The RAGE Trial (Radial Arterial Graft in the Elderly)- A Pilot Study

Use of radial artery (RA) as a second arterial conduit in Coronary Artery Bypass Grafting (CABG) is well established and appreciated for its higher long-term patency rate compared to vein grafts. This study tends to investigate if there are any detrimental consequences when it is used in elderly (aged 60 and above) population of Bangladesh. A total of 71 patients who received RA grafts at elective, isolated CABG operation were consecutively enrolled in this study from May 2018 to September 2019. 31 patients were in the Elderly group and 40 patients were in the Non-elderly group. The groups were compared for baseline characteristics and co-morbidities; preoperative techniques, findings, events and procedures; and postoperative outcomes or end-point variables inclusive of local complications related to RA harvesting wound. Elderly and Non-elderly groups had statistically different age (p=0.000) and Society of Thoracic Surgery (STS) Score predicted mortality (p=0.000). Operative techniques, events, findings and procedures were similar. Clinical outcomes were found to be similar with no statistical difference between the groups. Number of deaths also was not statistically different. There were no local complications related to RA harvesting wound in either of the two groups. Harvesting and grafting of radial artery in suitable patients, using meticulous "no-touch" technique and for ideal target coronary artery stenosis is as safe in the elderly patients as in the younger ones. CBMJ 2020 July: Vol. 09 No. 02 P: 08-13

EP.WE.962Pre-emptive arterial stenting with covered vascular stents to prevent mycotic haemorrhage in infected fields following failed kidney and pancreas transplants prior to graft explant

Aims Allograft nephrectomy and pancreatectomy present a significant surgical challenge in contaminated surgical fields, with risks of post-operative pseudoaneurysms and mycotic bleeds. We report on our experience of prophylactic endovascular stenting shortly before or after allograft nephrectoym and pancreatectomy to reduce the risk of subsequent pseudoaneurysm formation from the donor arterial conduit. Methods A retrospective analysis of all patients undergoing arterial stenting by interventional radiology prior to graft explant in our unit was performed. Results Twelve patients were identified, 6 of whom had undergone kidney transplant and 6 simultaneous pancreas kidney transplant (SPK) with an average age of 46. Iliac stenting was prophylactic in 7 patients, for pseudoaneurysm (28%), graft pancreatitis (28%), acute rejection (28%), enteric anastomotic leak (16%) and transplant pyelonephritis (14%). Therapeutic stenting was performed in 5 patients, all of whom had ruptured pseudoaneurysms. Post-operative 30-day mortality occurred in 1 patient resulting from an acute on chronic limb ischaemia and subsequent sepsis and death. Of the remaining patients, none experienced complications from stenting. 9 of the 12 stented patients remain alive, with the 3 mortalities resulting from other pathology not relating to stenting. Conclusion Prophylactic iliac stenting around the time of graft excision in inflamed or infected fields provides a safe and effective technique to completely exclude the donor arterial stump, with no subsequent vascular complications reported within our series. Preventing mycotic aneurysm formation in this way may mitigate the risk of potentially catastrophic post-operative mycotic arterial bleeds.

SHORT- AND LONG-TERM OUTCOMES OF A SECOND ARTERIAL CONDUIT FOLLOWING CORONARY BYPASS GRAFTING

Background: The aim of this study was to assess the effect on short-term outcomes and long-term survival in patients following coronary artery bypass grafting in whom second arterial conduit(right internal thoracic artery-RITA or radial artery-RA) or saphenous vein was grafted and between RITA and RA as second best arterial conduit. Methods: Between January-2006 and June-2018, 7857-patients met the inclusion criteria and were divided into two groups: single internal thoracic artery: SITA+Vein group(n=7140) and 2nd-arterial conduit group(n=717), of these 537-patients received RITA and 180-patients received RA. Short‐term outcomes included: 30-day mortality and Major Adverse Cardiac and Cerebral Events(MACCE), reoperation for bleeding and deep sternal wound infection(DSWI). The long‐term outcome was all‐cause mortality. propensity score(PS) matching was used to match patients between the groups. Results: Before as well as after PS-matching, no significant differences were observed between 2nd-arterial conduit vs SITA+Vein groups and between RITA vs RA groups in terms of 30-day mortality, 30-day MACCE, reoperation for bleeding and incidence of DSWI. The use of 2nd-arterial conduit was associated with a significant reduction in long-term mortality before(HR:0.52;95%CI;0.43-0.64;p<0.001) as well as after PS-matching(HR:0.77;95%CI;0.60-0.99;p=0.04). RA and RITA as second arterial conduit had comparable long-term mortality before(HR:1.22;95%CI;0.82-1.82;p=0.3) as well as after PS-matching(HR:0.96;95%CI;0.58-1.58;p=0.87). Conclusions: The use of 2nd-arterial conduit vs vein is associated with improved long-term survival. As for the 2nd-best arterial conduit, RA and RITA had comparable long-term mortality.

Survival benefit from a second arterial conduit to the circumflex circulation persists in elderly after coronary artery bypass surgery

Background This retrospective propensity matched study investigated the impact of age on the survival benefit from a second arterial conduit to the left-sided circulation. Methods Data for isolated coronary artery bypass surgery were collected from October 2004 to March 2014. All patients with an internal mammary artery graft to left anterior descending artery and additional arterial or venous graft to the circumflex circulation were included. Propensity matching was used to balance co-variates and generate odds of death for each observation. Odds ratios (venous vs. arterial) were charted against age. Results The in-hospital mortality rate was 1.12% (arterial) vs. 1.24% (venous) (p = 0.77). The overall 10-year survival was 74.6% (venous) vs. 82.6% (arterial) (p = 0.001). A total of 1226 patients were successfully matched to the venous or arterial (second conduit to circumflex territory after left internal mammary artery to left anterior descending artery) cohorts. Odds ratio for death (venous to arterial) showed a linear decremental overall survival benefit for the second arterial graft to circumflex circulation with increasing age. Conclusions The survival benefit of a second arterial graft persists through all age groups with a gradual decline with increasing age over the decades. Elderly patients should not be denied a second arterial graft to the circumflex circulation based on age criterion alone.

Creating an appropriate access for endovascular repair by replacing a dissected femoral artery in aortic dissection

Transfemoral endovascular repair has been widely accepted as an effective treatment for type B aortic dissection. However, if the dissection extends to the femoral artery, the transfemoral approach increases the risk of access complications. We describe a case of acute complicated type B aortic dissection involving the dissected bilateral femoral arteries. Successful endovascular repair without access complications was performed through an appropriate access route created by a femoral arterial conduit. We believe that this approach results in reliable cannulation of the true lumen and the reduction of the risk for intimal injury in aortic dissection with the dissected femoral artery.