Original Article
Comparison of Stenting with Minimally Invasive Bypass Surgery for Stenosis of the Left Anterior Descending Coronary Artery
N Engl J Med 2002; 347:561-566August 22, 2002
- Abstract
Background
Minimally invasive bypass surgery and coronary-artery stenting are both accepted treatments for isolated stenosis of the proximal left anterior descending coronary artery. We compared the clinical outcomes after these two procedures.
Methods
A total of 220 symptomatic patients with high-grade lesions in the proximal left anterior descending coronary artery were randomly assigned to treatment — 110 to surgery and 110 to stenting. The combined clinical end point was freedom from major adverse cardiac events, such as death from cardiac causes, myocardial infarction, and the need for repeated revascularization of the target lesion within six months.
Results
A major adverse cardiac event occurred in 31 percent of patients after stenting, as compared with 15 percent in the surgery group (P=0.02). The difference was predominantly due to a higher rate of repeated revascularization of the target vessel for restenosis after stenting (29 percent vs. 8 percent, P=0.003). The combined rates of death and myocardial infarction did not differ significantly between groups (3 percent in the stenting group and 6 percent in the surgery group, P=0.50). Adverse events occurred more frequently after surgery. The percentage of patients free from angina after six months was 79 percent in the surgery group, as compared with 62 percent in the stenting group (P=0.03).
Conclusions
In patients with isolated high-grade lesions of the proximal left anterior descending artery, both minimally invasive bypass surgery and stenting are effective. Stenting yields excellent short-term results with fewer periprocedural adverse events, but surgery is superior with regard to the need for repeated intervention in the target vessel and freedom from angina at six months of follow-up.
Media in This Article
Figure 1
Numbers of Patients Included in the Analyses.Table 1
Base-Line Characteristics of the Patients.Article Activity
- Article
High-grade stenosis of the proximal left anterior descending coronary artery in patients with single-vessel disease is associated with a significantly worse prognosis than lesions at any other location.1,2 Both percutaneous transluminal coronary angioplasty and coronary-artery bypass grafting have been shown to improve symptoms in such patients.3,4 In several studies, the incidence of medium-term adverse events and the proportion of patients requiring repeated revascularization of the target lesion were consistently higher after balloon angioplasty than after conventional coronary-artery bypass grafting in patients with single-vessel5,6 or multivessel7-9 disease. With the introduction of intracoronary stents, however, the rate of restenosis has been substantially reduced.10-12 At the same time, minimally invasive direct coronary-artery bypass surgery, in which the left internal thoracic artery is used for grafting of the left anterior descending artery through a limited left thoracotomy performed on the beating heart, has substantially decreased the trauma associated with surgical treatment.13-15 In this single-site, randomized study, we compared the merits of the two techniques for the treatment of patients with isolated lesions of the proximal left anterior descending coronary artery.
Methods
Study Patients
Patients with isolated high-grade lesions (stenosis of ≥75 percent of the luminal diameter) in the proximal left anterior descending artery were included in the study. The lesion had to be confined to the segment between the origin of the left circumflex coronary artery and the first major septal branch. Patients were excluded if they had acute coronary syndromes requiring immediate intervention, additional clinically significant coronary lesions or valvular heart disease requiring treatment, or stenosis of the first diagonal branch or stenosis extending over a major diagonal branch or if they had previously undergone interventional or surgical treatment for coronary artery disease. Patients with total occlusion and patients with an intramyocardial course of the left anterior descending artery were also excluded, since minimally invasive surgery requires full visualization of the target vessel. The cardiac surgeon and the cardiologist had to agree on the eligibility of each patient before randomization. The study was approved by the local ethics committee. Written informed consent was obtained from all patients. Balanced randomization was performed by means of the drawing of sealed, unlabeled, unordered envelopes from an urn.
Angiographic Analysis
Angiography was performed in multiple projections after intracoronary application of nitroglycerin. Quantitative computed analysis was performed by an operator who was unaware of the patient's identity, using a validated image-processing algorithm (CMS, version 3.0, Medis). The diameters of the normal segments proximal and distal to the treated area were averaged to determine the reference diameter. Minimal luminal diameter and percentage of stenosis were calculated. In the surgery group, the reduction in luminal diameter was confined to the anastomotic site; therefore, no distal reference diameter of the internal thoracic artery could be obtained. Restenosis was defined as stenosis of more than 50 percent of the luminal diameter.
Stenting Procedure
Stenting was performed according to standard clinical practice. The femoral approach was used, with a 6-French or 8-French guiding catheter. All patients began to receive 350 mg of aspirin per day and either 500 mg of ticlopidine per day or 300 mg of clopidogrel per day on the day before the procedure. Administration of ticlopidine or clopidogrel continued for a minimum of four weeks, and aspirin was given indefinitely. A bolus of 10,000 U of heparin was given at the beginning of the intervention. Selection of the balloon size was based on visual assessment of the target vessel. A balloon-to-vessel ratio of between 1.1 and 1.2 was recommended. Primary stenting without predilation was used whenever feasible. The choice of stent was left to the operator.
Minimally Invasive Bypass Surgery
The technique of minimally invasive direct coronary-artery bypass surgery has been described in detail elsewhere.15 In brief, a limited left anterolateral thoracotomy was performed through the fourth intercostal space. The internal thoracic artery was harvested under direct vision. After the administration of heparin (100 U per kilogram of body weight), the internal thoracic artery was divided distally. Local immobilization of the anastomotic site was achieved with mechanical stabilizers. The anastomosis was performed with the use of one running 8-0 polypropylene suture on the beating heart. Protamine was applied to neutralize 80 percent of the dose of heparin. Wounds were closed in a standard fashion.
