Cardiology Research and Practice

Cardiology Research and Practice / 2019 / Article
Special Issue

Mechanisms, Diagnosis, and Treatment on Aging-Related Heart and Coronary Artery Diseases

View this Special Issue

Research Article | Open Access

Volume 2019 |Article ID 6857232 | 8 pages | https://doi.org/10.1155/2019/6857232

Predictors for New Native-Vessel Occlusion in Patients with Prior Coronary Bypass Surgery: A Single-Center Retrospective Research

Academic Editor: Erhe Gao
Received17 Jun 2019
Accepted30 Aug 2019
Published23 Sep 2019

Abstract

Objectives. Chronic total occlusion (CTO) is prevalent in patients with prior coronary artery bypass grafting (CABG). However, data available concerning the prevalence of new-onset CTO of native vessels in patients with prior CABG is limited. Therefore, the objective of the study is to determine predictors for new native-vessel occlusion in patients with prior coronary bypass surgery. Methods. 354 patients with prior CABG receiving follow-up angiography are selected and analyzed in the present study, with clinical and angiographic variables being analyzed by logistic regression to determine the predictors of new native-vessel occlusion. Results. The overall new occlusion rate was 35.59%, with multiple CTOs (42.06%) being the most prevalent (LAD 24.60% and RCA 18.25%, respectively). Additionally, current smoking (OR: 2.67; 95% CI: 2.60 to 2.74; ), reduced ejection fraction (OR: 1.76; 95% CI: 1.04 to 2.97; ), severe stenosis (OR: 3.65; 95% CI: 2.55 to 5.24; ), and diabetes mellitus (OR: 1.86; 95% CI: 1.34 to 2.97; ) serve as the independent predictors for new native-vessel occlusion. Conclusion. As to high incidence of postoperative CTO, appropriate revascularization strategies and postoperative management should be taken into careful consideration.

1. Introduction

Coronary artery disease (CAD), one of the biggest killers, is responsible for approximately 9 million deaths in 2016 [1]. For most CAD patients, they must receive either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). In some cases, they must receive the combined treatment of CABG and PCI. Clinically, patients treated by CABG therapy tend to experience more complicated conditions and a higher level of severe coronary artery stenosis because they are selected from the total CAD population based on the complexity of coronary heart disease [2]. The mortality and morbidity advantages of CABG in patients with diabetes have been demonstrated by many research studies [3, 4]. A long-term follow-up study showed that CABG shows a superiority in patients with diabetes and multivessel disease over PCI and medication [5]. Similarly, traditional theory holds that CABG is the gold standard in the treatment of the left main coronary artery (LMCA) disease [6].

Despite survival benefits of successful revascularization being firmly established, bypass grafting has several disadvantages. Meta-analysis has demonstrated that patients treated with CABG will experience higher risks in a cerebrovascular accident [7]. Another disadvantage of CABG, as shown by some research studies, is the progression of primary lesions [8, 9]. It was reported in one study that the prevalence of chronic total occlusion (CTO) among CAD patients with and without prior CABG was 89% and 31%, respectively [10], along with a clinical observation of significant increase of CTO. Another study reported that a bypass graft was associated with new native-vessel disease progression [11]. More importantly, relevant study has shown that native coronary artery CTOs are associated with adverse long-term outcomes [12].

Available evidence has shown that CABG is associated with a high incidence of CTOs, and this may lead to poor prognosis of patients [2].

However, few data regarding the prevalence of new-onset CTOs in native arteries are available, with the relevant risk factors of new-onset CTOs remaining unclear. At present, there is a lack of relevant research on Chinese people, who are the majority of East Asians. Our center, which has the largest number of CABG in China, performs thousands of CABG every year. Therefore, we design this retrospective study to determine incidence and identify independent predictors for postoperative new occlusion in the native vessel.

2. Methods

2.1. Study Population

This study, following the Helsinki Declaration, was approved by the institutional review board and exempted from written informed consent.

