In patients undergoing coronary artery bypass grafting, is endoscopic harvesting superior to open radial artery harvesting?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'In patients undergoing coronary artery bypass grafting, is endoscopic radial artery harvesting (ERAH) superior to open radial artery harvesting in terms of postoperative complications, mortality, graft quality and patency rates?'. Altogether 130 papers were found using the reported search, of which 5 represented the best evidence to answer the clinical question. Two studies were meta-analyses and 3 were randomized trials. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. In terms of graft quality, 2 randomized studies showed preserved endothelial integrity and vasoreactivity with ERAH, whereas 1 randomized study found superior endothelial function with open radial artery harvesting. Importantly, 3 studies showed graft patency was not compromised with ERAH. One meta-analysis reported no differences in graft patency between groups at 1 year [odds ratio (OR) 1.24] and up to 3-5-years follow-up (OR 1.81), as well as similar perioperative myocardial infarction rates (OR 0.80). Two meta-analyses found similar mortality in the perioperative period (OR 0.62-0.78) and up to 5 years (OR 0.64-0.67); ERAH reduced the incidence of perioperative wound complications (P-values 0.001-0.03); however, harvest times were increased with ERAH (P < 0.0005). We conclude that ERAH is non-inferior to open radial artery harvesting in terms of mortality, graft quality and patency rates, but superior in terms of reducing perioperative wound complications, with good cosmetic effect. However, these benefits come at the cost of increased harvesting time.

The Potential Role of Efficacy and Safety Evaluation of N-Acetylcysteine Administration During Liver Procurement. The NAC-400 Single Center Randomized Controlled Trial.

BACKGROUND: N-acetylcysteine infusions have been widely used to reduce ischemia/reperfusion damage to the liver; however, convincing evidence of their benefits is lacking. OBJECTIVE: To perform the largest randomized controlled trial to compare the impact of N-acetylcysteine infusion during liver procurement on liver transplant outcomes. METHODS: Single center, randomized trial with patients recruited from La Fe University Hospital, Spain, from February 2012 to January 2016. A total of 214 grafts were transplanted and randomized to the N-acetylcysteine group (n = 113) or to the standard protocol without N-acetylcysteine (n = 101). The primary endpoint was allograft dysfunction (Olthoff criteria). Secondary outcomes included metabolomic biomarkers of oxidative stress levels, interactions between cold ischemia time and alanine aminotransferase level and graft and patient survival (ID no. NCT01866644). RESULTS: The incidence of primary dysfunction was 34% (31% in the N-acetylcysteine group and 37.4% in the control group [P = 0.38]). N-acetylcysteine administration reduced the alanine aminotransferase level when cold ischemia time was longer than 6 h (P = 0.0125). Oxidative metabolites (glutathione/oxidized glutathione and ophthalmic acid) were similar in both groups (P > 0.05). Graft and patient survival rates at 12 mo and 3 y were similar between groups (P = 0.54 and P = 0.69, respectively). CONCLUSIONS: N-acetylcysteine administration during liver procurement does not improve early allograft dysfunction according to the Olthoff classification. However, when cold ischemia time is longer than 6 h, N-acetylcysteine improves postoperative ALT levels.

Liver Allografts From Older Donors With or Without Recovery of Thoracic Organs and Their Impact on Hepatic Graft and Patient Survival.

