ESCTS 2012

1. Impact Of Previous Stenting On The
Outcome Of CABG
In Multivessel Disease
Saeed M. Refaat Elassy, M.D.
Associate professor CTS
Ain Shams University

2. BACKGROUND
• Interventional cardiologists have a growing role in
treatment of coronary artery stenosis due to
improvement of technology.
• Its “less invasiveness” is more attractive to patients.
• Around one-third of patients with multivessel
disease treated with bare metal stents will require
re-intervention within few years.
Hannan N Engl J Med 2005;352:2174–2183

3. BACKGROUND
Mortality & MI Relief of angina Repeat revascularization
GABI PCI PCI CABG
EAST No difference CABG CABG
RITA No difference CABG CABG
ERACI No difference CABG CABG
CABRI No difference CABG CABG
BARI No difference N/A CABG
MASS II CABG (MI) N/A CABG
Awesome No difference No difference CABG
ERACI II PCI CABG CABG
SOS CABG (mortality) CABG CABG
ARTS No difference CABG CABG

4. BACKGROUND
• Even after the introduction of DES, repeat
revascularization rate is inferior to CABG.
• In the SYNTAX randomized patients, 4-year MACCE
rates were significantly higher for PCI than CABG,
mainly driven by higher repeat revascularization in
the PCI arm.
• Significant increase of MI compared to CABG at 4
years driven by higher PCI MI rate between years 1
and 2 and years 2 and 3

5. OBJECTIVE
Does previous successful coronary stenting has an
impact on the outcome of subsequent CABG in
multivessel disease ?

6. PATIENTS AND METHODS
• 200 patients referred for CABG.
• Between May 2009 and January 2011.
• Divided into two groups:
Group A: with no previous stent
Group B: with previous stent (DES 100, BMS 98)
Exclusion criteria
• Single vessel disease.
• CABG with other procedure except IMR.
• Emergency CABG after PCI.
• Redo CABG.

7. PATIENTS AND METHODS ( cont.)
Echo examination preoperatively and 3 months
after the operation to monitor:
• LVEDD
• LVESD
• EF
• SWMA at rest

8. PATIENTS CHARACTERISTICS
Group I Group II P value
Age, mean SD (y) 57.2±8.52 53.3 7.95 0.0009
Male, % 91 82 0.494
Diabetes, % 61 61 1.000
Hypertension, % 27 37 0.130
Dyslipidemia, % 47 40 0.318
Heart failure, % 2 0 0.155
Valve lesions, % 39 39 1.0
Cardiogenic shock, % 0 2 0.155
Unstable angina, % 14 14 1.000
COPD, % 10 9 0.809
Neurological deficits, % 1 2 0.561
Chronic renal impairment, % 2 8 0.052
Pulmonary hypertension, % 1 4 0.174

9. PATIENTS CHARACTERISTICS
Group I Group II P value
Recent MI, % 7 6 0.774
Mean NYHA class, mean SD 1.55 ± 0.88 1.86 ± 0.94 0.012
Previous cardiac surgery, % 2 2 1.000
Active endocarditis, % 2 0 0.155
Peripheral vascular disease, % 16 6 0.027
Mitral repair+ CABG, % 4 0 0.043
Urgent CABG, % 0 8 0.004
Previous MI, % 25 69 0.001
ESD, mean SD (cm) 3.87±0.95 3.66±0.78 0.092
EDD, mean SD (cm) 4.95±0.93 5.21±0.64 0.021
EF, mean SD (%) 55.59±9.81 56±10 0.316
Euroscore, mean SD 2.8 ± 5.4 2.1 ± 2.2 0.246

10. PATIENTS CHARACTERISTICS
Group I Group II P value
Diseased vessels, mean SD(n) 3.34±0.52 3.28±0.45 NS
Left main, % 10 18 NS
Three vessels, % 68 72 NS
Four vessels, % 30 28 NS
five vessels, % 2 0 NS

11. OPERATIVE CHARACTERISTICS
Group I Group II P value
OPCAB, (%) 26 35 0.167
ACC time, mean SD (min.) 69.49±24.73 61.81±28.40 0.0994
Bypass time , mean SD (min.) 102.07±29.79 91.47±41.49 0.0926
Total grafts, mean SD (n) 3.12±0.73 2.46±0.85 0.001
Arterial grafts, mean SD (n) 1.24±0.54 1.07±0.33 0.001
Venous grafts, mean SD (n) 1.89±0.74 1.39±0.90 0.001
Total Revascularization(%) 79 50 0.001
Total Arterial Revascularization(%) 18 1 0.001

12. POSTOPERATIVE EVENTS
Group I Group II P value
Hospital stay, mean SD (d) 9.30±3.80 11.23±3.80 0.001
ICU stay, mean SD (d) 3.30±4.51 2.89±1.44 NS
M. ventilation, mean SD (hr) 13.2 ± 12.7 10.2 ± 11.9 NS
IABP, (%) 11 13 NS
Inotropes, (%) 40 62 0.001
Clinical symptoms of HF, (%) 11 11 NS
Reopen for bleeding, (%) 9 25 0.002
Dehiscent sternum, (%) 9 5 NS
Superficial Wound infection, (%) 18 35 0.004
Deep Wound infection, (%) 3 15 0.002