Follow-up
All patients were monitored for at least 24 hours. Creatine kinase activity was measured and 12-lead electrocardiography was performed immediately after the procedure and 6, 12, and 18 hours later. Patients assigned to surgery underwent angiography before discharge. Myocardial infarction was diagnosed either if the ratio of serum creatine kinase MB isoenzyme (CK-MB) to total cardiac enzyme exceeded 0.1 or if the CK-MB value was three times the upper limit of normal. In addition, standard electrocardiographic criteria were applied.
Six-month follow-up included a complete clinical workup with a symptom-limited exercise stress test and coronary angiography. In case of recurrence of angina, a positive stress test, or both, a repeated intervention was performed.
Statistical Analysis
The primary composite end point was defined as freedom from major adverse cardiovascular events, which included death from cardiac causes, myocardial infarction, and the need for repeated revascularization of the target lesion within six months. Secondary end points included each individual component of the composite end point, the clinical status as assessed according to the Canadian Cardiovascular Society (CCS) classification,16 and the need for antianginal drugs at six months of follow-up. In addition, periprocedural adverse events were documented.
The sample size was chosen in order to achieve 95 percent statistical power with a type I error of 5 percent with the use of a two-sided Fisher's exact test. In order to allow for losses to follow-up, we recruited 10 additional patients for each group. On the basis of previous reports, it was assumed that 30 percent of the patients treated by stenting and 9 percent of those treated by surgery would reach the combined primary end point.
All analyses were conducted according to the intention-to-treat principle. All events occurring after randomization were included in the analysis. Patients who were lost to follow-up were excluded from further analysis. In addition, patients who did not undergo repeated angiography were excluded from the calculation of the overall rate of restenosis (Figure 1Figure 1
Numbers of Patients Included in the Analyses.). Data for the categorical variables are expressed as the number and the percentage of patients. For continuous variables, data are reported as estimated means ±SD, and values were compared by unpaired Student's t-tests after testing for normal distribution. Fisher's exact test or a chi-square test was used for categorical variables with nominal scales, and the Wilcoxon or Mann–Whitney rank-sum test was used for those with ordinal scales. Rates of events were compared by the calculation of unadjusted relative risks with 95 percent confidence intervals. All statistical tests were two-tailed. A P value of less than 0.05 was considered to indicate statistical significance. There were no interim analyses.Results
Study Patients
Between June 1997 and June 2001, 220 consecutive patients were randomly assigned to treatment — 110 to stenting and 110 to minimally invasive surgery. There were no significant differences between the groups with respect to demographic characteristics or base-line variables (Table 1Table 1
Base-Line Characteristics of the Patients.). The mean (±SD) interval between randomization and treatment was 2±3 days (range, 0 to 23) among patients assigned to stenting and 14±46 days (range, 0 to 106) among patients assigned to surgery (P<0.001). All patients received the assigned treatment, and there were no adverse events in patients awaiting surgery or stenting.Clinical Outcome
Stenting
Stenting was successful in all patients, and there were no complications. The mean percentage of stenosis was significantly reduced (Table 2Table 2
Results of Quantitative Coronary Angiography.). An average of 1.2±0.4 stents were implanted at a mean stent-dilation pressure of 13.3±1.7 atm. The mean length of a stent was 15.1±4.3 mm. GFX stents (Medtronic) were used in 64 patients, Pura-Vario (Devon Medical) in 10, Inflow (Inflow Dynamics) in 9, Micro II (Arterial Vascular Engineering) in 7, MAC (AMG) in 10, MAC Carbon (AMG) in 4, and Sito (Jomed) in 6.After stenting, a retroperitoneal hematoma developed in two patients; the hematomas were managed conservatively. One patient had an acute myocardial infarction due to early stent thrombosis, which was treated with balloon angioplasty and abciximab. In another patient who stopped taking aspirin and ticlopidine, subacute stent thrombosis developed two weeks after stent implantation; the occlusion was recanalized by balloon angioplasty. In one patient, a ruptured plaque in the left circumflex coronary artery caused an acute myocardial infarction two months after hospital discharge. Two patients died from strokes three months after the intervention.
Minimally Invasive Bypass Surgery
Minimally invasive surgery was successfully performed in 95 percent of the patients in the surgery group. In five patients, conversion to a full sternotomy was necessary because of an intramyocardial segment of the left anterior descending coronary artery (in three patients), an injured internal thoracic artery (in one patient), and severe pleural adhesions (in one patient). These patients had an otherwise uneventful course.
Three patients underwent reoperation during the hospitalization for the first operation because of anastomotic stenosis or occlusion; two of these patients had a perioperative myocardial infarction during the first operation. In two patients, the anastomosis was erroneously performed on the first diagonal branch; in one of these patients, stenting of the native vessel had to be performed; the second patient had adequate perfusion of the territory of the left anterior descending artery. Two other patients had perioperative myocardial infarction despite grafts that were shown to be patent on angiography. One patient had an ischemic stroke five days after the procedure. Chest-wall hernia requiring surgical repair occurred in two patients during the six-months of follow-up.
One patient died during a maximal bicycle exercise test 10 days after surgery. Autopsy revealed rupture of the graft, which was probably caused by mechanical resuscitation. Another patient died at a rehabilitation center 15 days after surgery; since this death was not witnessed and no autopsy was performed, the cause of death could not be ascertained. During follow-up, one patient had an acute myocardial infarction due to a new lesion of the left circumflex artery, which was treated by stenting. The mean duration of hospitalization after surgery was 9±4 days (range, 4 to 36), as compared with 2±3 days after stenting (range, 1 to 28) (P<0.001).
Follow-up Results
Follow-up was complete for all patients except for two patients in the surgery group. Two asymptomatic patients refused repeated cardiac catheterization after stenting, as did eight patients after surgery (Figure 1).