OBJECTIVES: Multiorgan procurement involving thoracic organs prolongs the liver recovery cross-clamp time. This may impact the outcome of hepatic allograft, more so in older donors (age > 60 years). We compared the outcomes of liver allografts from older donors with and without recovery of thoracic organs. MATERIALS AND METHODS: Using the Scientific Registry of Transplant Recipients database, we compared survival outcomes of 258 adults who received a liver allograft from older donors with thoracic organ recovery (group A) with 6006 patients who received liver allografts from older donor without thoracic organ recovery (group B). Furthermore, we performed a subgroup analysis matched for recipient and donor risk factors including presence of hypertension, diabetes mellitus, renal function, donor age, and use of inotropes. For the final analyses, there were 159 patients in group A and 468 in group B. RESULTS: The 1-month, 1-year, 3-year, and 5-year patient survival rates in group A were 95%, 91.6%, 70.1%, and 65.5% compared with 95%, 92%, 70%, and 57.7% in group B, respectively (P = .695). Graft survival rates for group A at the same time points were 91.5%, 81.0%, 71.7%, and 57.4% compared with 91.3%, 81.1%, 61.9%, and 50.4% in group B, respectively (P = .791). In the matched population, patient survival rates at 1 month, 1 year, 3 years, and 5 years were 95%, 83.1%, 77.1%, and 68.8% compared with 94.4%, 81.6%, 72.2%, and 66.8% in group B, respectively (P = .69). Graft survival rates at the same time points were 88.7%, 76.8%, 71.5%, and 63.1% in group A and 90.0%, 77.5%, 70.4%, and 62.5% in group B, respectively (P = .956). CONCLUSIONS: Liver procurement with or without recovery of thoracic organs from donors > 60 years old does not affect liver grafts and recipient outcomes in the short-term or long-term and should be encouraged.

Long-Term Outcome of Live Kidney Donation in South Korea.

BACKGROUND Kidney donors may be at increased risk for end-stage renal disease (ESRD) as well as cardiovascular and all-cause mortality. In particular, data on long-term safety after kidney donation in Asian populations are lacking. We aimed to assess the safety of live kidney donation in Korean donors by using a matched control group. MATERIAL AND METHODS We conducted a retrospective cohort study using a hospital-based database (Asan Medical Center, Seoul, Korea) and a control group from the national health insurance claims database in South Korea. We analyzed the health status of 1608 kidney donors who underwent donation between September 1990 and December 2015, and we compared their characteristics with those of matched 6426 non-donors (1: 4 ratio). We also measured the glomerular filtration rate (GFR) with 5¹Cr EDTA and urinary albumin excretion and assessed the prevalence of hypertension, diabetes, and general health status in 200 volunteer donors. RESULTS Mortality was significantly lower in kidney donors compared with the matched controls (130.2 vs. 185.4 per 100,000 person-years, P=0.02). There was no significant difference in mortality if a donor had hypertension or was a current smoker at the time of donation. There was also no significant difference in ESRD (43.1 vs. 35.2 per 100,000 person-years, P=0.07) between the 2 groups regardless of hypertension and smoking status. Among the 200 donors with measured GFR, 11.5% had GFR values <60 ml/min/1.73 m² at 9.4±5.3 years after donation. Older age (P=0.001) and female sex (P=0.021) were significantly associated with GFR values <60 mL/min/1.73 m². CONCLUSIONS Mortality and ESRD were uncommon in carefully selected kidney donors. However, donors with pre-existing risk factors should be followed up more closely to ensure long-term safety.

The clinical application of microincision vein harvesting of the great saphenous vein in coronary artery bypass grafting.

BACKGROUND: The present study aimed to summarize the clinical application of microincision vein harvesting (MVH) of the great saphenous vein in coronary artery bypass grafting (CABG). METHODS: From July 2014 to October 2017, 160 patients underwent coronary artery bypass grafting. Among them, 80 patients received MVH of the great saphenous vein, and 80 received open venous harvesting (OVH). The results of the sampling operation, complications during hospitalization, and the long-term patency of the great saphenous vein were compared between the two groups. RESULTS: All the patients in both groups received successful operations. The difference in the length of the veins obtained and the injury of the veins was not statistically significant (P > 0.05). The difference in the long-term patency rate of the graft vessels between the two groups was not statistically significant. The in-hospital mortality rate was the same in both groups. The MVH group had noticeable advantages over the OVH group in terms of the vein collection times, the incision length, and the complications experienced when performing the leg incisions (P < 0.01). The time relating to the patients' observed early out-of-bed activity was significantly longer in the MVH group. Furthermore, the patients' hospitalization length was significantly shorter in the MVH group compared to the OVH group (P < 0.05). The MVH group had significant advantages in pain score and patient satisfaction, and this difference was also statistically significant (P < 0.05). CONCLUSIONS: The MVH procedure met the requirements of CABG in vein grafting. When compared with OVH, MVH can significantly reduce leg incision complications and improve patients' overall satisfaction with their hospital experience.

