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1.  Anterior ischemic optic neuropathy after conventional coronary artery bypass graft surgery 
Summary
Background
Perioperative optic neuropathy is a disease which can lead to serious, irreversible damage of vision. This complication could be the result of non-ocular surgery, for example, cardiac or spinal procedures.
We present a case of anterior ischemic neuropathy (AION) which occurred following a conventional coronary artery bypass graft procedure.
Case Report
A 57-year-old man, 4 days after Conventional Coronary Artery Bypass Graft surgery as result of multi-vessel stabile coronary artery disease and history of anterolateral wall myocardial infarction, was admitted to the Eye Clinic due to significant loss of vision in his right eye. The patient had hypertension and was a heavy smoker. On admission, the slit lamp examination revealed a relative afferent pupillary defect in the right eye. The fundus examination showed optic disc edema with the presence of flame hemorrhages. Best corrected visual acuity (BCVA) was 0.02. The results of eye examination and fluorescein angiography confirmed the diagnosis of AION. Anti-aggregation and antithrombotic treatment was continued with steroids and vasodilators. After 7 days of this treatment we noticed the improvement of BCVA to 0.2. At 6-month follow-up, the vision was stable, and fundus examination revealed optic disc atrophy.
Conclusions
After cardiac surgical operations, such as coronary artery bypass graft procedures, anterior ischemic optic neuropathy may occur. In those cases, close cooperation between the various specialists is necessary.
doi:10.12659/MSM.881798
PMCID: PMC3539541  PMID: 21629193
coronary artery bypass graft; off-pump coronary artery bypass; perioperative ischemic neuropathy; anterior ischemic optic neuropathy
2.  Ischemic Optic Neuropathy Following Spine Surgery 
Perioperative visual loss (POVL) is a devastating injury that has been reported infrequently after nonocular surgery. The most common cause of POVL is ischemic optic neuropathy (ION). Increasing numbers of cases of ION are being reported after spine surgery, but the etiology of postoperative ION remains poorly understood. After a MEDLINE search of the literature, we reviewed published case reports of ION, specifically those reported after spine surgery performed with the patient in the prone position. Most of the cases involved posterior ION (PION, n = 17), and the remainder anterior (AION, n = 5). Most patients had no or few preoperative vascular disease risk factors. All except one PION and 2 of 5 AION cases reported symptom onset within the first 24 hours after surgery. Visual loss was frequently bilateral (40% of AION, 47% of PION cases). Mean operative time exceeded 450 minutes. The lowest average intraoperative mean arterial blood pressure was 64 mm Hg and the mean lowest intraoperative hematocrit was 27%. The average blood loss was 1.7 L for AION and 5 L for PION patients. PION patients received an average of 8 L of crystalloid solution and 2.2 L of colloid intraoperatively. This compilation of case reports suggests that a combination of prolonged surgery in the prone position, decreased ocular perfusion pressure, blood loss and anemia/hemodilution, and infusion of large quantities of intravenous fluids are some of the potential factors involved in the etiology of postoperative ION. However, levels of blood pressure and anemia intraoperatively were frequently at levels considered acceptable in anesthesia practice. The etiology of postoperative ION remains incompletely understood. Potential strategies to avoid this complication are discussed.
PMCID: PMC2699455  PMID: 15632541
ischemic optic neuropathy; optic nerve; spine surgery; visual loss
3.  Perioperative visual loss: what do we know, what can we do? 
BJA: British Journal of Anaesthesia  2009;103(Suppl 1):i31-i40.
Perioperative visual loss (POVL), a rare, but devastating complication, can follow non-ocular surgery. Highest rates of visual loss are with cardiac and spine surgery. The main causes of visual loss after non-ocular surgery are retinal vascular occlusion and ischaemic optic neuropathy. This review updates readers on the incidence, suspected risk factors, diagnosis, and treatment of POVL due to these conditions.