All patients were identified from a retrospective review of the institution’s database recording detailed information including baseline characteristics, clinical presentation, angiographic data, and medical and surgical treatment. From Jan 2008 to Jan 2017, a total of 5813 patients undergoing CABG were enrolled in the retrospective single-center study, with the following exclusions (1) insufficient data; (2) patients undergoing concomitant valvular or aortic surgery; (3) patients undergoing emergent or urgent surgery; (4) patients with renal failure requiring dialysis; (5) pregnancy; (6) patients with age less than 18 or more than 75 years; (7) without or follow-up angiography less than 1 or more than 5 years; (8) target lesion revascularization within 1 year; and (9) myocardial infarction in recent 3 months. Follow-up angiography analysis was performed after excluding the subjects above.

2.2. Coronary Angiography

A baseline angiography was required for patients within 4 weeks before CABG, and one to five year angiographic follow-up was received for them, along with the performing of diagnostic coronary angiography by experienced and credentialed operators after obtaining written informed consent of angiography. The choice of artery access site (radial or femoral) was made by the interventional physician. Procedures were performed by inserting a 6 or 7 Fr guiding catheter under intravenous administration of 3000–5000 IU heparin, with a requirement of injection of each study vessel with at least 2 orthogonal views. Preoperative coronary angiograms were reviewed by two interventional cardiologists blinded to patient outcomes to determine the presence, location, and length of coronary lesions, along with the conduction of postoperative angiograms by two cardiologists blinded to the baseline interpretation. The major epicardial arteries and major branches (≥2.0 mm in diameter) were assessed, the estimation of which was based on the first onset of angina, prior history of myocardial infarction in the target vessel territory, or comparison with a prior angiogram.

2.3. Surgical Procedures and Perioperative Management

Operative reports available were reviewed. SYNTAX (Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery) score was calculated with each pre-CABG coronary angiogram as the criterion of surgical intervention. After evaluating the severity of coronary lesions, the procedure and selection of grafting were based on the patient’s clinical presentation, angiographic features, and conduit availability. Pharmacologic treatment obtained from electronic medical records was determined by cardiovascular comorbidities. Patients received aspirin on the first postoperative day, along with indefinite continuation of low-dose aspirin and statin treatment.

2.4. Study Outcomes

Qualified readers evaluated angiograms for initial severity of stenosis, morphologic features, location, and occurrence of lesion progression or occlusion using a side-by-side film review, with the primary study outcome as the occurrence of total occlusion in native coronary arteries.

2.5. Definition

CTO is defined as a coronary obstruction with thrombolysis in zero-grade flow of myocardial infarction (TIMI) persisting for at least 3 months. Multivessel coronary disease (MVD) is defined as lesions occurring in the left main coronary artery and or over 50% stenosis of the diameter occurring in at least two main epicardial arteries or the primary branches. Progression was defined as further definite narrowing by 25% [13].

2.6. Statistical Analysis

Results for continuous variables were presented as mean ± standard deviation, whereas discrete parameters are expressed as the counts and percentages. Continuous parameters were compared with one-way ANOVA, along with the comparison of discrete data using the Mann–Whitney U test. The odd ratio (OR) with 95% CI from a logistic regression model was applied to estimate the risks of particular variables on occlusion of the native vessel. All analyses were performed with the Statistical Package for the Social Science (SPSS) software (version 19; Chicago, IL, USA), which were regarded as statistically significant when the critical value .

3. Results

3.1. Patient Characteristics

As shown in Figure 1, of 5813 patients undergoing CABG, a total of 354 patients with 938 vessels met the inclusion criteria and were analyzed subsequently, with baseline characteristics of those 354 patients who underwent follow-up angiography being demonstrated in Table 1. Diabetes mellitus (38.16% vs. 49.20%, ), current smoking (16.67% vs. 47.62%, ), and lower ejection fraction (59.28% ± 0.07% vs. 56.89% ± 0.1%, ) are more common for patients who suffered postoperative new total occlusion of native arteries (new CTO group) than those without new vessel occlusion during the particular follow-up periods (no new CTO group). In addition, most patients were men with multiple cardiovascular risk factors including hypertension and hypercholesterolemia, however without significant difference between the two groups. Of particular concern were overweight (BMI ≥ 24.0 kg/m2) taking up for in nearly 90% of the patients and obesity (BMI ≥ 28.0 kg/m2) accounting for approximately one-third of them according to the post-CABG BMI. However, there was no significant difference in the proportion stratified by the BMI category.


