Influence of Diabetes Mellitus on Changes in Intra-Operative Decision Making in Coronary Artery Bypass Grafting
DOI:
https://doi.org/10.59958/hsf.7413Keywords:
coronary artery disease, diabetes, coronary artery bypass grafting, high frequency ultrasound, transit time flow measurementAbstract
Background: We evaluated whether patients with diabetes mellitus experienced more surgical strategy changes than patients without diabetes when undergoing coronary artery bypass graft surgery utilizing a protocol for intraoperative high frequency ultrasound and transit-time flow measurement. Methods: Outcomes of coronary artery bypass grafting (CABG) patients with and without diabetes enrolled in the multicenter prospective Registry for Quality Assessment with Ultrasound Imaging and TTFM in Cardiac Bypass Surgery (REQUEST) study were retrospectively compared. The primary endpoint was frequency of intraoperative surgical strategy changes. We also evaluated the differences in patient characteristics and operative characteristics including graft configuration. Results: We compared 614 non-diabetic patients with 402 diabetic patients, among whom 128 were insulin dependent. Patients with diabetes had higher rates of surgical strategy change for the aortic component of the operation (10.2% vs. 6.4%, odds ratio (OR) = 1.67; 95% confidence interval (CI) = 1.06–2.65; p = 0.026). Surgical strategy changes related to in-situ conduits were more common in on-pump procedures in comparison to off-pump in diabetics (4.0% vs. 0%; p = 0.007). Diabetes was associated with less frequent use of bilateral internal mammary arteries (BIMA) (25.6% vs. 33.7%; p = 0.006), more frequent use of radial artery (31.3% vs. 16.9%; p < 0.001) and multi-arterial configuration (48.3% vs. 39.9%, p = 0.009), and more total grafts (3.1 ± 1.1 vs. 2.8 ± 0.9; p < 0.001). Conclusions: When performing isolated CABG on diabetic patients, surgeons were more likely to change surgical strategy for the aortic component of the operation based on high-frequency ultrasound (HFUS), and more likely to make a change related to in-situ conduits in on-pump procedures in diabetics. Among diabetic patients, there was less frequent use of BIMA, more frequent use of radial artery, more frequent multi-arterial configuration, and more total grafts.
References
Leon BM, Maddox TM. Diabetes and cardiovascular disease: Epidemiology, biological mechanisms, treatment recommendations and future research. World Journal of Diabetes. 2015; 6: 1246–1258.
Lee CD, Folsom AR, Pankow JS, Brancati FL, Atherosclerosis Risk in Communities (ARIC) Study Investigators. Cardiovascular events in diabetic and nondiabetic adults with or without history of myocardial infarction. Circulation. 2004; 109: 855–860.
Haffner SM, Lehto S, Rönnemaa T, Pyörälä K, Laakso M. Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction. The New England Journal of Medicine. 1998; 339: 229–234.
Kappetein AP, Head SJ, Morice MC, Banning AP, Serruys PW, Mohr FW, et al. Treatment of complex coronary artery disease in patients with diabetes: 5-year results comparing outcomes of bypass surgery and percutaneous coronary intervention in the SYNTAX trial. European Journal of Cardio-thoracic Surgery: Official Journal of the European Association for Cardio-thoracic Surgery. 2013; 43: 1006–1013.
Nicholls SJ, Tuzcu EM, Kalidindi S, Wolski K, Moon KW, Sipahi I, et al. Effect of diabetes on progression of coronary atherosclerosis and arterial remodeling: a pooled analysis of 5 intravascular ultrasound trials. Journal of the American College of Cardiology. 2008; 52: 255–262.
Lester WM, Roberts WC. Diabetes mellitus for 25 years or more. Analysis of cardiovascular findings in seven patients studied at necropsy. The American Journal of Medicine. 1986; 81: 275–279.
Burchfiel CM, Reed DM, Marcus EB, Strong JP, Hayashi T. Association of diabetes mellitus with coronary atherosclerosis and myocardial lesions. An autopsy study from the Honolulu Heart Program. American Journal of Epidemiology. 1993; 137: 1328–1340.