[Wound infections following open heart surgery - review].

Wound infections are common complications after open heart surgery, both in the sternotomy and vein harvest wound. Fortunately, most of these infections are superficial and respond to minor wound debridement and antibiotics, however, 1-3% of patients develop deep sternal wound infection with mediastinis; an infection that can be fatal. Late infections with sternocutaneous fistulas are encountered less often, but also represent a complex surgical problem. The vein harvest site is the most common site for wound infections after cardiac surgery and these infections result in significant patient morbidity and increases health-care costs. This evidence-based review covers etiology, risk factors, prevention and treatment of wound infections following open heart surgery with special focus on advances in treatment, especially negative-pressure wound therapy.

The landscape of international living kidney donation in the United States.

In the United States, kidney donation from international (noncitizen/nonresident) living kidney donors (LKDs) is permitted; however, given the heterogeneity of healthcare systems, concerns remain regarding the international LKD practice and recipient outcomes. We studied a US cohort of 102 315 LKD transplants from 2000-2016, including 2088 international LKDs, as reported to the Organ Procurement and Transplantation Network. International LKDs were more tightly clustered among a small number of centers than domestic LKDs (Gini coefficient 0.76 vs 0.58, P < .001). Compared with domestic LKDs, international LKDs were more often young, male, Hispanic or Asian, and biologically related to their recipient (P < .001). Policy-compliant donor follow-up was substantially lower for international LKDs at 6, 12, and 24 months postnephrectomy (2015 cohort: 45%, 33%, 36% vs 76%, 71%, 70% for domestic LKDs, P < .001). Among international LKDs, Hispanic (aOR = 0.23 0.360.56 , P < .001) and biologically related (aOR = 0.39 0.590.89 , P < .01) donors were more compliant in donor follow-up than white and unrelated donors. Recipients of international living donor kidney transplant (LDKT) had similar graft failure (aHR = 0.78 0.891.02 , P = .1) but lower mortality (aHR = 0.53 0.620.72 , P < .001) compared with the recipients of domestic LDKT after adjusting for recipient, transplant, and donor factors. International LKDs may provide an alternative opportunity for living donation. However, efforts to improve international LKD follow-up and engagement are warranted.

A systematic review of isolated radial artery harvesting as a conduit for lower limb bypass grafting.

BACKGROUND: Whilst autologous vein conduits have been heralded as the first-line approach for patients undergoing lower limb bypass grafting procedures, patients with peripheral arterial occlusive disease may have exhausted venous options given prior use for cardiac surgery, varicose vein surgery, or lower limb revascularization. Hence, the use of a radial artery graft may serve as a viable alternative. METHODS: The systematic review was performed in accordance to the Preferred Reporting Items for Systematic Review and Meta-analysis guidelines. An electronic search was performed on the following databases: Medline (via PubMed); EMBASE; Cochrane library to search for relevant publications. A narrative analysis was conducted. RESULTS: Four publications were included in this review including two retrospective cohort studies, one case series, and one case report, with a total of 43 patients. The most common indication for lower limb bypass grafting was critical limb ischemia, and the radial artery was chosen as graft conduit, most commonly due to the absence of suitable arm or leg vein. There was one case of 30-day mortality and 11 reinterventions. CONCLUSION: Despite the encouraging results, the paucity of high-quality studies prevents the establishment of any firm conclusion. This warrants the need for appropriately conducted randomized controlled trials to compare the radial artery graft to autologous vein grafts and prosthetic grafts for lower limb bypass grafting.

Does No-Touch Technique Better than Conventional or Intermediate Saphenous Vein Harvest Techniques for Coronary Artery Bypass Graft Surgery: a Systematic Review and Meta-analysis.