VariablesAll (N = 354)No new CTO (n = 228)New CTO (n = 126) value

Age (yrs.)61.71 ± 9.4762.75 ± 7.9361.80 ± 8.380.492
 <65 (%)212 (59.89%)136 (59.64%)76 (60.31%)
 65 to <75 (%)142 (40.11%)92 (40.35%)50 (39.68%)
Sex0.694
 Male264 (74.58%)169 (74.12%)95 (75.40%)
 Female90 (25.42%)59 (25.88%)31 (24.60%)
BMI (kg/m2)26.57 ± 3.8827.06 ± 2.9726.59 ± 3.480.397
 ≤18.4000
 18.5–23.954 (15.25%)30 (13.16%)24 (19.05%)
 24.0–27.9186 (52.54%)125 (54.82%)61 (48.41%)
 ≥28112 (31.64%)72 (31.58%)40 (31.75%)
Hypertension248 (70.06%)158 (69.30%)90 (71.43%)0.532
Hypercholesterolemia206 (58.19%)129 (56.59%)77 (61.11%)0.217
Diabetes mellitus140 (39.55%)87 (38.16%)62 (49.20%)0.044
 Diet-controlled10 (7.14%)6 (6.90%)4 (6.45%)
 Tablet-controlled64 (45.71%)39 (44.82%)30 (48.39%)
 Insulin treatment66 (47.15%)42 (48.28%)28 (45.16%)
Smoker
 Never112 (31.64%)79 (34.64%)33 (26.19%)
 Former144 (40.68%)111 (48.68%)33 (26.19%)
 Current98 (27.68%)38 (16.67%)60 (47.62%)
Prior MI90 (25.42%)58 (25.44%)32 (25.40%)0.990
Prior PCI68 (19.21%)47 (20.61%)21 (16.67%)0.178
Prior cardiac surgery2 (0.57%)2 (0.88%)0 (0.00%)0.525
Prior heart failure36 (10.17%)21 (9.21%)15 (11.91%)0.237
Peripheral vascular disease74 (20.90%)45 (19.74%)29 (23.02%)0.279
70 (19.77%)46 (20.18%)24 (19.05%)0.704
Cerebrovascular disease24 (6.78%)14 (6.14%)10 (7.94%)0.337
Family history of CAD80 (22.60%)52 (22.81%)28 (22.22%)0.345
Atrial fibrillation/flutter36 (10.17%)18 (7.90%)18 (14.29%)0.480
0.104
Presentation of ACS12 (3.39%)8 (3.51%)4 (3.17%)
CCS class of angina218 (61.58%)145 (63.60%)73 (57.94%)
 Grade 1110 (31.07%)68 (29.82%)42 (33.33%)
 Grade 214 (3.69%)8 (3.51%)6 (2.78%)
 Grade 358.43 ± 0.08%59.28% ± 0.07%56.89% ± 0.1%0.010
 Grade 411 (3.10%)3 (1.32%)8 (6.35%)
Ejection fraction (%)31 (8.76%)14 (6.14%)17 (13.49%)
 ≤40%312 (88.14%)211 (92.54%)101 (80.16%)
 40%–50%0.404
 ≥50%150 (42.37%)101 (44.30%)49 (38.89%)
Left ventricular grade164 (46.33%)100 (43.86%)64 (50.79%)
 Class I38 (10.73%)26 (11.40%)12 (9.52%)
 Class II2 (0.57%)2 (0.88%)0 (0.00%)
 Class III77.6 ± 20.4773.93 ± 17.9479.09 ± 21.300.079
 Class IV87.2 ± 22.4990.5 ± 20.1185.89 ± 23.330.172
Creatinine (μmol/l)38 (10.73%)51.19 ± 7.0346.46 ± 11.850.484
GFR (ml/min/1.73 m2)2.47 ± 4.273.01 ± 4.402.26 ± 4.220.700
GFR < 60 ml/min/1.73 m2
Hs-CRP (mg/L)