Shahian DM, O'Brien SM, Filardo G, Ferraris VA, Haan CK, Rich JB, et al. The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 1–coronary artery bypass grafting surgery. The Annals of Thoracic Surgery. 2009; 88: S2–S22.
Alserius T, Hammar N, Nordqvist T, Ivert T. Improved survival after coronary artery bypass grafting has not influenced the mortality disadvantage in patients with diabetes mellitus. The Journal of Thoracic and Cardiovascular Surgery. 2009; 138: 1115–1122.
Robich MP, Iribarne A, Leavitt BJ, Malenka DJ, Quinn RD, Olmstead EM, et al. Intensity of Glycemic Control Affects Long-Term Survival After Coronary Artery Bypass Graft Surgery. The Annals of Thoracic Surgery. 2019; 107: 477–484.
Farkouh ME, Domanski M, Sleeper LA, Siami FS, Dangas G, Mack M, et al. Strategies for multivessel revascularization in patients with diabetes. The New England Journal of Medicine. 2012; 367: 2375–2384.
Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, et al. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2011; 124: e652–e735.
Sousa-Uva M, Neumann FJ, Ahlsson A, Alfonso F, Banning AP, Benedetto U, et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. European Journal of Cardio-thoracic Surgery: Official Journal of the European Association for Cardio-thoracic Surgery. 2019; 55: 4–90.
Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. European Heart Journal. 2019; 40: 87–165.
Taggart DP, Thuijs DJFM, Di Giammarco G, Puskas JD, Wendt D, Trachiotis GD, et al. Intraoperative transit-time flow measurement and high-frequency ultrasound assessment in coronary artery bypass grafting. The Journal of Thoracic and Cardiovascular Surgery. 2020; 159: 1283–1292.e2.
Rosenfeld ES, Trachiotis GD, Sparks AD, Napolitano MA, Lee KB, Wendt D, et al. Intraoperative surgical strategy changes in patients with chronic and end-stage renal disease undergoing coronary artery bypass grafting. European Journal of Cardio-thoracic Surgery: Official Journal of the European Association for Cardio-thoracic Surgery. 2021; 59: 1210–1217.
Kannel WB, Dawber TR, Kagan A, Revotskie N, Stokes J, 3rd. Factors of risk in the development of coronary heart disease–six year follow-up experience. The Framingham Study. Annals of Internal Medicine. 1961; 55: 33–50.
Sprafka JM, Burke GL, Folsom AR, McGovern PG, Hahn LP. Trends in prevalence of diabetes mellitus in patients with myocardial infarction and effect of diabetes on survival. The Minnesota Heart Survey. Diabetes Care. 1991; 14: 537–543.
Virani SS, Alonso A, Aparicio HJ, Benjamin EJ, Bittencourt MS, Callaway CW, et al. Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association. Circulation. 2021; 143: e254–e743.
Bypass Angioplasty Revascularization Investigation (BARI) Investigators. Comparison of coronary bypass surgery with angioplasty in patients with multivessel disease. The New England Journal of Medicine. 1996; 335: 217–225.
Influence of diabetes on 5-year mortality and morbidity in a randomized trial comparing CABG and PTCA in patients with multivessel disease: the Bypass Angioplasty Revascularization Investigation (BARI). Circulation. 1997; 96: 1761–1769.
Kapur A, Hall RJ, Malik IS, Qureshi AC, Butts J, de Belder M, et al. Randomized comparison of percutaneous coronary intervention with coronary artery bypass grafting in diabetic patients. 1-year results of the CARDia (Coronary Artery Revascularization in Diabetes) trial. Journal of the American College of Cardiology. 2010; 55: 432–440.
Hlatky MA, Boothroyd DB, Bravata DM, Boersma E, Booth J, Brooks MM, et al. Coronary artery bypass surgery compared with percutaneous coronary interventions for multivessel disease: a collaborative analysis of individual patient data from ten randomised trials. Lancet (London, England). 2009; 373: 1190–1197.
