European Heart Journal Advance Access originally published online on April 19, 2007
European Heart Journal 2007 28(10):1265; doi:10.1093/eurheartj/ehm061
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Safety and efficacy concerns regarding elective coronary artery surgery in patients with prior coronary stents
Department of Cardiothoracic Surgery
Mount Sinai Hospital
New York, USA
Department of Cardiothoracic Surgery
St Mary's Hospital NHS Trust
London, UK
Department of Surgery
Imperial College London
London, UK
Department of Cardiology
Royal Brompton and Harefield NHS Trust
London, UK
Department of Cardiac Medicine
Royal National Heart and Lung Institute
Imperial College London
London, UK
Department of Cardiothoracic Surgery
Royal Brompton and Harefield NHS Trust
London, UK
Tel: +1 207 617 7261 Fax: +1 207 735 7449 E-mail address: chikwe{at}gmail.com
Recent data have raised concerns about the safety of drug-eluting stents.1 Stents are used in over 70% of percutaneous coronary interventions (PCIs) because they reduce the risk of acute major complications of PCI and long-term restenosis. Despite the low procedural morbidity afforded by stenting, coronary artery bypass graft (CABG) surgery offers significantly greater freedom from angina, repeat revascularization, myocardial infarction, stroke, and death in the treatment of multivessel ischaemic heart disease.2 Stenting has, however, become first line treatment in increasing numbers of patients that are surgical candidates. Many of these patients eventually require coronary artery surgery: in the UK over 5% of patients undergoing CABG have a history of previous PCI.3
Surgeons suspect that prior stenting may have a negative impact on outcome after elective coronary surgery for several reasons. In-stent restenosis is associated with a higher risk of early venous graft failure.4 The presence of coronary stents means that grafts are anastomozed more distally, and endarterectomy may be required. Anti-platelet medication adds to increased morbidity and potential mortality, resulting from excess post-operative bleeding, and stopping this medication has been associated with stent thrombosis in off-pump CABG patients.
Pathophysiological processes associated with stenting may adversely affect surgical outcomes.5 Stenting causes prolonged endothelial dysfunction and local and systemic inflammatory syndromes, more profound than after balloon angioplasty, because of persistent radial mechanical strain, vessel wall rupture, and the presence of an intravascular foreign body. The local inflammatory response is stimulated by disruption of the coronary endothelium, and is characterized by a florid macrophage response that does not occur after balloon angioplasty. Six months after PCI endothelium-dependent vasomotor function has been shown to be more abnormal in stented coronaries compared with those undergoing balloon angioplasty. Two years after stenting a chronic inflammatory response surrounds the stent, characterized by non-occlusive mural thrombi. Drug-eluting stents induce this inflammatory response, most prominently at the edges of the stent, but also where endothelialization is delayed leaving the intima exposed to metal within the stent. Troponin release is higher in patients receiving stents compared with those undergoing angioplasty alone, and is associated with increased peri-procedural mortality, rates of myocardial infarction, and repeat revascularization.
UK data suggest that patients with previous PCI had higher mortality after CABG than patients without prior PCI, even when patients undergoing salvage CABG for failed PCI are excluded from the analysis.3 Unfortunately, the timing of PCI in 90% of the remaining patients, and the proportion of PCIs that involve stenting are unknown. We propose a prospective longitudinal multi-centre study to evaluate the effect of previous stenting on clinical outcomes after elective coronary surgery, using peak oxygen consumption (VO2) as the primary outcome. For 80% power to detect a difference of 1.5 mL/kg/min in VO2 at the 5% two-tailed significance level, we would need 176 patients in each group. Secondary outcome measures include major adverse clinical events, quality-of-life adjusted years, and perfusion imaging with a 5-year follow-up.
References
- Wijns WC, Krucoff MW. Increased mortality after implantation of first generation drug-eluting stents: seeing the smoke, where is the fire? Eur Heart J (2006) 27:2737–2739.
[Free Full Text] - Guyton RA. Coronary artery bypass is superior to drug-eluting stents in multivessel coronary artery disease. Ann Thorac Surg (2006) 81:1949–1957.
[Abstract/Free Full Text] - Keogh B. The Society of Cardiothoracic Surgeons of Great Britain and Ireland Fifth National Adult Cardiac Surgical Database Report—DRK, ed. (2003) Henley-on-Thames: Dendrite Clinical Systems. 352.
- Gaudino M, Luciani N, Glieca F, Cellini C, Pragliola C, Trani C, Burzotta F, Schiavoni G, Anselmi A, Possati G. Patients with in-stent restenosis have an increased risk of mid-term venous graft failure. Ann Thorac Surg (2006) 82:805.
[Free Full Text] - Gomes WJ, Buffolo E. Coronary stenting and inflammation: implications for further surgical and medical treatment. Ann Thorac Surg (2006) 81:1918–1925.
[Abstract/Free Full Text]
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  C. Rao, R. D. L. Stanbridge, J. Chikwe, J. Pepper, P. Skapinakis, O. Aziz, A. Darzi, and T. Athanasiou Does Previous Percutaneous Coronary Stenting Compromise the Long-Term Efficacy of Subsequent Coronary Artery Bypass Surgery? A Microsimulation Study Ann. Thorac. Surg., February 1, 2008; 85(2): 501 - 507. [Abstract] [Full Text] [PDF]
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