doi:10.1093/bja/aep295
PMCID: PMC2791856  PMID: 20007988
complications, neurological; complications, neuropathy; eye, intraocular pressure; eye, pupil; surgery, spinal
4.  Perioperative visual loss in ocular and nonocular surgery 
Incidence estimates for perioperative vision loss (POVL) after nonocular surgery range from 0.013% for all surgeries up to 0.2% following spine surgery. The most common neuro-ophthalmologic causes of POVL are the ischemic optic neuropathies (ION), either anterior (AION) or posterior (PION). We identified 111 case reports of AION following nonocular surgery in the literature, with most occurring after cardiac surgery, and 165 case reports of PION following nonocular surgery, with most occurring after spine surgery or radical neck dissection. There were an additional 526 cases of ION that did not specify if the diagnosis was AION or PION. We also identified 933 case reports of central retinal artery occlusion (CRAO), 33 cases of pituitary apoplexy, and 245 cases of cortical blindness following nonocular surgery. The incidence of POVL following ocular surgery appears to be much lower than that seen following nonocular surgery. We identified five cases in the literature of direct optic nerve trauma, 47 cases of AION, and five cases of PION following ocular surgery. The specific pathogenesis and risk factors underlying these neuro-ophthalmic complications remain unknown, and physicians should be alert to the potential for loss of vision in the postoperative period.
PMCID: PMC2893763  PMID: 20596508
perioperative; postoperative; vision loss; ocular surgery; nonocular surgery
5.  Amaurosis after spine surgery: survey of the literature and discussion of one case 
European Spine Journal  2010;20(2):171-176.
Postoperative vision loss (POVL) associated with spine surgery is a well known, albeit very rare complication. POVL incidence after spinal surgery ranges from 0.028 to 0.2%; however, due to the increase in number and duration of annual complex spinal operations, the incidence may increase. Origin and pathogenesis of POVL remain frequently unknown. A 73-year-old patient presented with lumbar disc herniation with associated neurological deficits after conservative pre-treatment at a peripheral hospital. Known comorbidities included arterial hypertension, moderate arterial sclerosis, diabetes mellitus type 2, mildly elevated blood lipids and treated prostate gland cancer. During lumbar spine surgery in modified prone position the patient presented with an acute episode of severe hypotension, which required treatment with catecholamines and Trendelenburg positioning. Three hours postoperatively, a visual loss in the right eye occurred, resulting in a complete amaurosis. Antihypertensive medication, arteriosclerosis and intraoperative hypotension are possible causes for the POVL. Intraoperative administration of catecholamines and Trendelenburg positioning for treatment of systemic hypotension might further compromise ocular perfusion. In patients with comorbidities compromising arterial blood pressure, blood circulation and microcirculation, POVL must be considered as a severe postoperative complication. It is recommended to inform patients about such complications and obtain preoperative informed consent regarding POVL. Any recent modification of antihypertensive medication must be reported and analysed for potential intraoperative hemodynamic consequences, prior to spine surgery in prone position.
doi:10.1007/s00586-010-1557-9
PMCID: PMC3030706  PMID: 20809093
Amaurosis; Blood pressure; Spinal surgery; Prone position; Postoperative vision loss (POVL)
6.  A case report and brief review of the literature on bilateral retinal infarction following cardiopulmonary bypass for coronary artery bypass grafting 
Postoperative visual loss is a devastating perioperative complication. The commonest aetiologies are anterior ischaemic optic neuropathy (AION), posterior ischaemic optic neuropathy (PION), and central retinal artery occlusion (CRAO). These appear to be related to certain types of operation, most commonly spinal and cardiac bypass procedures; with the rest divided between: major trauma causing excessive blood loss; head/neck and nasal or sinus surgery; major vascular procedures (aortic aneurysm repair, aorto-bifemoral bypass); general surgery; urology; gynaecology; liposuction; liver transplantation and duration of surgery. The non-surgical risk factors are multifactorial: advanced age, prolonged postoperative anaemia, positioning (supine v prone), alteration of venous drainage of the retina, hypertension, smoking, atherosclerosis, hyperlipidaemia, diabetes, hypercoagulability, hypotension, blood loss and large volume resuscitation. Other important cardiac causes are septic emboli from bacterial endocarditis and emboli caused by atrial myxomata. The majority of AION cases occur during CPB followed by head/neck surgery and prone spine surgery. CPB is used to allow coronary artery bypass grafting on a motionless heart. It has many side-effects and complications associated with its use and we report here a case of bilateral retinal infarction during routine coronary artery bypass grafting in a young male patient with multiple risk factors for developing this complication despite steps to minimise its occurrence.
doi:10.1186/1749-8090-6-154
PMCID: PMC3253690  PMID: 22104114
7.  Transient bilateral post-operative visual loss in spinal surgery 
European Spine Journal  2011;21(Suppl 4):495-498.