Woodfield SL, Lundergan CF, Reiner JS, Greenhouse SW, Thompson MA, Rohrbeck SC, et al. Angiographic findings and outcome in diabetic patients treated with thrombolytic therapy for acute myocardial infarction: the GUSTO-I experience. Journal of the American College of Cardiology. 1996; 28: 1661–1669.
van der Linden J, Hadjinikolaou L, Bergman P, Lindblom D. Postoperative stroke in cardiac surgery is related to the location and extent of atherosclerotic disease in the ascending aorta. Journal of the American College of Cardiology. 2001; 38: 131–135.
Gaudino M, Angiolillo DJ, Di Franco A, Capodanno D, Bakaeen F, Farkouh ME, et al. Stroke After Coronary Artery Bypass Grafting and Percutaneous Coronary Intervention: Incidence, Pathogenesis, and Outcomes. Journal of the American Heart Association. 2019; 8: e013032.
Kapetanakis EI, Stamou SC, Dullum MKC, Hill PC, Haile E, Boyce SW, et al. The impact of aortic manipulation on neurologic outcomes after coronary artery bypass surgery: a risk-adjusted study. The Annals of Thoracic Surgery. 2004; 78: 1564–1571.
Zhao DF, Edelman JJ, Seco M, Bannon PG, Wilson MK, Byrom MJ, et al. Coronary Artery Bypass Grafting With and Without Manipulation of the Ascending Aorta: A Network Meta-Analysis. Journal of the American College of Cardiology. 2017; 69: 924–936.
Albert A, Ennker J, Hegazy Y, Ullrich S, Petrov G, Akhyari P, et al. Implementation of the aortic no-touch technique to reduce stroke after off-pump coronary surgery. The Journal of Thoracic and Cardiovascular Surgery. 2018; 156: 544–554.e4.
Salenger R, Rodriquez E, Efird JT, Gouge CA, Trubiano P, Lundy EF. Clampless technique during coronary artery bypass grafting for proximal anastomoses in the hostile aorta. The Journal of Thoracic and Cardiovascular Surgery. 2013; 145: 1584–1588.
Suvarna S, Smith A, Stygall J, Kolvecar S, Walesby R, Harrison M, et al. An intraoperative assessment of the ascending aorta: a comparison of digital palpation, transesophageal echocardiography, and epiaortic ultrasonography. Journal of Cardiothoracic and Vascular Anesthesia. 2007; 21: 805–809.
Djaiani G, Ali M, Borger MA, Woo A, Carroll J, Feindel C, et al. Epiaortic scanning modifies planned intraoperative surgical management but not cerebral embolic load during coronary artery bypass surgery. Anesthesia and Analgesia. 2008; 106: 1611–1618.
Iwakawa N, Tanaka A, Ishii H, Kataoka T, Niwa K, Hitora Y, et al. Impact of Diabetes Mellitus on the Aortic Wall Changes as Atherosclerosis Progresses: Aortic Dilatation and Calcification. Journal of Atherosclerosis and Thrombosis. 2020; 27: 509–515.
Zingone B, Rauber E, Gatti G, Pappalardo A, Benussi B, Dreas L, et al. The impact of epiaortic ultrasonographic scanning on the risk of perioperative stroke. European Journal of Cardio-thoracic Surgery: Official Journal of the European Association for Cardio-thoracic Surgery. 2006; 29: 720–728.
Kim KM, Arghami A, Habib R, Daneshmand MA, Parsons N, Elhalabi Z, et al. The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2022 Update on Outcomes and Research. The Annals of Thoracic Surgery. 2023; 115: 566–574.
Singh SK, Desai ND, Petroff SD, Deb S, Cohen EA, Radhakrishnan S, et al. The impact of diabetic status on coronary artery bypass graft patency: insights from the radial artery patency study. Circulation. 2008; 118: S222–S225.
Deb S, Singh SK, Moussa F, Tsubota H, Une D, Kiss A, et al. The long-term impact of diabetes on graft patency after coronary artery bypass grafting surgery: a substudy of the multicenter Radial Artery Patency Study. The Journal of Thoracic and Cardiovascular Surgery. 2014; 148: 1246–1253; discussion 1253.
