269 consecutive patients (mean age 65 years) underwent AFB. Indications included occlusive disease with severe intermittent claudication (IC) (n = 86), critical limb ischaemia (CLI, n = 97) and aneurysmo-occlusive disease (n = 86). Results: From 2000–07 on, AFB was performed more frequently for occlusive disease with CLI than for other indications (48% vs. 31% before 2000, P = 0.009) and also in women (51% vs. 32% before 2000, P = 0.003), compared to the period before 2000. Thirty-day mortality was reduced during 2000–2007 to 2.4%, compared with 4.3% during 1993–1999, although this difference was not statistically significant (P = 0.73). Morbidity did not change substantially over the study period. Predictors of 30-day mortality included indication (CLI = 4.1% vs. claudication = 1.2% (P = 0.37)) and chronic kidney disease (CKD, serum creatinine > 1.5 mg dl−1) (11.1% vs. 2.9% in normal renal function, P = 0.07), the latter being the single predictor on multivariate analysis (hazard risk 4.2, P = 0.047). Overall 5 and 10-year assisted primary and secondary patency was 95% and 88%, and 99% and 95%, respectively. Survival at 5 and 10 years was 69% and 48%, respectively. Patient age (hazard risk 1.05, P < 0.001), CKD (hazard risk 1.79, P = 0.018) and diabetes (hazard risk 1.56, P = 0.022) were independent predictors of worse long-term survival. Long-term outcome did not change over the course of the study. Conclusions: In the contemporary era, AFB is more likely to be performed for CLI and in women than in the past. Despite these changes, perioperative mortality and morbidity remain low and long-term outcome excellent. [Copyright &y& Elsevier]

We herein report the case of a patient demonstrating both coronary artery and peripheral artery occlusive disease with neurofibromatosis, which were successfully treated during the same session with coronary artery bypass graft surgery and a femoropopliteal bypass graft surgery procedure. The recognition of a possible association between neurofibromatosis and coronary artery and other vascular structures will further facilitate the successful surgery and clinical management of this rare clinical entity. [ABSTRACT FROM AUTHOR]