Background
Post-operative visual loss (POVL) following spinal surgery is a rare but devastating complication. Although a number of intra-operative and post-operative factors have been implicated, the exact etiology may still remain unclear.
Purpose
To report a unique case of transient bilateral POVL in a patient who had undergone lumbar surgery in the prone position.
Study design/setting
This patient was followed up prospectively for 1 year.
Methods
Prospective follow-up of a single patient following spinal surgery, who developed transient bilateral POVL.
Results
This patient’s visual loss improved within 48 h.
Conclusion
This is the only documented case of POVL to have resolved completely within 48 h.
doi:10.1007/s00586-011-2117-7
PMCID: PMC3369061  PMID: 22170448
Post-operative; Visual loss; Spinal surgery
8.  Perioperative vision loss: A complication to watch out 
Postoperative vision loss, a rare but devastating complication, has been reported after spine, cardiac, and head–neck surgeries. Its incidence following spine surgeries exceeds that after cardiothoracic surgeries. Various causes attributed to postoperative blindness include ischemic optic neuropathy, central or branch retinal artery occlusion, cortical blindness, and rarely external ocular injury. Other contributory factors described are microvascular diseases and intraoperative hemodynamic compromise. However, the exact association of these factors with postoperative blindness has not yet been confirmed. In this review, we describe causes, presentation, and treatment of postoperative blindness and also recommend practical guidelines to avoid this complication. The search strategies for this review included both search of electronic databases as well as manual search of relevant articles.
doi:10.4103/0970-9185.92427
PMCID: PMC3275941  PMID: 22345938
Postoperative blindness; spine surgery; vision loss
9.  Bilateral anterior ischemic optic neuropathy after bilateral neck dissection 
Purpose:
The risk of visual loss after nonocular surgeries is very low, between 0.2% and 4.5%. According to the American Society of Anesthesiologists, ischemic optic neuropathy has been reported mostly after spinal surgery (54.2%), followed by cardiac surgery and radical neck dissection (13.3%). It may occur in association with some conditions that include systemic hypotension, acute blood loss and hypovolemia.
Case report:
A 46-year-old woman, whose diagnosis was laryngeal squamous cell carcinoma, complained of visual loss in her right eye two days after surgery (laryngectomy with bilateral radical neck dissection and left jugular ligature) and one day later in her left eye. The diagnosis was nonarteritic anterior ischemic optic neuropathy.
Conclusion:
Anterior ischemic optic neuropathy related to nonocular surgery is usually bilateral and its prognosis is very poor, resulting in blindness or severe visual loss. Although rare, patients should be warned about this complication, which has a profound impact on quality of life, since no therapeutic measure, including correction of hypotension and anemia, seems to improve the prognosis of this complication.
PMCID: PMC2835530  PMID: 20234774
ischemic optic neuropathy; visual loss; radical neck dissection; blood loss
10.  Bilateral internal thoracic artery grafting 
Annals of Cardiothoracic Surgery  2013;2(4):485-492.
The effectiveness of the left internal mammary artery graft to the anterior descending coronary artery as a surgical strategy has been shown to improve the survival rate and decrease the risk of adverse cardiac events in patients undergoing coronary bypass surgery. These clinical benefits appear to be related to the superior short and long-term patency rates of the internal thoracic artery graft. Although the advantages of using of both internal thoracic arteries (ITA) for bypass grafting have taken longer to prove, recent results from multiple data sets now support these findings. The major advantage of bilateral ITA grafting appears to be improved survival rate, while the disadvantages of complex ITA grafting include the increased complexity of operation, and an increased risk of wound complications. While these short-term disadvantages have been mitigated in contemporary surgical practice, they have not eliminated. Bilateral ITA grafting should be considered the procedure of choice for patients undergoing coronary bypass surgery that have a predicted survival rate of longer than ten years.
doi:10.3978/j.issn.2225-319X.2013.07.04
PMCID: PMC3741891  PMID: 23977627
Coronary bypass surgery; bilateral internal thoracic artery grafting
11.  Patients' Perspective on Full Disclosure and Informed Consent Regarding Postoperative Visual Loss Associated With Spinal Surgery in the Prone Position 
Mayo Clinic Proceedings  2011;86(9):865-868.