3.2. Procedural and Angiographic Characteristics

Procedural and lesion characteristics in both groups are presented in Table 2, finding that 35.04% (124 of all cases) patients with at least one CTO had been treated with CABG, and CTOs occurred in 70.62% (250) of cases after CABG (Table 3). Of these, 35.59% (126) suffered from postoperative new total occlusion of native arteries, with preoperative CTO being more likely presented in RCA (14.97%) and most patients having a single postoperative CTO (74.4%), predominantly in the RCA (30.4%). As shown in Table 3, total CTO distribution was as follows: RCA (21.47%); LAD (19.49%); LCX (10.73%); and multiple distributions (18.08%). The overall new occlusion rate was 35.59%, and multiple CTO (42.06%) was most prevalent, followed by LAD (24.60%) and RCA (18.25%). New CTO distribution is summarized in Table 4, showing that among the new CTO patients, the initial lesion was more severe (stenosis ≥ 70%, LAD 90.48% vs. 76.32%; LCX 70.63% vs. 53.95%; RCA 77.78% vs. 57.89%, ). There was no significant difference in the coronary bypass grafting profiles. The mean follow-up was 37 months, without reaching statistical significance compared to the no new CTO (37.52 ± 17.39 vs. 32.65 ± 15.84, ). Although not statistically significant, we found a relatively low proportion of free of symptom and a slightly high revascularization rate (predominantly incomplete revascularization) in patients with new CTO. Moreover, disease progression in native vessels is shown in Table 5 as follows: LM (2.38%); LAD (26.60%); LCX (13.70%); and RCA (18.25%).


VariablesNo new CTO (n = 228)New CTO (n = 126) value

Preoperative angiogram
 Vessel stenosis at baseline0.001
  Moderate (40%–69%)
   LAD18 (7.89%)7 (5.56%)
   LCX18 (7.89%)6 (4.76%)
   RCA22 (9.65%)9 (7.14%)
  Severe (≥70%)
   LAD174 (76.32%)114 (90.48%)
   LCX123 (53.95%)89 (70.63%)
   RCA132 (57.89%)98 (77.78%)
  Coronary lesion category0.775
   Single-vessel disease18 (7.89%)8 (6.35%)
   Double-vessel disease62 (27.19%)31 (24.60%)
   Triple-vessel disease116 (64.47%)87 (69.05%)
  Left main involvement102 (44.74%)48 (38.10%)0.508
Total no. of patients with ≥1 CTO83 (36.40%)44 (34.92%)0.416
  Total of CTO vessel0.984
   LAD23 (10.09%)15 (11.91%)
   LCX15 (6.58%)7 (5.56%)
   RCA35 (15.35%)18 (14.29%)
   Multivessel8 (3.51%)3 (2.38%)
  Mean no. of bypass grafts3.0 ± 0.633.06 ± 0.750.599
  Types of graft0.460
   Internal mammary artery183 (80.26%)107 (84.92%)
   Saphenous vein2.22 ± 0.642.25 ± 0.73
  Graft patency0.522
   LIMA190 (83.33%)109 (86. 51%)
   SVG-D195 (85.53%)96 (76.19%)
   SVG-LCX/OM185 (81.14%)93 (73.81%)
   SVG-RCA/PDA163 (71.49%)84 (66.67%)
  Postoperative medication0.902
   Aspirin215 (94.30%)118 (93.65%)
   Statin185 (81.14%)98 (77.78%)
  Follow-up time (Mths)32.65 ± 15.8437.52 ± 17.390.175
  Free of symptom123 (53.94%)56 (44.44%)0.087
  Incomplete revascularization112 (49.12%)70 (55.56%)0.125


VesselPre-CABG (n = 12 35.04%)Post-CABG (n = 250 70.62%)

LM0 (0%)3 (0.85%)
LAD38 (10.73%)69 (19.47%)
LCX22 (6.22%)38 (10.73%)
RCA53 (14.97%)76 (21.47%)
Multi vessels11 (3.12%)64 (18.08%)


VesselNew CTO in native vessels (n = 126)

LM3 (2.38%)
LAD31 (24.6%)
LCX16 (12.7%)
RCA23 (18.25%)
Multivessels53 (42.06%)


VesselOverall (N = 938)No new CTO (n = 586)New CTO (n = 352)

LM22 (2.38%)12 (2%)3 (0.85%)
LAD250 (26.6%)42 (7.11%)69 (19.49%)
LCX129 (13.7%)17 (2.97%)38 (10.73%)
RCA171 (18.25%)37 (6.53%)40 (11.47%)