Saphenous vein (SV) is a common graft being used in coronary artery bypass grafting (CABG). Conventional (CON), intermediate (I), and no-touch (NT) are the most common harvesting techniques of SV for CABG. The aim of this study is to systematically review the NT versus CON and I techniques in harvesting SV for CABG. Twelve databases were searched for randomized controlled trials comparing the CON, I, and NT techniques in harvesting SV for CABG. Twelve reports of six RCTs were included. Our meta-analysis showed that with NT technique, patency rate was significantly higher when compared to I technique up to 18-month follow-up duration. In contrast, this significant difference was not maintained in terms of minor complications of leg wounds with both techniques. The NT has significantly higher patency rate compared to I vein harvesting technique. However, more RCTs are warranted to confirm these results.

Morbidity and mortality of hepatic right lobe living donors: systematic review and perspectives.

BACKGROUND AND AIMS: The main restriction in the development of adult-adult Living Donor Liver Transplantation (LDLT) is the risk of morbidity and mortality for donors, which raises ethical questions. The objectives of this study are to review published studies dealing with morbidity and mortality in LDLT and to identify the proposed management and strategies for preventing donor mortality and morbidity in LDLT. METHODS: The Medline database was searched from 2000 to 2017 using the MeSH terms "liver transplantation" and "morbidity" or "mortality" in combination with keywords "living donor liver transplantation". RESULTS: Among the 382 articles obtained, 43 articles were relevant for morbidity, 15 for mortality and 6 for both morbidity and mortality. Twenty-three papers reported donor deaths. The major cause of death was sepsis (30%). Morbidity ranged from 10% to 78.3% depending on the studies. CONCLUSIONS: The living donors' morbidity and mortality is high, currently representing the main restriction in the development of LDLT. Some promising techniques, such as the donor portal vein flow modulation could lead to the further development of LDLT.

Life-threatening or nearly life-threatening complications in living liver donors.

OBJECTIVE: To determine the relationship between a transplant center's experience and life-threatening or nearly life-threatening complications during living donor hepatectomy (LDH). METHODS: The medical records of 1140 patients who underwent LDH were analyzed. To determine the relationship between life-threatening complications and a transplant center's experience, the following comparisons between LDH cases were performed: first 100 vs subsequent 100; first 100 vs subsequent 1040; first 200 vs subsequent 940; right hepatectomy vs left hepatectomy; and first 5 years of experience vs subsequent 5 years. RESULTS: A total of 36 life-threatening or nearly life-threatening complications developed in 34 of 1140 (2.98%) healthy individuals undergoing LDH. Of these, 5 occurred intraoperatively, 26 within 1 month, and 5 beyond 1 month. The most common complications were biliary problems and postoperative bleeding. None of the donors died at follow-up. One donor underwent deceased donor liver transplantation (DDLT) for severe hepatic failure. Only 2 comparisons were significantly different with regard to life-threatening complications: the first 100 vs the subsequent 1040 (P = .03) and the first 200 vs the subsequent 940 (P = .01). CONCLUSION: This study indicates that the incidence of life-threatening or nearly life-threatening complications are reduced by increased center experience (>200 LDHs).

Endoscopic versus open radial artery harvesting: A meta-analysis of randomized controlled and propensity matched studies.

BACKGROUND: We sought to investigate the impact of radial artery harvesting techniques on clinical outcomes using a meta-analytic approach limited to randomized controlled trials and propensity-matched studies for clinical outcomes, in which graft patency was analyzed. METHODS: A systematic literature review was conducted using PubMed and MEDLINE to identify publications containing comparisons between endoscopic radial artery harvesting (ERAH) and open harvesting (ORAH). Only randomized controlled trials and propensity-matched series were included. Data were extracted and analyzed with RevMan. The primary endpoint was wound complication rate, while secondary endpoints were patency rate, early mortality, and long-term cardiac mortality. RESULTS: Six studies comprising 743 patients were included in the meta-analysis. Of them 324 (43.6%) underwent ERAH and 419 (56.4%) ORAH. ERAH was associated with a lower incidence of wound complications (odds ratio: 0.33, confidence interval 0.14-0.77; p = 0.01). There were no differences in graft patency, and early and long-term cardiac mortality between the two techniques. CONCLUSION: ERAH reduces wound complications and does not affect graft patency, or short- and long-term mortality compared to ORAH.