OBJECTIVE: To determine patients' opinions regarding the person, method, and timing for disclosure of postoperative visual loss (POVL) associated with high-risk surgery.
PATIENTS AND METHODS: On the basis of findings of a pilot study involving 219 patients at Mayo Clinic in Florida, we hypothesized that at least 80% of patients would prefer disclosure of POVL by the surgeon, during a face-to-face discussion, before the day of scheduled surgery. To test the hypothesis, we sent a questionnaire to 437 patients who underwent prolonged prone spinal surgical procedures at Mayo Clinic in Rochester, MN, or Mayo Clinic in Arizona from December 1, 2008, to December 31, 2009.
RESULTS: Among the 184 respondents, 158 patients gave responses supporting the hypothesis vs 26 with at least 1 response not supporting it, for an observed incidence of 86%. The 2-sided 95% confidence interval is 80% to 91%.
CONCLUSION: At least 80% of patients prefer full disclosure of the risk of POVL, by the surgeon, during a face-to-face discussion before the day of scheduled surgery. This finding supports development of a national patient-driven guideline for disclosing the risk of POVL before prone spinal surgery.
doi:10.4065/mcp.2011.0279
PMCID: PMC3258003  PMID: 21878598
12.  Saphenous vein graft vs. radial artery graft searching for the best second coronary artery bypass graft 
Coronary artery bypass grafting (CABG) was first used in the late 1960s. This revolutionary procedure created hope among ischemic heart disease patients. Multiple conduits are used and the golden standard is the left internal mammary artery to the left anterior descending artery. Although all approaches were advocated by doctors, the use of saphenous vein grafts became the leading approach used by the majority of cardiac surgeons in the 1970s. The radial artery graft was introduced at the same time but was not as prevalent due to complications. It was reintroduced into clinical practice in 1989. The procedure was not well received initially but it has since shown superiority in patency as well as long-term survival after CABG. This review provides a summary of characteristics, technical features and patency rates of the radial artery graft in comparison with venous conduits. Current studies and research into radial artery grafts and saphenous vein grafts for CABG are explored. However, more studies are required to verify the various findings of the positive effects of coronary artery bypass grafting with the help of radial arteries on mortality and long-lasting patency.
doi:10.1016/j.jsha.2013.06.001
PMCID: PMC3818632  PMID: 24198449
Coronary artery bypass grafting (CABG); Arterial grafts; Saphenous vein vs. radial artery; Radial artery graft patency; Radial artery graft spasm; RA graft long-term outcome
13.  Bilateral ischemic optic neuropathy after transurethral prostatic resection: a case report 
BMC Ophthalmology  2006;6:32.
Background
Nonarteritic ischemic optic neuropathy affects the anterior portion of the optic nerve and is characterized by sudden, painless visual loss. The affected eye has a relative afferent pupillary defect. The typical funduscopic appearance includes optic disc edema, with associated nerve fiber layer hemorrhage. Risk factors include advanced age, systemic hypertension, nocturnal hypotension, diabetes mellitus, and a small cup-to-disc ratio. Bilateral presentation is rare. Postoperative optic neuropathy has been associated with nonocular surgery; risk factors include a combination of prolonged surgical times, acute systemic hypotension, anemia due to blood loss, or prone positioning. We report for the first time a patient with bilateral, simultaneous anterior ischemic optic neuropathy after elective transurethral prostatic resection.
Case presentation
A 66-year old man underwent surgery for benign prostatic hyperplasia. The preoperative blood pressure was 140/85 mmHg, hemoglobin 15.9 g/dL, and hematocrit 48.6%. Two hours postoperatively, the blood pressure, hemoglobin, and hematocrit dropped dramatically. One day later, transient horizontal diplopia developed. Funduscopy showed a congenitally small cup-to-disc ratio without papillary edema. Other ocular findings were unremarkable. By 4 days postoperatively, sudden and painless amaurosis bilaterally developed when the patient awoke with nausea and vomiting. Visual acuity was no light perception bilaterally. The optic discs were swollen with small hemorrhages. Scans of the head and orbits and electrolyte levels were normal. There were no responses on visual evoked potentials bilaterally. The blood pressure was 90/50 mm Hg, the hemoglobin 7.0 g/dL, and the hematocrit 22.9%, necessitating infusion of three units of packed red blood cells. The blood pressure, hematocrit, and hemoglobin increased to normal levels. Three months later the visual acuity remained no light perception. The pupils were unreactive and there was marked optic disc atrophy bilaterally.