3.3. Predictors for New Native Coronary Artery Occlusion

Univariate and multivariate analyses were performed to determine the predictors of new native coronary artery occlusion (Table 6). Current smoking (OR: 2.67; 95% CI: 2.60 to 2.74; ), reduced ejection fraction (OR: 1.76; 95% CI: 1.04 to 2.97; ), diabetes mellitus (OR: 1.86; 95% CI: 1.34 to 2.97; ), and initial stenosis ≥ 70%(OR: 3.65; 95% CI: 2.55 to 5.24; ) were associated with an increased risk of new native-vessel occlusion, apart from which, severe stenosis serves as the most powerful predictor among them.


VariablesUnivariate analysisMultivariate analysis
OR95% CI valueOR95% CI value

DM1.571.01–2.430.0441.861.34–2.970.04
Current smoking2.951.51–5.750.0012.672.60–2.740.01
Ejection fraction2.161.19–3.920.0101.761.04–2.970.04
Creatinine1.350.91–1.970.079
Severe stenosis (≥70%)3.852.16–6.870.0013.652.55–5.240.01

4. Discussion

Revascularization of coronary arteries with severe stenosis has reached a consensus in the area of cardiovascular therapeutics and research. For patients with revascularization indications, aggressive revascularization by CABG or PCI is favorable [14]. In clinical practice, patients presenting with complex coronary atherosclerosis, especially multivessel disease, typically are referred for CABG surgery. The preference has also been well supported by published literatures reporting CTO prevalence and treatment. Previous studies have demonstrated that patients with a CTO undergoing PCI and CABG surgery were 4.6–44.98% and 23–40%, respectively, and patients without a CTO were 36–52.9% and 23.2–28%, respectively [1518]. Surgical revascularization benefits patients with three-vessel or LMCA disease and CTOs including improvement of angina, left ventricular function, and mortality; however, CABG can accelerate stenosis progression of native vessels [16, 19]. Previously, with more attention being paid to graft patency, we observed new native-vessel occlusion after CABG and identified clinical and angiographic predictors for exacerbation of coronary lesions.

Prevalence of CTO is common in patients with prior CABG, and it was reported up to 50% [17]. Similar to previous studies, we found the morbidity of multiple coronary artery stenosis and total occlusion of native arteries in patients post-CABG are considerable in the current study [8, 11, 13]. In this regard, we favor the reasons that patients with complex coronary atherosclerosis were always recommended for surgery and bypass grafts which accelerate stenosis in native vessels [8, 11, 13, 17]. So far, the underlying mechanism remains unknown, and it is speculated that flow competition between the native vessel and graft contributes this progression [8, 11, 13]. In addition, we also found new occlusion which was more common in non-LAD with the findings consistent with the aforementioned studies [8, 11, 13]. Considering the current surgical practice and previous findings that greater incidence of disease progression in segments bypassed with venous grafts, we speculate that it might be associated with the use of venous grafts [19]. However, no significant difference was found between the type of grafts and the new occlusion in this study. Moreover, the present data do not exclude the possibility that local vascular anatomy is the critical pathogenic factor. Regarding the further therapy, patients presenting with recurrent ischemic symptoms, graft failure, or significant progression of native vessels are eligible to undergo revascularization after surgery. It is established that PCI of native coronary arteries is a preferred revascularization strategy for patients with prior CABG, especially those with patent left internal artery bypass grafts. Reasons are given as follows: for the repeat CABG, technical difficulties, increased mortality, and limited symptomatic improvement are major obstacles, and for graft intervention, the increased risk and worse long-term outcomes than native coronary arteries are also a frustrating problem. Even so, previous CABG was associated with the failure of CTO intervention combined with traditionally low success rates and high complication rates [20]. Despite this, the procedural success rate for CTO-PCI has improved over the years with the development of device, technique, and strategy. However, apart from experienced operators, there are several major drawbacks: higher radiation doses, higher volume of contrast agent administered, more severe complications, higher incidence of repeat revascularization, and lower procedural success rates, as compared with non-CTO-PCI [14, 15, 17, 21, 22]. We thus suggest patients with complex multivessel CAD undergo a hybrid approach, such as two-vessel disease with proximal LAD coronary artery occlusion. The hybrid approach is a potential alternative, namely, PCI, for the nonoccluded artery while leaving the CTO vascularized through minithoracotomy approaches, to avoid following weaknesses: surgery-related progression of native coronary lesions, graft stenosis, low primary success rate, and relatively high risk-benefit ratio of CTO-PCI. Furthermore, the hybrid approach facilitates PCI for non-bypassed segments to achieve more complete revascularization by reducing the incidence of new native-vessel occlusion.

