[HSF] AATS

Sun May 18 12:16:10 EDT 2008

No way am I saying that U.S.A. C.A.D. is better or worse than elsewhere -
just different.  Clearly the patients that Prasanna sees for CABG are
probably different than what we see and the management of those problems.
All I know is I see a lot of very fat people with big ugly legs, crappy
veins to begin with, crappy targets, lots of comorbidities (like the rest of
us) - I am sure many of these people would have been turned down for surgery
years ago, but now we operate on them - and as a result, I am amazed that
some of these grafts stay open for a month.

and dont say total arterial revasc. is the answer.

-michael

On 5/18/08, Prasanna Simha M <prasannasimha at gmail.com> wrote:
>
> I can confirm Ani's statement. The IMA's of Germans looked like hose pipes
> compared to our patients and coronaries are very much smaller on the
> average
> in Indian patients.Indian patients also get disease earlier, have diabetes
> more often (many are non smokers too).
> Prasanna
>
> On Sun, May 18, 2008 at 6:56 PM, Ani Anyanwu <anianyanwu at hotmail.com>
> wrote:
>
> > Don, Hal, Michael et al
> >
> > We are influenced by preconceptions - that is the essence of decision
> > making. What differs is what that preconception is and how much weight we
> > add to it. I must agree that my preconception here is that all veins are
> bad
> > so that is my bias.
> >
> > My suggestion of low vein graft patency is not however a preconception
> but
> > based on fact. If you were to study data from the 1980s and 1990s, most
> > studies you will come across found a vein graft patency of 85 to 90%.
> > However, if you look at contemporary multicentre US studies published in
> > last 5 years that included graft patency as an outcome, the story is
> > different with patency of 70%.
> >
> > Hal - you may *think* your vein graft patency has remained constant over
> > the years, but I seriously doubt that is the case and that if you
> performed
> > angiograms you would surprised at how many of your patients are walking
> > around, many asymptomatic, with blocked grafts. Before I go into any
> data,
> > think back Hal on those patients you operate on (done elsewhere or by
> you)
> > for ischemic MR following previous CABG - have you not come across
> several
> > with grafts down to circumflex or RCA within a year or two of surgery? We
> > certainly have.
> >
> > For anyone who wants data, a good starting point is the recent analysis
> > from Prevent IV trial published recently in annals. Magee et al Annals of
> > Thoracic SurgeryVolume 85, Issue 2, February 2008, Pages 494-500. This
> > included data from over 3000 CABGs done 2002-3 in 107 US centers so I
> find
> > it hard to believe this will not be generalizable to the most of the US.
> > About 2,000 (over 4,000) had one-year angiograms as per study protocol.
> The
> > results? A stunning 46% of patients on-pump and 45% off-pump had at least
> > one vein graft stenosed within a year of surgery. Analysis by graft,
> rather
> > than patient, showed 25% of veins, both on or off-pump, were stenosed
> within
> > a year of surgery (IMA failure rate 8%). The authors looked for
> predictors
> > of vein graft stenosis and guess what? Endoscopic harvest was a predictor
> of
> > early failure of vein graft, more so with off-pump (odds-ratio 1.8) than
> > on-pump (odss ratio 1.3). This is very believable and I suspect is the
> case
> > in all our centers.
> >
> > Michael - while quality of targets may have a role, do not for one second
> > think US patients have the worst quality in terms of conduit or distals.
> > Speak to Prasanna and he might give you a different perspective. Indeed
> one
> > of the things that struck me on moving from the UK to the US was the
> > abundance of good quality distals to graft here, as opposed to the tiny
> > indian vessels typical of west london. I doubt one could explain
> decreasing
> > vein graft patency on quality of conduits and targets alone.
> >
> > Biologically too there are reasons to believe endoscopic harvest is
> > inferior and that initial intimal disruption does predispose to vein
> graft
> > thrombosis. Unfortunately the early trials of endoscopic harvest were
> > introduced without trials that included the true outcome (angio patency)
> so
> > we may never know for sure.
> >
> > Don I hear you regarding anaortic grafts. I operated 2 days ago OBCAB*3
> on
> > an 80 year old with 90% Left main stenosis on corticosteroids for
> rheumatoid
> > arthritis - would you do bilateral IMA OPCAB in him? Odd I placed a vein
> > graft and quoted you as justification because I thought you taught me not
> to
> > rely on a single IMA inflow for a tight left main? Or have you ditched
> the
> > vein entirely
> >
> > Ani
> >
> >
> >
> >
> >
> >
> > > From: donross at bigpond.com> Subject: Re: [HSF] AATS> Date: Sun, 18 May
> > 2008 14:15:12 +1000> To: OpenHeart-L at lists.hsforum.com> CC: > > I agree,
> > Hal.> Ani has shown himself to be influenced by preconceived ideas like
> the
> > > rest of us.> Just because he has seen an odd SVG acutely occluded the
> > cause must > be traumatic harvest. Ani, welcome to anecdote land!> SVGs
> > start to fall off the perch at ten years so why is a good eight > year
> > patency so special?> I can't understand why anyone would want to use them
> > for a > significant stenosis anyway, but that is just my unsubstantiated
> > view.> So, if you need a CABG Ani, Martin Misfeld can now fix you up with
> an
> > > anaortic arterial opcab.> Don> > On 18/05/2008, at 8:24 AM,
> > Hgrmd at aol.com wrote:> > > Ani,> > For such an analytical fellow, I'm
> > surprised at the conclusions > > you've> > drawn about endoscopically
> > harvested veins. As far as I know, > > there's never> > been a head to
> head
> > study comparing open versus closed harvesting > > of the veins> > in
> regards
> > to patency. I have the clinical experience of having > > done CABG's> >
> for
> > at least 10 to 12 years of open veins and around 6-8 years of > >
> > endoveins.> > I certainly haven't perceived a difference in patency. In
> > other > > words, I> > can't tell that a lot more cases are coming to cath
> > with closed > > grafts as> > compared to open harvested veins. Indeed,
> there
> > may be a > > difference, but it has> > been imperceptible to us.> > Our
> > P.A.'s are extremely skilled at rapidly delivering an > > endoscopic
> vein> >
> > through a 2 cm stab wound (usually no incision in groin at all) > > that
> > rarely> > has avulsed branches requiring repair with 7-0. Quite frankly,
> I >
> > > can't tell> > the difference in appearance between open and closed
> > harvested > > veins. Your> > point about dilating with blood and
> papaverine
> > is well taken. > > That preparation> > may be less stressful to the
> vein's
> > endothelium. However, in the > > end, no> > matter how you prep them, the
> > veins die no matter what you do to > > them. That's> > why it is
> imperative
> > that we spend more time harvesting arterial > > conduits and> > not
> letting
> > concerns about time supervene.> >> > Hal> >> >> >> >
> **************Wondering
> > what's for Dinner Tonight? Get new twists > > on family> > favorites at
> AOL
> > Food.> > (http://food.aol.com/dinner-tonight?NCID=aolfod00030000000001)>
> >
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> --
> Prasanna Simha M
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