Conclusion
Bilateral and simultaneous acute ischemic optic neuropathy may be a rare but devastating surgical complication. The combination of anemia and hypotension may increase the risk of anterior ischemic optic neuropathy postoperatively after transurethral prostatic resection.
doi:10.1186/1471-2415-6-32
PMCID: PMC1624848  PMID: 17034630
14.  Measures to Increase the Number of Mammary Artery Coronary Artery Anastomoses 
Texas Heart Institute Journal  1986;13(1):123-129.
Patients with single internal mammary artery (IMA) grafts along with saphenous vein grafts have been found to have fewer coronary events and longer survival after operation. To reduce bypass graft failure from intimal hyperplasia and atherosclerosis, as well as to improve results, three or more IMA grafts were placed in 215 patients from October 1982 through May 1985. Careful planning helped in bypassing the maximum number of coronary artery obstructions with arterial conduits. By using bilateral IMA grafts, sequential, and Y grafts, the number of IMA coronary artery anastomoses increases and the need for saphenous vein grafts decreases. Meticulous dissection and preparation of the entire IMA and proper construction of the anastomosis are essentials for these procedures to be successful. Two of the 215 patients died early and four died late. Ninety-five percent of the postoperative stress tests were negative and 92% of the 39 IMA grafts visualized in 13 patients studied postoperatively were patent. We found this to be a safe, challenging procedure that improved late bypass conduit success and prolonged survival.
Images
PMCID: PMC324608  PMID: 15226842
15.  Limited access myocardial revascularization. A preliminary report. 
Texas Heart Institute Journal  1996;23(2):81-84.
A technique of limited access, direct vision surgery for performing coronary artery bypass grafting with the internal mammary artery is presented in this preliminary report. The procedure is performed without cardiopulmonary bypass. To gain access to the left (or right) coronary artery and the mammary artery, segments of the 3rd and 4th costal cartilages are removed. Before the pericardium is opened, the mammary artery is dissected distally under the 5th costal cartilage and proximally under the 3rd costal cartilage to the level of the 2nd costal cartilage. If the left anterior descending coronary artery is suitable for bypass, it is dissected and the bypass graft is placed. Limited access coronary bypass has been completed successfully in 8 of our first 9 patients. All 9 patients have had relief of anginal pain. This experience proves that coronary bypass operations can be performed in selected lesions without a quiet, bloodless field, thus avoiding the potential complications of cardiopulmonary bypass.
PMCID: PMC325318  PMID: 8792536
16.  Complete Off-Pump Coronary Revascularization in Patients with Dialysis-Dependent Renal Disease 
Texas Heart Institute Journal  2004;31(2):153-156.
Patients who have dialysis-dependent renal disease frequently present with coronary artery disease but are considered at high risk for coronary artery bypass grafting.
From 1 September 2000 through 31 August 2003, we performed complete off-pump coronary revascularization in 6 patients who had end-stage dialysis-dependent renal failure, and we prospectively studied the perioperative and early postoperative results. The effect of off-pump coronary artery bypass grafting on mortality, morbidity, postoperative complications, and transfusion requirements in this group of patients was investigated. No perioperative deaths or ischemic cardiac events were observed after off-pump coronary artery bypass grafting. In all patients, anginal symptoms were relieved during the postoperative period. The mean duration of follow-up was 17.2 ± 12.4 months.
Patients with dialysis-dependent chronic renal failure who present with coronary artery disease should be thoroughly evaluated preoperatively for risk factors and coexistent severe diseases. We believe that in patients with end-stage dialysis-dependent chronic renal failure, off-pump coronary revascularization is a good alternative.