Outcomes of Solid Organ Transplants After Simultaneous Solid Organ and Vascularized Composite Allograft Procurements: A Nationwide Analysis.

BACKGROUND: Current knowledge of the impact of facial vascularized composite allograft (VCA) procurement on the transplantation outcomes of the concomitantly recovered solid organs is limited to isolated case reports and short-term results. Here we report on a nationwide analysis of facial allograft donor surgery experience and long-term outcomes of the concomitantly recovered solid organs and their recipients. METHODS: There were 10 facial VCA procurements in organ donors between December 2008 and October 2014. We identified the population of subjects who received solid organs from these 10 donors using the Scientific Registry of Transplant Recipients. We retrospectively reviewed operative characteristics, intraoperative parameters, and postoperative outcomes. RESULTS: Six of 10 donor surgeries were performed at outside institutions, all on brain-dead donors. Mean operative duration for facial VCA recovery was 6.9 hours (range, 4-13.25 hours). A total of 36 solid organs were recovered and transplanted into 35 recipients. Survival rates for kidney and liver recipients were 100% and 90% at a median follow-up of 33 and 27.5 months, respectively (range, 6-72 months). Graft survival rates for kidneys and livers were 15 of 16 (94%) and 9 of 10 (90%), respectively. Recipient and graft survival rates for hearts and lungs were 75% (n = 4) and 100% (n = 3) at mean follow-up time of 14.75 and 16 months, respectively. A liver recipient died at 22 months from unknown causes and a heart recipient died of leukemia at 10 months. CONCLUSIONS: Facial VCA procurement does not appear to adversely affect the outcomes of transplant recipients of concomitantly recovered solid organ allografts.

Effect of airplane transport of donor livers on post-liver transplantation survival.

AIM: To evaluate the effect of long haul airplane transport of donor livers on post-transplant outcomes. METHODS: A retrospective cohort study of patients who received a liver transplantation was performed in Perth, Australia from 1992 to 2012. Donor and recipient characteristics information were extracted from Western Australian liver transplantation service database. Patients were followed up for a mean of six years. Patient and graft survival were evaluated and compared between patients who received a local donor liver and those who received an airplane transported donor liver. Predictors of survival were determined by univariate and multivariate analysis using cox regression. RESULTS: One hundred and ninety-three patients received a local donor liver and 93 patients received an airplane transported donor liver. Airplane transported livers had a significantly lower alanine transaminase (mean: 45 U/L vs 84 U/L, P = 0.035), higher donor risk index (mean: 1.88 vs 1.42, P < 0.001) and longer cold ischemic time (CIT) (mean: 10.1 h vs 6.4 h, P < 0.001). There was a weak correlation between CIT and transport distance (r2 = 0.29, P < 0.001). Mean follow up was six years and 93 patients had graft failure. Multivariate analysis found only airplane transport retained significance for graft loss (HR = 1.92, 95%CI: 1.16-3.17). One year graft survival was 0.88 for those with a local liver and was 0.71 for those with an airplane transported liver. One year graft loss was due to primary graft non-function or associated with preservation injury in 20.8% of recipients of an airplane transported liver compared with 4.6% in those with a local liver (P = 0.027). CONCLUSION: Airplane transport of donor livers was independently associated with reduced graft survival following liver transplantation.

Short- and long-term outcomes of every graft recovered during a multi-organ procurement procedure including the intestine.