After surgery, the mean CCS angina class improved from 2.6±0.9 to 0.3±0.7 (P<0.001), and 79 percent of patients were free of angina. After stenting, the angina class improved from 2.6±0.9 to 0.7±1.0 (P<0.001 for the comparison with base line; P=0.02 for the comparison with the surgery group), and 62 percent were free of angina (P=0.03 for the comparison with the surgery group). Six percent of patients in the surgery group required antianginal drug therapy, as compared with 19 percent in the stenting group (P=0.006). Physical-work capacity, however, was similar in the two groups (a workload of 120±37 W in the stenting group and 127±34 W in the surgery group, P=0.15).
At six months of follow-up, in-stent restenosis was detected in 35 patients, and 29 of these underwent repeated revascularization (by balloon angioplasty in 25 patients and surgery in 4 patients) for recurrent angina, a positive stress test, or both. Subgroup analysis showed a restenosis rate of 18 percent for type A lesions, 26 percent for type B lesions, and 56 percent for type C lesions (P=0.008). The classification of stenoses is based on a variety of morphologic criteria that assess the degree of complexity of the lesion.17 In the surgery group, 18 patients had a stenosis of more than 50 percent of the luminal diameter at the anastomotic region or in the bypass graft; 5 of those patients required interventional treatment, and the other 13 patients, who were asymptomatic, were treated conservatively, since the restenoses at the anastomotic site were in the range of 50 to 60 percent of the luminal diameter.
There were significantly more repeated interventions after stenting than after surgery (Table 3Table 3
Major Adverse Cardiac Events during Six Months of Follow-up.). However, death from cardiac causes and myocardial infarction, alone or together, were uncommon, and the rates did not differ significantly between groups.Discussion
Stenting has become the preferred treatment for isolated lesions of the left anterior descending coronary artery. The combination of balloon angioplasty, stenting, and antiplatelet treatment has reduced the rate of acute dissections and restenoses even among lesions with complex morphology. Interventional approaches have therefore found widespread application, whereas primary surgical treatment is recommended in only a few cases, despite the lack of randomized studies comparing the two approaches.
Location of the lesion in the proximal left anterior descending artery has been defined as an independent risk factor for restenosis after balloon dilation,18 as well as after stenting. Despite implementation of state-of-the-art techniques in our study, the restenosis rate remained essentially unchanged from previous studies, in which rates ranged from 33 percent to 44 percent.10,19,20 In one study, a restenosis rate of only 19 percent was reported, but the investigators had excluded patients with well-known risk factors for restenosis, such as long lesions (>15 mm in length), small vessels (<3 mm in diameter), and a high mean percentage of stenosis.12 In our study, stent implantation might have been suboptimal in some patients, since the final percentage of stenosis was more than 10 percent; this fact might be explained by the visual rather than quantitative assessment during the procedure. Another factor influencing the restenosis rate might be the use of stents with a strut thickness of more than 100 μm, which is also an independent risk factor for restenosis.21
Our results reflect the advantages and disadvantages of stenting of the proximal left anterior descending artery. Stenting is a safe intervention even in lesions with complex morphologic features. The rate of periprocedural adverse events is low, with stent thrombosis in 2 of 110 patients. However, only 2 percent of our patients received additional glycoprotein IIb/IIIa inhibitors, which is a potential limitation of the study. The incidence of early occlusions at the target site might have been reduced by the more frequent use of these platelet inhibitors, which have been shown to reduce the rate of periprocedural events, particularly among high-risk patients.22,23 Our study confirms the predictive value of lesion morphology for the development of subsequent restenosis.24 A restenosis rate of 56 percent was found among type C lesions, as compared with a rate of 18 percent among type A lesions. In contrast, in the surgery group, the risk of subsequent restenosis was independent of the type of lesion.
The major factors contributing to restenosis — elastic recoil and vessel-wall remodeling — are addressed by stenting. However, given that drug-eluting stents and intravascular radiation have not yet been approved for general use, there is currently no effective therapy for the prevention of neointimal proliferation.25,26
Previous studies have demonstrated two major clinical outcomes favoring conventional coronary bypass surgery (with a sternotomy and cardiopulmonary bypass) over balloon dilation without stenting for the treatment of isolated lesions in the proximal left anterior descending artery: more complete relief of angina and a reduced need for repeated revascularization.5,6 Despite these benefits, many patients prefer the less invasive catheter-based approach to conventional coronary bypass surgery.
The minimally invasive surgical approach minimizes surgical trauma by limiting the access to the heart and avoiding cardiopulmonary bypass. Medium-term patency rates similar to those achieved with conventional bypass grafting have been reported.27 A recent study demonstrated a survival rate of 98 percent and a rate of repeated revascularization of less than 2 percent.15 The limited thoracotomy preserves sternal integrity and allows for a more rapid return to daily activities. More important, the avoidance of cardiopulmonary bypass reduces the immune response, preserves blood components, and improves postoperative neurocognitive function as compared with conventional cardiac surgery.28,29 However, the limited access makes the procedure more challenging technically and may impair the quality of the anastomosis,14,30 which is reflected in our study by a 3 percent rate of early reoperation for acute graft failure, two cases in which the anastomotic site was erroneously selected, and a 5 percent rate of conversion to full sternotomy.
After six months, all bypass grafts were patent, but irregularities at the anastomotic site were demonstrated by angiography in 18 percent of cases. This rate of irregularities can be partially attributed to the fact that, in contrast to other studies, our study used quantitative coronary angiography that is more sensitive than qualitative assessment in detecting restenosis.14,31 However, repeated revascularization was necessary in only 5 percent of the patients, since most of the stenoses were in the range of 50 to 60 percent of luminal diameter. The limited degree of restenosis is also reflected by the more complete relief of anginal symptoms in the surgery group than in the stenting group. In studies comparing balloon angioplasty with bypass surgery, such differences were attenuated during later follow-up because of additional revascularization procedures.6,9
Minimally invasive surgery is still a relatively new technique. Therefore, future developments and improved patient selection may further reduce periprocedural morbidity and the rate of early reinterventions. Because of the single-center design of this study, only experienced surgeons and interventional cardiologists participated in the trial. Finally, longer follow-up will be needed to address the long-term efficacy and costs of either stenting or surgery, since the efficacy of any therapy will be increasingly weighed against its costs.