PMCID: PMC427375  PMID: 15212126
Cardiac surgical procedures/adverse effects; cardiopulmonary bypass/adverse effects; coronary artery bypass; hemofiltration; kidney failure, chronic/complications; postoperative complications; renal dialysis; treatment outcome; uremia/complications
17.  Perioperative infusion of low- dose of vasopressin for prevention and management of vasodilatory vasoplegic syndrome in patients undergoing coronary artery bypass grafting-A double-blind randomized study 
Preoperative medication by inhibitors of angiotensin-converting enzyme (ACE) in coronary artery patients predisposes to vasoplegic shock early after coronary artery bypass grafting. Although in the majority of the cases this shock is mild, in some of them it appears as a situation, "intractable" to high-catecholamine dose medication. In this study we examined the possible role of prophylactic infusion of low-dose vasopressin, during and for the four hours post-bypass after cardiopulmonary bypass, in an effort to prevent this syndrome. In addition, we studied the influence of infused vasopressin on the hemodynamics of the patients, as well as on the postoperative urine-output and blood-loss. In our study 50 patients undergoing coronary artery bypass grafting were included in a blind-randomized basis. Two main criteria were used for the eligibility of patients for coronary artery bypass grafting: ejection fraction between 30-40%, and patients receiving ACE inhibitors, at least for four weeks preoperatively. The patients were randomly divided in two groups, the group A who were infused with 0.03 IU/min vasopressin and the group B who were infused with normal saline intraoperativelly and for the 4 postoperative hours. Measurements of mean artery pressure (MAP), central venous pressure (CVP), systemic vascular resistance (SVR), ejection fracture (EF), heart rate (HR), mean pulmonary artery pressure (MPAP), cardiac index (CI) and pulmonary vascular resistance (PVR) were performed before, during, and after the operation. The requirements of catecholamine support, the urine-output, the blood-loss, and the requirements in blood, plasma and platelets for the first 24 hours were included in the data collected. The incidence of vasodilatory shock was significantly lower (8% vs 20%) in group A and B respectively (p = 0,042). Generally, the mortality was 12%, exclusively deriving from group B. Postoperatively, significant higher values of MAP, CVP, SVR and EF were recorded in the patients of group A, compared to those of group B. In group A norepinephrine was necessary in fewer patients (p = 0.002) and with a lower mean dose (p = 0.0001), additive infusion of epinephrine was needed in fewer patients (p = 0.001), while both were infused for a significant shorter infusion-period (p = 0.0001). Vasopressin administration (for group A) was associated with a higher 24 hour diuresis) (0.0001).
In conclusion, low-dose of infused vasopressin during cardiopulmonary bypass and for the next 4 hours is beneficial for its postoperative hemodynamic profile, reduces the doses of requirements of catecholamines and contributes to prevention of the postcardiotomy vasoplegic shock in the patient with low ejection fraction who is receiving ACE preoperatively.
doi:10.1186/1749-8090-5-17
PMCID: PMC2855562  PMID: 20346182
18.  Amiodarone induced optic neuropathy 
Aim: To determine the clinical features of amiodarone induced optic neuropathy, which may help distinguish it from non-arteritic anterior ischaemic optic neuropathy.
Methods: Retrospective observational case series of patients diagnosed with amiodarone induced optic neuropathy at the neuro-ophthalmology service from March 1998 to February 2001. Amiodarone was discontinued after discussion with the patient's cardiologist. Visual acuity, colour vision, automated perimetry, and funduscopy were performed on initial and follow up examinations.
Results: Three patients with amiodarone induced optic neuropathy presented with mildly decreased vision, visual field defects, and bilateral optic disc swelling. Upon discontinuing the medication, visual function and optic disc swelling slowly improved in all three patients.
Conclusion: Amiodarone induced optic neuropathy can present with visual dysfunction, and is typically a bilateral process. Upon discontinuation of amiodarone, slow resolution of optic disc swelling occurs and visual function improves in some patients.
PMCID: PMC1771608  PMID: 12642303
amiodarone; optic neuropathy
19.  Protocol for the Arterial Revascularisation Trial (ART). A randomised trial to compare survival following bilateral versus single internal mammary grafting in coronary revascularisation [ISRCTN46552265] 
Trials  2006;7:7.
Background
Standard coronary artery bypass graft surgery uses a single internal mammary artery and supplemental vein or radial artery grafts. Several observational studies have suggested a survival benefit with two internal mammary artery grafts compared to a single internal mammary artery graft, but this has not been tested in a randomised trial. The Arterial Revascularisation Trial is a Medical Research Council and British Heart Foundation funded, multi-centre international trial comparing single internal mammary artery grafting versus bilateral internal mammary artery grafting.