Recurrence of effort angina increasing over time was frequently observed in patients with prior CABG. Campeau et al. have revealed the proportion of patients without symptoms after the procedure decreased from 72% to 37% in 10 years of follow-up [23]. In the present study, we found a higher proportion of patients with new occlusion complained of recurrent angina which has driven more repeat percutaneous revascularization of native coronary arteries, with accompanying majority incomplete revascularization. Correspondingly, greater follow-up major adverse cardiovascular event (MACE) rates were also found in these patients. According to a previous study, there were pathological differences in CTO patients with and without CABG [24]. CTOs with CABG have extensive calcification which has largely been attributed to blood stasis and low shear stress resulting from competitive flow between the native and bypass graft [25]. It has also been confirmed that calcification makes CTO-PCI difficult, and the success rate for CTO with prior CABG is significantly lower than those without CABG [25, 26]. Therefore, it is difficult or impossible to achieve complete revascularization. Incomplete revascularization results in persistent left ventricular dysfunction which in turn leads to a worse outcome on follow-up (higher mortality) [20, 27].

Previously, a study has reported clinical and angiographic predictors for native coronary vessel occlusion including bypass graft for non-LAD arteries and graft occlusion and no use of aspirin for LADs [11]. Our data suggest that independent risk factors for lesion occlusion also included diabetes, current smoking, initial lesion severity, and lower ejection fraction. The correlation of initial lesion severity with disease worsening is similar to the finding that progression of atherosclerosis with significant stenosis occurs 10 times as frequently in bypassed arteries as in non-bypassed arteries [13]. In addition, CTO-PCI was frequently performed among patients with prior CABG with lower technical success rates compared to patients without prior CABG [25]. In this regard, minimally diseased coronary arteries were recommended not to be bypassed [13]. In conclusion, our data show few predictors of occlusion in native arteries after CABG. Of note, these indicate the clinical importance of risk factor management against subsequent native-vessel occlusion in the postoperative period. It is worth noting that these predictors are also risk factors for general CAD patients except lower ejection fraction. Patients with these predictors tend to have more complexity of coronary heart diseases. For patients with these predictors, appropriate revascularization strategies such as a hybrid approach should be taken into careful consideration to reduce new native-vessel occlusion. Further study is needed to explore the differences of predictors for new native-vessel occlusion between the average CAD patient population and patients with prior CABG.

4.1. Study Limitation

There were several limitations to our study. First, it is a retrospective design. Second, the surgical procedures were performed in a single institution but not by a single surgeon. Our institution does not routinely perform coronary angiography on all patients who have undergone CABG. This means that the study has a bias in the cohort. A prospective study is needed to further explore this issue. An additional limitation of the study is the heterogeneity bias for operator-related and procedure-related factors.

Data Availability

The data of this study can be obtained from the corresponding author only with a reasonable request. The data are not publicly available because the availability of these clinical data was made under ethical license conditions applied for this study, which contained information that could compromise the privacy of research participants.

Conflicts of Interest

There are no conflicts of interest.

Acknowledgments

This work was supported by a grant from the National Natural Science Fund of China (no.81570388).