Both stenting and minimally invasive bypass surgery are safe and effective treatment options for high-grade lesions in the proximal left anterior descending artery. Although stenting is the only truly minimally invasive therapy associated with fewer periprocedural events than surgery and can be considered the first-line option for lesions without complex morphologic features, surgery provides excellent outcome irrespective of the morphology of the lesion. Our study demonstrates that decisions about how to treat an isolated lesion in the proximal left anterior descending artery require an interdisciplinary approach. Patients should be informed about the alternative treatment options and about the rates of success and of periprocedural events among patients with lesions morphologically similar to theirs.
We are indebted to Carola Dönath and Kathrin Luderer for performing the quantitative angiographic analysis and to Dr. Goetz Gelbrich, biometrician at the Coordination Center for Clinical Trials, Leipzig, Germany, for his assistance with statistical analysis.
Source Information
From the Department of Cardiac Surgery (A.D., V.F., F.W.M.) and the Department of Internal Medicine and Cardiology (H.T., R.H., N.S., P.S., K.W.D., G.S.), University of Leipzig Heart Center, Leipzig, Germany.
Address reprint requests to Dr. Schuler at the Department of Internal Medicine and Cardiology, University of Leipzig Heart Center, Strümpellstr. 39, 04289 Leipzig, Germany, or at schug@medizin.uni-leipzig.de.
- References
References
1
Varnauskas E, European Coronary Surgery Study Group
Full Text | Web of Science | Medline2
Klein LW ,Weintraub WS ,Agarwal JB , et al. Prognostic significance of severe narrowing of the proximal portion of the left anterior descending coronary artery. Am J Cardiol 1986;58:42-46
CrossRef | Web of Science | Medline3
Hueb WA ,Bellotti G ,de Oliveira SA , et al. The Medicine, Angioplasty or Surgery Study (MASS): a prospective, randomized trial of medical therapy, balloon angioplasty or bypass surgery for single proximal left anterior descending artery stenoses. J Am Coll Cardiol 1995;26:1600-1605
CrossRef | Web of Science | Medline4
Parisi AF ,Folland ED ,Hartigan P . A comparison of angioplasty with medical therapy in the treatment of single-vessel coronary artery disease. N Engl J Med 1992;326:10-16
Full Text | Web of Science | Medline5
Goy JJ ,Eeckhout E ,Burnand B , et al. Coronary angioplasty versus left internal mammary artery grafting for isolated proximal left anterior descending artery stenosis. Lancet 1994;343:1449-1453
CrossRef | Web of Science | Medline6
Goy JJ ,Eeckhout E ,Moret C , et al. Five-year outcome in patients with isolated proximal left anterior descending coronary artery stenosis treated by angioplasty or left internal mammary artery grafting: a prospective trial. Circulation 1999;99:3255-3259
Web of Science | Medline7
The Writing Group for the Bypass Angioplasty Revascularization Investigation (BARI) Investigators
CrossRef | Web of Science8
Henderson RA ,Pocock SJ ,Sharp SJ , et al. Long-term results of RITA-1 trial: clinical and cost comparisons of coronary angioplasty and coronary-artery bypass grafting. Lancet 1998;352:1419-1425
CrossRef | Web of Science | Medline9
Pocock SJ ,Henderson RA ,Rickards AF , et al. Meta-analysis of randomised trials comparing coronary angioplasty with bypass surgery. Lancet 1995;346:1184-1189
CrossRef | Web of Science | Medline10
Fischman DL ,Leon MB ,Baim DS , et al. A randomized comparison of coronary-stent placement and balloon angioplasty in the treatment of coronary artery disease. N Engl J Med 1994;331:496-501
Full Text | Web of Science | Medline11
Serruys PW ,de Jaegere P ,Kiemeneij F , et al. A comparison of balloon-expandable-stent implantation with balloon angioplasty in patients with coronary artery disease. N Engl J Med 1994;331:489-495
Full Text | Web of Science | Medline12
Versaci F ,Gaspardone A ,Tomai F ,Crea F ,Chiariello L ,Gioffre PA . A comparison of coronary-artery stenting with angioplasty for isolated stenosis of the proximal left anterior descending coronary artery. N Engl J Med 1997;336:817-822
Full Text | Web of Science | Medline13
Calafiore AM ,Giammarco GD ,Teodori G , et al. Left anterior descending coronary artery grafting via left anterior small thoracotomy without cardiopulmonary bypass. Ann Thorac Surg 1996;61:1658-1663
CrossRef | Web of Science | Medline14
Calafiore AM ,Di Giammarco G ,Teodori G , et al. Midterm results after minimally invasive coronary surgery (LAST operation). J Thorac Cardiovasc Surg 1998;115:763-771
CrossRef | Web of Science | Medline15
Diegeler A ,Falk V ,Matin M , et al. Minimally invasive coronary artery bypass grafting without cardiopulmonary bypass: early experience and follow-up. Ann Thorac Surg 1998;66:1022-1025
CrossRef | Web of Science | Medline16
Campeau L . Grading of angina pectoris. Circulation 1976;54:522-523
Web of Science | Medline17
Ellis SG ,Vandormael MG ,Crowley MJ , et al. Coronary morphologic and clinical determinants of procedural outcome with angioplasty for multivessel coronary disease: implications for patient selection. Circulation 1990;82:1193-1202
