Virchow Triad, but Not Use of an Aortic Connector Device, Predicts Early Graft Failure after Off-Pump Coronary Bypass
DOI:
https://doi.org/10.1532/HSF98.20041090Abstract
The risk of early thrombosis of coronary artery bypass (CAB) grafts may be increased after off-pump CAB, particularly after the use of an aortic connector device (ACD) to perform the proximal aortosaphenous anastomosis. We have been investigating tools that quantify the risk of early vein graft thrombosis after off-pump CAB on the basis of the Virchow triad of hypercoagulability, endothelial disease, and low conduit flow. These tools were applied in this prospective trial of a heterogeneous group of patients with varying degrees of aortic disease and who received the Symmetry ACD. After controlling for the Virchow risk factor triad, we hypothesized that the ACD does not independently influence graft thrombosis. There was no statistically significant difference in the early thrombosis rates of vein grafts connected with an ACD versus hand-sewn grafts (6.7% versus 6.5%). We found a wide range of graft flow measurements, platelet function, and vein endothelial phenotypes in patients with traditionally hand-sewn vein grafts and with grafts connected with an ACD in patients with a wide range of ascending aortic atherosclerosis. The perioperative combination of platelet hyperreactivity, marginal graft flow, and endothelial disease proved to be highly predictive of early graft failure as seen with postoperative computed tomographic angiography.References
Stein PD, Dalen JE, Goldman S, Schwartz L, Theroux P, Turpie AG. 1995. Antithrombotic therapy in patients with saphenous vein and internal mammary artery bypass grafts. Chest 108:424S-30S.nTraverse JH, Mooney MR, Pedersen WR, et al. 2003. Clinical, angiographic, and interventional follow-up of patients with aortic-saphenous vein graft connectors. Circulation 108:452-6.nvan der Linden J, Hadjinikolaou L, Bergman P, Lindblom D. 2001. Postoperative stroke in cardiac surgery is related to the location and extent of atherosclerotic disease in the ascending aorta. J Am Coll Cardiol 38:131-5.nCavendish JJ, Penny WF, Madani MM, et al. 2004. Severe ostial saphenous vein graft disease leading to acute coronary syndromes following proximal aorto-saphenous anastomoses with the symmetry bypass connector device: is it a suture device or a "stent"? J Am Coll Cardiol 43:133-9.nMariani MA, Gu YJ, Boonstra PW, Grandjean JG, van Oeveren W, Ebels T. 1999. Procoagulant activity after off-pump coronary operation: is the current anticoagulation adequate? Ann Thorac Surg 67:1370-5.nNihoyannopoulos P, Joshi J, Athanasopoulos G, Oakley CM. 1993. Detection of atherosclerotic lesions in the aorta by transesophageal echocardiography. Am J Cardiol 71:1208-12.nPOST CABG Investigators. 1997. The effect of aggressive lowering of low-density lipoprotein cholesterol levels and low-dose anticoagulation on obstructive changes in saphenous-vein coronary-artery bypass grafts: the Post Coronary Artery Bypass Graft Trial Investigators. N Engl J Med 336:153-63.nPrandoni P, Bilora F, Marchiori A. 2003. An association between atherosclerosis and venous thrombosis. N Engl J Med 348:1435-41.nScarborough JE, White W, Derilus FE, Mathew JP, et al. 2003. Combined use of off-pump techniques and a sutureless proximal aortic anastomotic device reduces cerebral microemboli generation during coronary artery bypass grafting. J Thorac Cardiovasc Surg 126:1561-7.nShore-Lesserson L, Manspeizer M, De Perio M, Francis S, Vela-Cantos F, Ergin MA. 1999. Thrombelastography-guided transfusion algorithm reduces transfusions in complex cardiac surgery. Anesth Analg 88:312-9.nStehbens WE. 1992. The role of thrombosis and variants of the thrombogenic theory in the etiology and pathogenesis of atherosclerosis. Prog Cardiovasc Dis 34:325-46.nYende S, Wunderink RG. 2001. Effect of clopidogrel on bleeding after coronary artery bypass surgery. Crit Care Med 29:2271-8.nD'Ancona G, Donias HW, Karamanoukian RL, Bergsland J, Karamanoukian HL. 2001. OPCAB therapy survey: off-pump clopidogrel, aspirin or both therapy survey. Heart Surg Forum 4:354-8.nFitzGerald GA, Tigges J, Barry P, Lawson JA. 1997. Markers of platelet activation and oxidant stress in atherothrombotic disease. Thromb Haemost 78:280-4.nGundry S, Romano M, Shattuck OH, Razzouk AJ, Bailey LL. 1998. Seven-year follow-up of coronary artery bypasses performed with and without cardiopulmonary bypass. J Thorac Cardiovasc Surg 115:1273-8.nHongo RH, Ley J, Dick SE, Yee RR. 2002. The effect of clopidogrel in combination with aspirin when given before coronary artery bypass grafting. J Am Coll Cardiol 40:231-7.nKawai S, Sasajima T, Satoh K, et al. 2003. Biologic degeneration of vein grafts after thrombotic occlusion: thrombectomy within 3 days results in better indices of viability. J Vasc Surg 38:305-12.nKhan NE, De Souza A, Mister R, et al. 2004. A randomized comparison of off-pump and on-pump multivessel coronary-artery bypass surgery. N Engl J Med 350:21-8.n