References

  1. WHO, “The top 10 causes of death,” 2018, http://www.whoint/news-room/fact-sheets/detail/the-top-10-causes-of-death. View at: Google Scholar
  2. P. Kolh, S. Windecker, F. Alfonso et al., “Task force on myocardial revascularization of the european society of Long term follow up of coronary bypass C, the european association for cardio-thoracic S and european association of percutaneous cardiovascular I. 2014 ESC/EACTS guidelines on myocardial revascularization: the task force on myocardial revascularization of the european society of cardiology (ESC) and the european association for cardio-thoracic surgery (EACTS). Developed with the special contribution of the european association of percutaneous cardiovascular interventions (EAPCI),” European Journal of Cardio-Thoracic Surgery, vol. 46, no. 4, pp. 517–592, 2014. View at: Publisher Site | Google Scholar
  3. M. E. Farkouh, M. Domanski, L. A. Sleeper et al., “Strategies for multivessel revascularization in patients with diabetes,” New England Journal of Medicine, vol. 367, no. 25, pp. 2375–2384, 2012. View at: Publisher Site | Google Scholar
  4. B. D. S. Group, R. L. Frye, P. August et al., “A randomized trial of therapies for type 2 diabetes and coronary artery disease,” New England Journal of Medicine, vol. 360, no. 24, pp. 2503–2515, 2009. View at: Publisher Site | Google Scholar
  5. W. Hueb, N. Lopes, B. J. Gersh et al., “Ten-year follow-up survival of the medicine, angioplasty, or surgery study (MASS II),” Circulation, vol. 122, no. 10, pp. 949–957, 2010. View at: Publisher Site | Google Scholar
  6. J. Fajadet and A. Chieffo, “Current management of left main coronary artery disease,” European Heart Journal, vol. 33, no. 1, pp. 36–50, 2012. View at: Publisher Site | Google Scholar
  7. S. J. Head, M. Milojevic, J. Daemen et al., “Stroke rates following surgical versus percutaneous coronary revascularization,” Journal of the American College of Cardiology, vol. 72, no. 4, pp. 386–398, 2018. View at: Publisher Site | Google Scholar
  8. E. L. Alderman, S. D. Corley, L. D. Fisher et al., “Five-year angiographic follow-up of factors associated with progression of coronary artery disease in the coronary artery surgery study (CASS),” Journal of the American College of Cardiology, vol. 22, no. 4, pp. 1141–1154, 1993. View at: Publisher Site | Google Scholar
  9. D. Pereg, P. Fefer, M. Samuel et al., “Native coronary artery patency after coronary artery bypass surgery,” JACC: Cardiovascular Interventions, vol. 7, no. 7, pp. 761–767, 2014. View at: Publisher Site | Google Scholar
  10. O. M. Jeroudi, M. E. Alomar, T. T. Michael et al., “Prevalence and management of coronary chronic total occlusions in a tertiary veterans affairs hospital,” Catheterization and Cardiovascular Interventions, vol. 84, no. 4, pp. 637–643, 2014. View at: Publisher Site | Google Scholar
  11. S.-H. Yoon, Y.-H. Kim, D. H. Yang et al., “Risk of new native-vessel occlusion after coronary artery bypass grafting,” The American Journal of Cardiology, vol. 119, no. 1, pp. 7–13, 2017. View at: Publisher Site | Google Scholar
  12. D. Pereg, P. Fefer, M. Samuel et al., “Long-term follow-up of coronary artery bypass patients with preoperative and new postoperative native coronary artery chronic total occlusion,” Canadian Journal of Cardiology, vol. 32, no. 11, pp. 1326–1331, 2016. View at: Publisher Site | Google Scholar
  13. W. L. Cashin, M. E. Sanmarco, S. A. Nessim, and D. H. Blankenhorn, “Accelerated progression of atherosclerosis in coronary vessels with minimal lesions that are bypassed,” New England Journal of Medicine, vol. 311, no. 13, pp. 824–828, 1984. View at: Publisher Site | Google Scholar
  14. W. J. Jang, J. H. Yang, S.-H. Choi et al., “Long-term survival benefit of revascularization compared with medical therapy in patients with coronary chronic total occlusion and well-developed collateral circulation,” JACC: Cardiovascular Interventions, vol. 8, no. 2, pp. 271–279, 2015. View at: Publisher Site | Google Scholar
  15. L. Azzalini, M. Vo, J. Dens, and P. Agostoni, “Myths to debunk to improve management, referral, and outcomes in patients with chronic total occlusion of an epicardial coronary artery,” The American Journal of Cardiology, vol. 116, no. 11, pp. 1774–1780, 2015. View at: Publisher Site | Google Scholar