CrossRef | Web of Science | Medline18
Frierson JH ,Dimas AP ,Whitlow PL , et al. Angioplasty of the proximal left anterior descending coronary artery: initial success and long-term follow-up. J Am Coll Cardiol 1992;19:745-751
CrossRef | Web of Science | Medline19
Carrozza JP Jr ,Kuntz RE ,Levine MJ , et al. Angiographic and clinical outcome of intracoronary stenting: immediate and long-term results from a large single-center experience. J Am Coll Cardiol 1992;20:328-337
CrossRef | Web of Science | Medline20
Kastrati A ,Schomig A ,Elezi S , et al. Predictive factors of restenosis after coronary stent placement. J Am Coll Cardiol 1997;30:1428-1436
CrossRef | Web of Science | Medline21
Kastrati A ,Mehilli J ,Dirschinger J , et al. Intracoronary Stenting and Angiographic Results: Strut Thickness Effect on Restenosis Outcome (ISAR-STEREO) trial. Circulation 2001;103:2816-2821
Web of Science | Medline22
The EPILOG Investigators
Full Text | Web of Science | Medline23
ESPRIT Investigators
CrossRef | Web of Science | Medline24
Kastrati A ,Schomig A ,Elezi S , et al. Prognostic value of the modified American College of Cardiology/American Heart Association stenosis morphology classification for long-term angiographic and clinical outcome after coronary stent placement. Circulation 1999;100:1285-1290
Web of Science | Medline25
Sousa JE ,Costa MA ,Abizaid A , et al. Lack of neointimal proliferation after implantation of sirolimus-coated stents in human coronary arteries: a quantitative coronary angiography and three-dimensional intravascular ultrasound study. Circulation 2001;103:192-195
Web of Science | Medline26
Teirstein PS ,Massullo V ,Jani S , et al. Catheter-based radiotherapy to inhibit restenosis after coronary stenting. N Engl J Med 1997;336:1697-1703
Full Text | Web of Science | Medline27
Mack MJ ,Magovern JA ,Acuff TA , et al. Results of graft patency by immediate angiography in minimally invasive coronary artery surgery. Ann Thorac Surg 1999;68:383-389
CrossRef | Web of Science | Medline28
Diegeler A ,Hirsch R ,Schneider F , et al. Neuromonitoring and neurocognitive outcome in off-pump versus conventional coronary bypass surgery. Ann Thorac Surg 2000;69:1162-1166
CrossRef | Web of Science | Medline29
Diegeler A ,Doll N ,Rauch T , et al. Humoral immune response during coronary artery bypass grafting: a comparison of limited approach, “off-pump“ technique, and conventional cardiopulmonary bypass. Circulation 2000;102:Suppl III:III-9530
Calafiore AM ,Teodori G ,Di Giammarco G , et al. Minimally invasive coronary artery bypass grafting on a beating heart. Ann Thorac Surg 1997;63:Suppl:S72-S75
CrossRef | Web of Science | Medline31
Gill IS ,Higginson LA ,Maharajh GS ,Keon WJ . Early and follow-up angiography in minimally invasive coronary bypass without mechanical stabilization. Ann Thorac Surg 2000;69:56-60
CrossRef | Web of Science | Medline
- Citing Articles (55)
Citing Articles
1
A. Diegeler. (2011) Koronare Bypassoperation ohne Einsatz der Herz-Lungen-Maschine. Zeitschrift für Herz-,Thorax- und Gefäßchirurgie
CrossRef2
L. David Hillis, Peter K. Smith, Jeffrey L. Anderson, John A. Bittl, Charles R. Bridges, John G. Byrne, Joaquin E. Cigarroa, Verdi J. DiSesa, Loren F. Hiratzka, Adolph M. Hutter, Michael E. Jessen, Ellen C. Keeley, Stephen J. Lahey, Richard A. Lange, Martin J. London, Michael J. Mack, Manesh R. Patel, John D. Puskas, Joseph F. Sabik, Ola Selnes, David M. Shahian, Jeffrey C. Trost, Michael D. Winniford. (2011) 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery. Journal of the American College of Cardiology
CrossRef3
Glenn N. Levine, Eric R. Bates, James C. Blankenship, Steven R. Bailey, John A. Bittl, Bojan Cercek, Charles E. Chambers, Stephen G. Ellis, Robert A. Guyton, Steven M. Hollenberg, Umesh N. Khot, Richard A. Lange, Laura Mauri, Roxana Mehran, Issam D. Moussa, Debabrata Mukherjee, Brahmajee K. Nallamothu, Henry H. Ting. (2011) 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention. Journal of the American College of Cardiology
CrossRef4
Seshasayee Narasimhan, Vankeepuram S. Srinivas, Joseph John DeRose. (2011) Hybrid Coronary Revascularization. Cardiology in Review 19:3, 101-107
CrossRef5
Glenn N. Levine, Eric R. Bates, James C. Blankenship, Steven R. Bailey, John A. Bittl, Bojan Cercek, Charles E. Chambers, Stephen G. Ellis, Robert A. Guyton, Steven M. Hollenberg, Umesh N. Khot, Richard A. Lange, Laura Mauri, Roxana Mehran, Issam D. Moussa, Debabrata Mukherjee, Brahmajee K. Nallamothu, Henry H. Ting, Alice K. Jacobs, Jeffrey L. Anderson, Nancy Albert, Mark A. Creager, Steven M. Ettinger, Robert A. Guyton, Jonathan L. Halperin, Judith S. Hochman, Frederick G. Kushner, E. Magnus Ohman, William Stevenson, Clyde W. Yancy. (2011) 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention. Catheterization and Cardiovascular Interventionsn/a-n/a
CrossRef6
