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Influence of moderate left subclavian artery stenosis on outcomes after coronary bypass surgery in patients requiring hemodialysis.
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Oda Ryoma, Kinoshita Takeshi, Endo Daisuke, Kajimoto Kan, Yamamoto Taira, Amano Atsushi, Tabata Minoru
Аннотация
OBJECTIVES: Left subclavian artery stenosis in patients requiring hemodialysis can cause coronary steal syndrome via the left internal thoracic artery (LITA) graft to the left anterior descending artery (LAD), potentially leading to graft failure. This study evaluated the influence of moderate left subclavian artery stenosis on long-term outcomes following LITA-LAD coronary artery bypass grafting.
METHODS: Among 1744 patients undergoing primary isolated coronary artery bypass grafting, 104 patients requiring hemodialysis with left upper limb arteriovenous fistulas and preoperative contrast-enhanced computed tomography were analyzed. Left subclavian artery stenosis was quantified as: (1-minimal lumen area/reference lumen area) × 100. Patients were grouped by stenosis severity: ≥50% (n = 25) versus <50% (n = 79). The primary end point was all-cause mortality; secondary end points included cardiac death and major adverse cardiac events (eg, heart failure admission, ischemic events, or cardiac death). Inverse probability of treatment weighting was used for covariate adjustment, and inverse probability of treatment weighting-adjusted Cox models estimated hazard ratios.
RESULTS: Mean follow-up was 4.6 ± 3.1 years. In the inverse probability of treatment weighting cohort, 5-year survival was 62% versus 26% (nonstenosis vs stenosis; log-rank P < .001). Left subclavian artery stenosis was associated with higher risks of all-cause death (hazard ratio, 2.09; 95% CI, 1.39-3.15; P < .001) and cardiac death (hazard ratio, 3.68; 1.46-9.30; P = .006), but not with major adverse cardiac events.
CONCLUSIONS: Moderate preoperative left subclavian artery stenosis was independently associated with increased long-term mortality and cardiac death after LITA-LAD coronary artery bypass graft in patients requiring hemodialysis. Routine preoperative subclavian imaging and consideration of revascularization or alternative inflow may be warranted.
METHODS: Among 1744 patients undergoing primary isolated coronary artery bypass grafting, 104 patients requiring hemodialysis with left upper limb arteriovenous fistulas and preoperative contrast-enhanced computed tomography were analyzed. Left subclavian artery stenosis was quantified as: (1-minimal lumen area/reference lumen area) × 100. Patients were grouped by stenosis severity: ≥50% (n = 25) versus <50% (n = 79). The primary end point was all-cause mortality; secondary end points included cardiac death and major adverse cardiac events (eg, heart failure admission, ischemic events, or cardiac death). Inverse probability of treatment weighting was used for covariate adjustment, and inverse probability of treatment weighting-adjusted Cox models estimated hazard ratios.
RESULTS: Mean follow-up was 4.6 ± 3.1 years. In the inverse probability of treatment weighting cohort, 5-year survival was 62% versus 26% (nonstenosis vs stenosis; log-rank P < .001). Left subclavian artery stenosis was associated with higher risks of all-cause death (hazard ratio, 2.09; 95% CI, 1.39-3.15; P < .001) and cardiac death (hazard ratio, 3.68; 1.46-9.30; P = .006), but not with major adverse cardiac events.
CONCLUSIONS: Moderate preoperative left subclavian artery stenosis was independently associated with increased long-term mortality and cardiac death after LITA-LAD coronary artery bypass graft in patients requiring hemodialysis. Routine preoperative subclavian imaging and consideration of revascularization or alternative inflow may be warranted.