  16. R. D. Christofferson, K. G. Lehmann, G. V. Martin, N. Every, J. H. Caldwell, and S. R. Kapadia, “Effect of chronic total coronary occlusion on treatment strategy,” The American Journal of Cardiology, vol. 95, no. 9, pp. 1088–1091, 2005. View at: Publisher Site | Google Scholar
  17. P. Fefer, M. L. Knudtson, A. N. Cheema et al., “Current perspectives on coronary chronic total occlusions,” Journal of the American College of Cardiology, vol. 59, no. 11, pp. 991–997, 2012. View at: Publisher Site | Google Scholar
  18. G. S. Werner, A. K. Gitt, U. Zeymer et al., “Chronic total coronary occlusions in patients with stable angina pectoris: impact on therapy and outcome in present day clinical practice,” Clinical Research in Cardiology, vol. 98, no. 7, pp. 435–441, 2009. View at: Publisher Site | Google Scholar
  19. H. I. Manninen, P. Jaakkola, M. Suhonen, S. Rehnberg, R. Vuorenniemi, and P. J. Matsi, “Angiographic predictors of graft patency and disease progression after coronary artery bypass grafting with arterial and venous grafts,” The Annals of Thoracic Surgery, vol. 66, no. 4, pp. 1289–1294, 1998. View at: Publisher Site | Google Scholar
  20. S. George, J. Cockburn, T. C. Clayton et al., “Long-term follow-up of elective chronic total coronary occlusion angioplasty,” Journal of the American College of Cardiology, vol. 64, no. 3, pp. 235–243, 2014. View at: Publisher Site | Google Scholar
  21. S. Rathore, H. Matsuo, M. Terashima et al., “Procedural and in-hospital outcomes after percutaneous coronary intervention for chronic total occlusions of coronary arteries 2002 to 2008,” JACC: Cardiovascular Interventions, vol. 2, no. 6, pp. 489–497, 2009. View at: Publisher Site | Google Scholar
  22. T. H. Lee, L. D. Hillis, and E. G. Nabel, “CABG vs. stenting—clinical implications of the SYNTAX trial,” New England Journal of Medicine, vol. 360, no. 8, p. e10, 2009. View at: Publisher Site | Google Scholar
  23. L. Campeau, M. Enjalbert, J. Lespérance et al., “The relation of risk factors to the development of atherosclerosis in saphenous-vein bypass grafts and the progression of disease in the native circulation,” New England Journal of Medicine, vol. 311, no. 21, pp. 1329–1332, 1984. View at: Publisher Site | Google Scholar
  24. K. Sakakura, M. Nakano, F. Otsuka et al., “Comparison of pathology of chronic total occlusion with and without coronary artery bypass graft,” European Heart Journal, vol. 35, no. 25, pp. 1683–1693, 2014. View at: Publisher Site | Google Scholar
  25. T. T. Michael, D. Karmpaliotis, E. S. Brilakis et al., “Impact of prior coronary artery bypass graft surgery on chronic total occlusion revascularisation: insights from a multicentre US registry,” Heart, vol. 99, no. 20, pp. 1515–1518, 2013. View at: Publisher Site | Google Scholar
  26. Y. Morino, M. Abe, T. Morimoto et al., “Predicting successful guidewire crossing through chronic total occlusion of native coronary lesions within 30 minutes,” JACC: Cardiovascular Interventions, vol. 4, no. 2, pp. 213–221, 2011. View at: Publisher Site | Google Scholar
  27. B. E. P. M. Claessen, R. J. van der Schaaf, N. J. Verouden et al., “Evaluation of the effect of a concurrent chronic total occlusion on long-term mortality and left ventricular function in patients after primary percutaneous coronary intervention,” JACC: Cardiovascular Interventions, vol. 2, no. 11, pp. 1128–1134, 2009. View at: Publisher Site | Google Scholar

Copyright © 2019 Ze Zheng et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


More related articles

644 Views | 306 Downloads | 1 Citation
 PDF  Download Citation  Citation
 Download other formatsMore
 Order printed copiesOrder

Related articles

We are committed to sharing findings related to COVID-19 as quickly and safely as possible. Any author submitting a COVID-19 paper should notify us at help@hindawi.com to ensure their research is fast-tracked and made available on a preprint server as soon as possible. We will be providing unlimited waivers of publication charges for accepted articles related to COVID-19. Sign up here as a reviewer to help fast-track new submissions.