Fiona M Clement, Braden J Manns, Brenda Brownell, Peter D Faris, Michelle M Graham, Karin Humphries, Michael Love, Merril L Knudtson, William A Ghali. (2011) A multi-region assessment of population rates of cardiac catheterization and yield of high-risk coronary artery disease. BMC Health Services Research 11:1, 323
CrossRef7
J. James Edelman, Tristan D. Yan, Ratnasari Padang, Paul G. Bannon, Michael P. Vallely. (2010) Off-Pump Coronary Artery Bypass Surgery Versus Percutaneous Coronary Intervention: A Meta-Analysis of Randomized and Nonrandomized Studies. The Annals of Thoracic Surgery 90:4, 1384-1390
CrossRef8
Holger Thiele, Steffen Desch, Volkmar Falk. (2010) Comparing MIDCAB surgery and stenting for isolated proximal left anterior descending stenosis. Interventional Cardiology 2:2, 199-208
CrossRef9
Brian J. Page, Dmitriy Kireyev, William E. Boden. (2010) The Role of Revascularization Versus Medical Therapy in Patients With Type 2 Diabetes Mellitus and Coronary Artery Disease. Current Diabetes Reports 10:1, 10-15
CrossRef10
Holger Thiele, Volkmar Falk. (2010) Coronary Artery Bypass Graft Versus Drug-Eluting Stent for High-Risk Proximal Left Anterior Descending Stenosis. Current Treatment Options in Cardiovascular Medicine 12:1, 36-45
CrossRef11
Joseph John DeRose. (2009) Current State of Integrated “Hybrid” Coronary Revascularization. Seminars in Thoracic and Cardiovascular Surgery 21:3, 229-236
CrossRef12
Alfredo Ceballos, Mark A. Chaney, Pierre T. LeVan, Joseph J. DeRose, Francis Robicsek. (2009) Case 3—2009 Robotically Assisted Cardiac Surgery. Journal of Cardiothoracic and Vascular Anesthesia 23:3, 407-416
CrossRef13
Holger Thiele, Patrick Neumann-Schniedewind, Stephan Jacobs, Enno Boudriot, Thomas Walther, Friedrich-Wilhelm Mohr, Gerhard Schuler, Volkmar Falk. (2009) Randomized Comparison of Minimally Invasive Direct Coronary Artery Bypass Surgery Versus Sirolimus-Eluting Stenting in Isolated Proximal Left Anterior Descending Coronary Artery Stenosis. Journal of the American College of Cardiology 53:25, 2324-2331
CrossRef14
Ricardo P. J. Budde, Patricia F. A. Bakker, Paul F. Gründeman, Cornelius Borst. (2009) High-frequency epicardial ultrasound: review of a multipurpose intraoperative tool for coronary surgery. Surgical Endoscopy 23:3, 467-476
CrossRef15
Ferdinando Varbella, Andrea Gagnor, Francesco Tomassini, Vincenzo Infantino, Maria Rosa Conte. (2008) Immediate and long-term results of treatment of complex lesions of the left anterior descending coronary artery involving a large diagonal branch with drug-eluting stents. Journal of Cardiovascular Medicine 9:11, 1088-1094
CrossRef16
Bob Kiaii, R. Scott McClure, Peter Stewart, Reiza Rayman, Stuart A. Swinamer, Yoshihiro Suematsu, Stephanie Fox, Jennifer Higgins, Caroline Albion, William J. Kostuk, David Almond, Kumar Sridhar, Patrick Teefy, George Jablonsky, Pantelis Diamantouros, Wojciech B. Dobkowski, Philip Jones, Daniel Bainbridge, Ivan Iglesias, John Murkin, Davy Cheng, Richard J. Novick. (2008) Simultaneous integrated coronary artery revascularization with long-term angiographic follow-up. The Journal of Thoracic and Cardiovascular Surgery 136:3, 702-708
CrossRef17
Barry Reicher, Robert S. Poston, Mandeep R. Mehra, Ashish Joshi, Patrick Odonkor, Zachary Kon, Peter A. Reyes, David A. Zimrin. (2008) Simultaneous “hybrid” percutaneous coronary intervention and minimally invasive surgical bypass grafting: Feasibility, safety, and clinical outcomes. American Heart Journal 155:4, 661-667
CrossRef18
Zachary N. Kon, Emile N. Brown, Richard Tran, Ashish Joshi, Barry Reicher, Michael C. Grant, Seeta Kallam, Nicholas Burris, Ingrid Connerney, David Zimrin, Robert S. Poston. (2008) Simultaneous hybrid coronary revascularization reduces postoperative morbidity compared with results from conventional off-pump coronary artery bypass. The Journal of Thoracic and Cardiovascular Surgery 135:2, 367-375
CrossRef19
Robert S. Poston, Richard Tran, Michael Collins, Marty Reynolds, Ingrid Connerney, Barry Reicher, David Zimrin, Bartley P. Griffith, Stephen T. Bartlett. (2008) Comparison of Economic and Patient Outcomes With Minimally Invasive Versus Traditional Off-Pump Coronary Artery Bypass Grafting Techniques. Transactions of the ... Meeting of the American Surgical Association 126, 281-289
CrossRef20
Jae-Won Lee, Sung Ho Jung, Hyung Gon Je. (2008) Minimally Invasive Cardiac Surgery. Journal of the Korean Medical Association 51:4, 335
CrossRef21
Valavanur A. Subramanian, Didier F. Loulmet, Nirav C. Patel. (2007) Minimally Invasive Coronary Artery Bypass Grafting. Seminars in Thoracic and Cardiovascular Surgery 19:4, 281-288
CrossRef22
Konstantinos Toutouzas, Chrysoula Patsa, Sophia Vaina, Eleftherios Tsiamis, Manolis Vavuranakis, Elli Stefanadi, Anastasios Spanos, Dimitiros Iliopoulos, Mathaios Panagiotou, Ioannis Chlorogiannis, Eustratios Pattakos, Christodoulos Stefanadis. (2007) Drug eluting stents versus coronary artery bypass surgery in patients with isolated proximal lesion in left anterior descending artery suffering from chronic stable angina. Catheterization and Cardiovascular Interventions 70:6, 832-837
CrossRef23