13. POSTOPERATIVE EVENTS
Group I Group II P value
Neurological complications 2 1 NS
Renal impairment 7 2 NS
Endocarditis 0 2 NS
Arrhythmias, (%) 10 21 0.026
Post operative organ failure, (%) 2 2 NS
Perioperative MI, (%) 18 18 NS
Total morbidity, (%) 40 66 0.001
Total mortality, (%) 7 6 NS

14. POSTOPERATIVE ECHO
3 Months
Group I Group II P value
ESD, mean SD (cm) 3.46±0.75 3.50±0.76 0.7148
EDD, mean SD (cm) 4.45±0.98 5.09±0.66 0.3107
EF, mean SD (%) 60.20±6.28 58±8 0.0001
RSWMA, (%) 16 43 <0.0001
Improvement of dimensions, (%) 87 73 0.048
Improvement of EF, (%) 85 70 0.038
Improvement of SWMA, (%) 97 78 <0.0001
Post op normal EF, (%) 78 57 0.005

15. POSTOPERATIVE ECHO
3 Months
Group I Group II P value
ESD, mean of the difference SD (cm) 0.34 ± 0.64 0.12 ± 0.57 0.015
EDD, mean of the difference SD (cm) 0.48 ± 0.67 0.11 ± 0.6 0.001
EF, mean of the difference SD (%) 4.1 ± 9.1 1.32 ± 6.8 NS

16. DISCUSSION
• Eifert et al has found that patients with prior PCI
presented for CABG with more severe CAD.
• Morbidity, mortality and reoperation rate during mid
term were significantly higher in patients with prior
PCI.
Eiffert et a l Vascular Health and Risk Management 2010:6 495–501

17. DISCUSSION
Chocron et al reanalyzed the primary end-point of the
IMAGINE trial and compared outcome after CABG in
455 patients with PCI and 2098 without prior PCI.
Patients with a history of PCI prior to surgery had a
worse outcome post-CABG than those with no prior
PCI as regards unstable angina requiring
hospitalization [HR ¼ 2.43 (1.54–3.83), P = 0.0001]
and repeat coronary revascularization [HR =1.85
(1.17–2.90), P ¼ 0.008].
European Heart Journal (2008) 29, 673–679

18. DISCUSSION
Hassan et al. compared outcome after CABG in 919 patients
with and 5113 without prior PCI. Although the prior PCI
group had less severe coronary artery disease and less co-
morbidity, multivariate analyses identified prior PCI as an
independent predictor of hospital mortality (HR 1.93; P=
0.003). In propensity-matched patients, the in-hospital
mortality was 3.6% in the prior vs. 1.7% in the non-prior PCI
group (P = 0.01).
Hassan et al. Am Heart J 2005;150:1026–1031

19. DISCUSSION
Thielmann and colleagues investigated outcome in 2626
consecutive patients undergoing first time CABG without
prior PCI in comparison with 360 after a single and 289
patients with multiple prior PCI. Using risk-adjusted
multivariate logistic regression analysis they reported that
multiple prior PCIs were associated with increased in-
hospital mortality [HR=2.24 (95% CI 1.52–3.21); P < 0.001]
and the risk of major adverse cardiovascular
Thielmann et al. J Thorac Cardiovasc Surg 2007;134:470–76.

20. DISCUSSION
• Kanemitsu et al, found that the clinical introduction
of DES was associated with more serious
preoperative conditions.
Kanemitsu et al interact CardioVasc Thorac Surg 2007;6:632-635
• Several meta-analyses have demonstrated that DES
have a high repeat revascularization rate.
• DES impair endothelialization, leaving a potentially
prothrombotic substrate within the vessel.

21. DISCUSSION
EXPLANATIONS
• Worse preoperative condition as age, ventricular function
and extent of coronary artery.
• Prior PCI patients often present with more unstable
symptoms.
• Prior stents encourage more distal bypass grafting with less
favorable graft run off.
• Lack of completeness of appropriate revascularization.
• DES cause dysfunction of the endothelium both overlying the
stent and further downstream.
• BMS may compromise endothelial function overlying the
stent which is exaggerated by changes in the inflammatory
and coagulation status precipitated by cardiac operations.

22. CONCLUSION
• Prior PCI (BMS & DES) increases the risk
of subsequent CABG.
• Prior PCI reduces the improvement of
cardiac function after subsequent CABG.

23. MESSAGE
• The belief that CABG can always be safely
deferred in favor of an initial strategy of
PCI in multivessel disease is not correct.
• These observations should be carefully
considered in patients with multivessel
disease who are likely eventually to
require CABG.

24. Thank you