Methods/Design
Twenty centres in the UK, Australia, Poland and Brazil are planning to randomise 3000 coronary artery bypass graft surgery patients to single or bilateral internal mammary artery grafting. Supplemental grafts may be either saphenous vein or radial artery. Coronary artery bypass grafting can be performed as an on-pump or off-pump procedure. The primary outcome is survival at 10 years and secondary end-points include clinical events, quality of life and cost effectiveness. The effect of age, left ventricular function, diabetes, number of grafts, vein grafts and off-pump surgery are pre-specified subgroups.
Discussion
The Arterial Revascularisation Trial is one of the first randomised trials to evaluate the effects on survival and other clinical outcomes of single internal mammary artery grafting versus bilateral internal mammary artery grafting, and will help to establish the best approach for patients requiring coronary artery bypass graft surgery.
doi:10.1186/1745-6215-7-7
PMCID: PMC1450314  PMID: 16573820
20.  Arterial bypass grafting of the coronary circulation 
Surgical coronary bypass has evolved continually, and recent developments favor performing coronary grafts with all-arterial conduits in order to obtain better long-term graft patencies. With bilateral internal mammary artery grafts and both radial arteries, four excellent arterial conduits exist for revascularization of the majority of multivessel disease patients, including those with valve disorders.
Using contemporary surgical techniques, it is possible to obtain greater than 95% overall long-term graft patencies that translate into better outcomes, including improved survival, freedom from myocardial infarction, percutaneous coronary intervention , and redo coronary bypass.
Two-thirds of patients receive a right internal mammary artery to the left anterior descending , a left internal mammary artery to the circumflex coronary artery system, and a radial artery to the right coronary artery Using newer management techniques, early postoperative complications, including the incidence of sternal infections, are extremely uncommon, and all-arterial grafts currently are used in over 75% of multivessel patients including those with concomitant valve disease. Because patencies and outcomes are so much better than with standard coronary bypass or percutaneous coronary intervention, referring physicians frequently favor all-arterial bypass as the primary therapy for patients with prognostically serious multivessel obstruction. Thus, all-arterial bypass could play an increasingly important role in the future treatment of severe coronary atherosclerosis.
PMCID: PMC3563437  PMID: 23439991
coronary artery bypass; IMA grafts; coronary artery disease; graft patency; outcome analysis
21.  A surgical approach to coexistent coronary and carotid artery disease. 
Heart  1997;77(2):164-167.
OBJECTIVE: To assess the early results of combined coronary artery bypass graft surgery and carotid endarterectomy. DESIGN: Retrospective and ongoing analysis of patients who underwent combined coronary artery bypass graft surgery and carotid endarterectomy. SETTING: Cardiothoracic unit in a London teaching hospital. PATIENTS: From June 1987 to March 1995, 64 patients were identified. They were patients who were scheduled to have coronary artery bypass graft surgery or required urgent coronary revascularisation and who were found to have significant coexistent carotid disease. (Unilateral carotid stenosis > 70%, bilateral carotid stenosis > 50%, or unilateral carotid stenosis > 50% with contralateral occlusion.) INTERVENTIONS: Both procedures were performed during one anaesthesia: the carotid endarterectomy was performed first without cardiopulmonary bypass. After completion of carotid endarterectomy, coronary artery bypass graft surgery was performed. MAIN OUTCOME MEASURES: The incidence of stroke, transient ischaemic attack, and myocardial infarction in the early postoperative period was analysed. RESULTS: Myocardial revascularisation was successful in all 64 patients. There were no perioperative infarcts. In three patients (4.7%) a new neurological deficit developed postoperatively: two recovered fully before hospital discharge. CONCLUSIONS: Combined coronary artery bypass graft surgery and carotid endarterectomy were performed safely and with good results.
PMCID: PMC484667  PMID: 9068401
22.  Clinical outcome of arterial myocardial revascularization using bilateral internal thoracic arteries in diabetic patients: a single centre experience 
OBJECTIVES
The use of bilateral internal thoracic arteries (BITAs) grafting has been documented to be advantageous over left internal thoracic artery (LITA) grafting. It has been shown to significantly improve clinical outcomes and increase long-term survival in patients with diabetes. However, harvesting BITAs may result in a greater risk of superficial wound infection (SWI) or deep sternal wound infection (DSWI) and cardiovascular complications (major adverse cardiac and cerebrovascular events; MACCE) in such a patient group. The objective of this study was to compare the incidence of SWI or DSWI and cardiovascular events in a series of isolated coronary artery bypass grafting (CABG) patients who underwent BITA grafting vs LITA grafting.