BACKGROUND: The development of intestinal transplant (Tx) programs introduces thymoglobulin donor treatment as well as an almost complete warm dissection of the abdominal organs to allocate them to different recipients. Our aim is to assess the reproducibility and feasibility of the surgical technique of multi-organ procurement with the use of thymoglobulin donor pre-treatment and report the short- and long-term outcomes of every graft harvested as part of multi-organ procurement (MTOp), including the intestine. METHODS: Data were collected of all organs harvested from MTOp, including the intestines allocated to our center from March 2006 to July 2011. Data from 92 recipients and 116 organs procured from 29 MTOp were analyzed. Twelve hearts, 2 lungs, and 1 cardio-pulmonary block were transplanted; primary graft dysfunction developed in 4 of the 12 hearts and in the cardio-pulmonary block. RESULTS: The survival rate was 75% and 100% for hearts and lungs, respectively. Nineteen livers, 9 kidney-pancreas, 19 kidneys, and 29 intestines were transplanted. Delayed graft function (DGF) of the pancreas developed in 3 of 9 kidney-pancreas, and the other 3 exhibited DGF of the kidney; 4 of 19 Tx kidneys had DGF. The survival was 84%, 78%, 95%, and 65.5% for livers, kidney-pancreas, kidneys, and intestines, respectively. CONCLUSIONS: Organs procured during MTOp including the intestine can be safely used, increasing organ availability and transplant applicability without compromising allocation, quality, and long-term results of the non-intestinal-procured organs.

Open versus endoscopic great saphenous vein harvest for lower extremity revascularization of critical limb ischemia.

OBJECTIVE: This study determined wound complication rates, intervention rates, failure mechanisms, patency, limb salvage, and overall survival after lower extremity revascularization using open vein harvest (OVH) vs endoscopic vein harvest (EVH) for critical limb ischemia. METHODS: A single-institution review was conducted of consecutive patients who underwent infrainguinal bypass with a single-segment reversed great saphenous vein between 2005 and 2012. RESULTS: A total of 251 patients with critical limb ischemia underwent revascularization, comprising 153 with OVH and 98 with EVH. The OVH group had a lower mean body mass index (26.7 vs 29.9 kg/m(2); P = .001). There were no other differences in demographics, comorbidities, medications, smoking, or in the proximal or distal anastomotic site. Median operative times were 249 minutes (OVH) vs 316 minutes (EVH; P < .001). Median postoperative hospital length of stay was 7 days (OVH) vs 5 days (EVH; P < .001). Median follow-up was 295 days (OVH) vs 313 days (EVH; P = .416). During follow-up, 21 OVH grafts (14%) and 27 EVH grafts (28%) underwent an intervention (P = .048). There were a similar number of surgical interventions: 50% (OVH) vs 61% (EVH; P = .449). Failed grafts had a mean of 1.2 stenoses per graft, regardless of harvest method. Median stenosis length was 2.1 cm (OVH) vs 2.5 cm (EVH; P = .402). At 1 and 3 years, the primary patency was 71% and 52% (OVH) vs 58% and 41% (EVH; P = .010), and secondary patency was 88% and 71% (OVH) vs 88% and 64% (EVH; P = .266). A secondary patency Cox proportional hazard model showed EVH had a hazard ratio of 2.93 (95% confidence interval, 1.03-8.33; P = .044). Overall and harvest-related wound complications were 44% and 29% (OVH) vs 37% and 12% (EVH; P = .226 and P = .002). At 5 years, amputation-free survival was 48% (OVH) vs 54% (EVH; P = .305), and limb salvage was 89% (OVH) and 91% (EVH; P = .615). CONCLUSIONS: OVH and EVH have similar failure mechanisms, limb salvage, amputation-free survival, and overall survival. EVH is associated with impaired patency, increased need for intervention, longer operative times, shorter hospital stays, and decreased vein harvest site wound complications. OVH of the great saphenous vein may provide optimal patency but was not necessarily associated with better patient-centered outcomes. Similar limb salvage rates and amputation-free survival may justify the use of EVH, despite inferior patency, to capture shorter hospital stays and decreased wound complications.

Long-term risks for kidney donors.