Cheol Whan Lee, Chong-Hiok Tan, Jon Suh, Se-Whan Lee, Duk-Woo Park, Seung-Whan Lee, Young-Hak Kim, Myeong-Ki Hong, Jae-Joong Kim, Seong-Wook Park, Seung-Jung Park. (2007) Sirolimus-eluting stent implantation for treatment of proximal left anterior descending coronary artery lesions: Long-term outcome and predictors of adverse cardiac events. Catheterization and Cardiovascular Interventions 70:3, 368-373
CrossRef24
Didier de Cannière, Gerhard Wimmer-Greinecker, Romuald Cichon, Vassilios Gulielmos, Frank Van Praet, Usha Seshadri-Kreaden, Volkmar Falk. (2007) Feasibility, safety, and efficacy of totally endoscopic coronary artery bypass grafting: Multicenter European experience. The Journal of Thoracic and Cardiovascular Surgery 134:3, 710-716
CrossRef25
Eun-Hwan Oh, Yuichi Imanaka, Kenshi Hayashida, Hiroe Kobuse. (2007) Meta-analysis comparing clinical effectiveness of drug-eluting stents, bare metal stents and coronary artery bypass surgery. International Journal of Evidence-Based Healthcare 5:3, 296-304
CrossRef26
M. Ruß, E. Fleck, K. Graf, E. Gams, K. Werdan. (2007) Chronische koronare Herzkrankheit. Der Kardiologe 1:1, 55-70
CrossRef27
Ahmed A. Khattab, Christian W. Hamm, Jochen Senges, Ralph Toelg, Volker Geist, Tassilo Bonzel, Malte Kelm, Benny Levenson, Christoph A. Nienaber, Georg Sabin, Ulrich Tebbe, Steffen Schneider, Gert Richardt. (2007) Incidence and predictors of target vessel revascularization after sirolimus-eluting stent treatment for proximal left anterior descending artery stenoses among 2274 patients fromthe prospectivemulticenter German Cypher Stent Registry. Clinical Research in Cardiology 96:5, 279-284
CrossRef28
Daniel Bainbridge, Davy Cheng, Janet Martin, Richard Novick. (2007) Does off-pump or minimally invasive coronary artery bypass reduce mortality, morbidity, and resource utilization when compared with percutaneous coronary intervention? A meta-analysis of randomized trials. The Journal of Thoracic and Cardiovascular Surgery 133:3, 623-631
CrossRef29
David M. Holzhey, Stephan Jacobs, Michael Mochalski, Thomas Walther, Holger Thiele, Friedrich W. Mohr, Volkmar Falk. (2007) Seven-Year Follow-up After Minimally Invasive Direct Coronary Artery Bypass: Experience With More Than 1300 Patients. The Annals of Thoracic Surgery 83:1, 108-114
CrossRef30
Yanai Ben-Gal, Rephael Mohr, Rony Braunstein, Ariel Finkelstein, Natalie Hansson, Alberto Hendler, Yaron Moshkovitz, Gideon Uretzky. (2006) Revascularization of Left Anterior Descending Artery With Drug-Eluting Stents: Comparison With Minimally Invasive Direct Coronary Artery Bypass Surgery. The Annals of Thoracic Surgery 82:6, 2067-2071
CrossRef31
Anuj Gupta, James Burke, Alfred Bove. (2006) Coronary artery revascularization: Past, present, future: Part II-newer technologies. Clinical Cardiology 29:8, 341-344
CrossRef32
Thomas A. Vassiliades, John S. Douglas, Douglas C. Morris, Peter C. Block, Ziyad Ghazzal, S. Tanveer Rab, Christopher U. Cates. (2006) Integrated coronary revascularization with drug-eluting stents: Immediate and seven-month outcome. The Journal of Thoracic and Cardiovascular Surgery 131:5, 956-962
CrossRef33
Ricardo P.J. Budde, Patricia F.A. Bakker, Rudy Meijer, Cornelius Borst, Paul F. Gründeman. (2006) Ultrasound Mini-Transducer with Malleable Handle for Coronary Artery Surgery. The Annals of Thoracic Surgery 81:1, 322-326
CrossRef34
Brett C. Sheridan, Michael R. Mill. 2006. Revascularización quirúrgica coronaria. , 112-118.
CrossRef35
George Dangas, Stephen G. Ellis, Richard Shlofmitz, Stanley Katz, David Fish, Steven Martin, Roxana Mehran, Mary E. Russell, Gregg W. Stone. (2005) Outcomes of paclitaxel-eluting stent implantation in patients with stenosis of the left anterior descending coronary artery. Journal of the American College of Cardiology 45:8, 1186-1192
CrossRef36
A. A. Khattab, C. W. Hamm, J. Senges, R. Toelg, V. Geist, T. Bonzel, M. Kelm, B. Levenson, C. A. Nienaber, G. Sabin, S. Schneider, U. Tebbe, G. Richardt. (2005) Sirolimus-eluting stent treatment for isolated proximal left anterior descending artery stenoses. Zeitschrift f
r Kardiologie 94:3, 187-192
CrossRef37
Kerem M. Vural, Zafer H. Iscan, Ayşegul Kunt, Erol Sener, Oguz Tasdemir. (2005) Off-Pump, In Situ Internal Thoracic Artery Grafting: A Durable Treatment for Single-Vessel Coronary Artery Disease. The Annals of Thoracic Surgery 79:3, 814-818
CrossRef38
Joaquín J. Alonso Martín, Alejandro Curcio Ruigómez, Carmen Cristóbal Varela, María Nieves Tarín Vicente, José María Serrano Antolín, Pedro Talavera Calle, Catherine Graupner Abad. (2005) Indicaciones de revascularización: aspectos clínicos. Revista Española de Cardiología 58:2, 198-216
CrossRef39
Volkmar Falk, Thomas Walther, Stephan Jacobs, Randall K. Wolf, Friedrich W. Mohr. (2005) Facilitated MIDCAB Using a Magnetic Coupling Device. The Annals of Thoracic Surgery 79:2, 691-693
CrossRef40
Ameet Bakhai, Ruaraidh A Hill, Yenal Dundar, Rumona C Dickson, Tom Walley, Ruaraidh A Hill. 2005. Percutaneous transluminal coronary angioplasty with stents versus coronary artery bypass grafting for people with stable angina or acute coronary syndromes. .