METHODS
A total of 147 patients with coronary artery disease and diabetes underwent isolated CABG at John Paul II Hospital. Of these, 38 procedures were performed using BITA grafting and 109 with LITA-saphenous vein grafting.
RESULTS
MACCE were similar in bilateral groups (7.9%—BITA group and 9.2%—LITA group). No significant difference was found in mortality and length of stay between bilateral groups. The MACCE risk factor was age. The incidence of SWI and DSWI and sternal re-fixation did not differ between the BITA or LITA groups (5.2 vs 9.1%, 5.2 vs 7.3% and 5.2 vs 6.4%). The risk factors for DSWI were age (odds ratio 3.47, P = 0.032 for every 10 years) and body mass index >30 kg/m2.
CONCLUSIONS
Perioperative complications do not increase with the use of BITAs in this group of diabetic patients. There are no statistically significant differences in the number of superficial or deep wound infections or number of sternal resuturing between the BITA and LITA groups.
doi:10.1093/icvts/ivs364
PMCID: PMC3501297  PMID: 22997249
Coronary artery bypass; thoracic arteries; Diabetes
23.  Coronary artery surgery: indications and recent experience. 
Postgraduate Medical Journal  1978;54(636):649-657.
The comprehensive experience of coronary artery surgery in a Cardiothoracic Unit over a 31-month period is reviewed. Hospital mortality for elective bypass grafting was 3.9% overall and 2.5% in those with good pre-operative left ventricular function. Major influences on hospital mortality were pre-operative left ventricular function, extent of coronary artery disease and extent of the surgical procedure undertaken in terms of number of aortocoronary grafts inserted, coronary endarterectomy and particularly concomitant valve surgery or aneurysm resection. Follow-up experience shows 74% of grafted patients to be symptom-free and 85% symptomatically improved one year after surgery with 70% symptom-free and 80% improved at two years. Early post-operative deaths appear related to early graft closure and recurrence of symptoms postoperatively to late graft closure or progression of coronary disease in the native circulation. The study provides a guide to the relative risks of coronary artery surgery for symptomatic coronary artery disease and expected symptomatic results in the early follow-up period.
PMCID: PMC2425097  PMID: 310999
24.  Laser recanalisation of coronary arteries by metal-capped optical fibres: early clinical experience in patients with stable angina pectoris. 
British Heart Journal  1988;59(2):168-174.
The delivery of laser energy to the coronary circulation by bare optical fibres may cause perforation of the vessel. Experimental studies have shown that this complication can be avoided if the optical fibre is fitted with a metal cap to prevent the potentially dangerous forward projection of the laser beam. This study was performed to assess the feasibility and short term effects of percutaneous coronary laser recanalisation with these modified fibres. Recanalisation of a severe stenosis of the left anterior descending artery was attempted in six patients who were referred for coronary artery bypass grafting. Although the percutaneous technique was used, the laser procedure was performed during coronary bypass surgery before the start of cardiopulmonary bypass to minimise the effects of potential complications. A 1.5 mm diameter metal-capped fibre coupled to an argon laser was advanced percutaneously over a guide wire positioned across the stenosis. In the first patient the delivery of 152 J resulted in the gradual passage of the fibre through a 3 cm long stenosis. Repeat angiography showed a reduction in the severity of the stenosis. In the second patient the delivery of 112 J failed to allow fibre advancement; a further 80 J pulse caused perforation which was repaired. In the remaining four patients the delivery of laser energy in the attempt to traverse the stenosis was limited to less than 90 J. In two of the four patients the severity of stenosis was reduced. No further complications were seen. Percutaneous coronary laser recanalisation with metal-capped optical fibres is feasible but improvements of currently available technology are needed to increase the primary success rate.
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PMCID: PMC1276979  PMID: 3342157
25.  Ischaemic optic neuropathy complicating cardiopulmonary bypass. 
Bilateral anterior ischaemic optic neuropathy occurred in two patients undergoing cardiopulmonary bypass grafting. The causes may have been vasoconstriction of the posterior ciliary arteries by increased circulating angiotensin and diminished ciliary blood flow in the setting of systemic hypotension and elevated intraocular pressure.
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PMCID: PMC1041163  PMID: 3495292

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