Previous studies have suggested that living kidney donors maintain long-term renal function and experience no increase in cardiovascular or all-cause mortality. However, most analyses have included control groups less healthy than the living donor population and have had relatively short follow-up periods. Here we compared long-term renal function and cardiovascular and all-cause mortality in living kidney donors compared with a control group of individuals who would have been eligible for donation. All-cause mortality, cardiovascular mortality, and end-stage renal disease (ESRD) was identified in 1901 individuals who donated a kidney during 1963 through 2007 with a median follow-up of 15.1 years. A control group of 32,621 potentially eligible kidney donors was selected, with a median follow-up of 24.9 years. Hazard ratio for all-cause death was significantly increased to 1.30 (95% confidence interval 1.11-1.52) for donors compared with controls. There was a significant corresponding increase in cardiovascular death to 1.40 (1.03-1.91), while the risk of ESRD was greatly and significantly increased to 11.38 (4.37-29.6). The overall incidence of ESRD among donors was 302 cases per million and might have been influenced by hereditary factors. Immunological renal disease was the cause of ESRD in the donors. Thus, kidney donors are at increased long-term risk for ESRD, cardiovascular, and all-cause mortality compared with a control group of non-donors who would have been eligible for donation.

Shipping impact on liver graft: results of liver transplantation program in Andalusia.

Liver transplantation for the treatment of patients with advanced liver disease is organized according to a waiting list taking into account different criteria. The agreed distribution model in Andalusia assumes that sometimes an organ is extracted in a different province to that where the implantation is to be performed (shipping), which, therefore, increases the graft ischemic time. The aim of the present study was to determine whether transportation of the organ and being harvested by a team other than the implantation team have a negative effect on final patient survival.

Analysis of mortality in low-risk patients undergoing coronary artery bypass grafting.

AIM: The aims of this study were to determine the early mortality rate in low-risk coronary artery bypass graft (CABG) patients and examine the causes of death, to identify problems that could be avoided in future surgeries. METHODS: All low-risk patients (EuroSCORE ≤ 2) who died after CABG were included. Their peri-operative information was meticulously studied by internal and independent external reviewers to identify causes of death, which were classified as: cardiac or non-cardiac; and a further division as: (1) non-preventable, (2) preventable (technical error), and (3) preventable (system error). RESULTS: Early mortality was 0.93% (24/2570). Eleven patients (45.8%) were classified as preventable deaths. In six of them the main problem was identified as graft thrombosis, which was secondary to a technical error of either the harvesting or anastomosis of the left internal mammarian artery. There were also five system errors identified as delays in the treatment of an identified and potentially reversible problem. CONCLUSION: Correction of technical and system errors, such as harvesting of the left internal mammarian artery, haemostasis during surgery, and establishing standard protocols for the transfer of patients from ward to intensive care units will eventually lead to improvement in both the quality of care and patient outcomes, even in low-risk groups.

Endoscopic vein harvesting is influenced by patient-related risk factors and may be of specific benefit in female patients.

OBJECTIVES: The standard of care regarding endoscopic vein harvesting (EVH) is still inhomogeneous across Europe. The current study aimed at elucidating patient-related factors favouring its application and procedure-related outcome in a tertiary care centre. METHODS: All patients who underwent coronary artery bypass grafting with or without concomitant valve procedures between 2008 and 2011 were included. Emergency surgery and all arterial revascularization patients were excluded. RESULTS: A total of 262 endoscopically harvested patients and 623 open vein harvested patients were included. Mortality, perfusion time and cross-clamp time were not significantly different. Peripheral artery disease predisposed open vein harvesting (odds ratio [OR] 1.9; P = 0.001); diabetes and a higher number of diseased coronary vessels favoured EVH (OR 0.6; P = 0.003 and 0.002). Further, the number of bypass grafts was significantly increased in the endoscopic group, but these patients required less periprocedural blood transfusions (1.4 ± 1.8 vs 1.8 ± 3.0; P = 0.035). Minor wound healing complications were more common in the open group (10.3 vs 3.8%; P = 0.001). Severe complications in the leg requiring surgical revision occured in 2.4% of open vein harvested patients compared with 1.1% for endoscopic patients (P = ns). After a multivariate regression analysis, only female gender remained as a significant risk factor for impaired wound healing (OR 2.4; P = 0.001), whereas EVH reduced the risk of wound-healing complications (OR 0.4; P = 0.008). CONCLUSIONS: EVH dramatically reduced postoperative would healing complications. Women were more likely to develop mild and severe leg wound complications. Therefore, women may benefit even more from EVH. In general, the favourable outcomes of EVH should result in a more widespread use of this technology in men and women.