CrossRef41
Soon Jun Hong, Do-Sun Lim, Hong Seog Seo, Young-Hoon Kim, Wan Joo Shim, Chang Gyu Park, Dong Joo Oh, Young Moo Ro. (2005) Percutaneous coronary intervention with drug-eluting stent implantation vs. minimally invasive direct coronary artery bypass (MIDCAB) in patients with left anterior descending coronary artery stenosis. Catheterization and Cardiovascular Interventions 64:1, 75-81
CrossRef42
Nedy Brambilla, Alessandra Repetto, Ezio Bramucci, Umberto Canosi, Maurizio Ferrario, Luigi Angoli, Marco Aiello, Mauro Rinaldi, Catherine Klersy, Mario Vigan
CrossRef43
Douglas West, Marcus Flather, John Pepper, Richard Trimlett, John Yap, Anthony De Souza. (2004) Improved Recovery after the Endoscopic Atraumatic Coronary Artery Bypass Procedure Compared with Sternotomy for Off-Pump Bypass of the Left Internal Thoracic Artery to the Left Anterior Descending Coronary Artery: A Case-Matched Study. The Heart Surgery Forum 7:6, E546-E550
CrossRef44
Kim A. Eagle, Robert A. Guyton, Ravin Davidoff, Fred H. Edwards, Gordon A. Ewy, Timothy J. Gardner, James C. Hart, Howard C. Herrmann, L. David Hillis, Adolph M. Hutter, Bruce Whitney Lytle, Robert A. Marlow, William C. Nugent, Thomas A. Orszulak, Elliott M. Antman, Sidney C. Smith, Joseph S. Alpert, Jeffrey L. Anderson, David P. Faxon, Valentin Fuster, Raymond J. Gibbons, Gabriel Gregoratos, Jonathan L. Halperin, Loren F. Hiratzka, Sharon Ann Hunt, Alice K. Jacobs, Joseph P. Ornato. (2004) ACC/AHA 2004 Guideline Update for Coronary Artery Bypass Graft Surgery: Summary Article. Journal of the American College of Cardiology 44:5, 1146-1154
CrossRef45
Artur Lichtenberg, Uwe Klima, Hans Paeschke, Max Pichlmaier, Stefanie Ringes-Lichtenberg, Thorsten Walles, Heidi Goerler, Axel Haverich. (2004) Impact of multivessel coronary artery disease on outcome after isolated minimally invasive bypass grafting of the left anterior descending artery. The Annals of Thoracic Surgery 78:2, 487-491
CrossRef46
Artur Lichtenberg, Uwe Klima, Hans Paeschke, Max Pichlmaier, Stefanie Ringes-Lichtenberg, Thorsten Walles, Heidi Goerler, Axel Haverich. (2004) Impact of diabetes on outcome following isolated minimally invasive bypass grafting of the left anterior descending artery. The Annals of Thoracic Surgery 78:1, 129-134
CrossRef47
Amit Banerjee, Subodh Satyarth, Nikhil Pendse. (2004) Was it unethical to do what we did?. Indian Journal of Thoracic and Cardiovascular Surgery 20:3, 149-150
CrossRef48
Roberto Casula, Thanos Athanasiou, Rodney Foale. (2004) Recent advances in minimal-access cardiac surgery using robotic-enhanced surgical systems. Expert Review of Cardiovascular Therapy 2:4, 589-600
CrossRef49
Harpreet Singh Grewal, Marco A Zenati, Robert Kormos, Srinivas Murali, William E Katz. (2004) Serial dobutamine stress echocardiography with Doppler assessment of the left internal thoracic artery graft after minimally invasive bypass for a patient with an orthotopic heart transplant. The Journal of Heart and Lung Transplantation 23:2, 256-259
CrossRef50
Khan, Natasha E., De Souza, Anthony, Mister, Rebecca, Flather, Marcus, Clague, Jonathan, Davies, Simon, Collins, Peter, Wang, Duolao, Sigwart, Ulrich, Pepper, John, . (2004) A Randomized Comparison of Off-Pump and On-Pump Multivessel Coronary-Artery Bypass Surgery. New England Journal of Medicine 350:1, 21-28
Full Text51
W.Douglas Boyd, Kenneth D Stahl. (2003) The janus syndrome: a perspective on a new era of computer-enhanced robotic cardiac surgery. The Journal of Thoracic and Cardiovascular Surgery 126:3, 625-630
CrossRef52
Patrick I. McConnell, E. William Schneeberger, Robert E. Michler. (2003) History and Development of Robotic Cardiac Surgery. Problems in General Surgery 20:2, 20-30
CrossRef53
Slobodan Obradovic, Sinisa Rusovic, Dragan Dincic, Branko Gligic, Branislav Baskot, Bela Balint, Dragana Stamatovic, Radoslav Romanovic, Andjelka Ristic, Zoran Trifunovic. (2003) Autologous pluripotent progenitor cells in the treatment of ischemic heart disease. Vojnosanitetski pregled 60:6, 725-731
CrossRef54
(2002) Minimally Invasive Bypass Surgery. New England Journal of Medicine 347:26, 2165-2168
Full Text55
MacGillivray, Thomas E., Vlahakes, Gus J., . (2002) Angioplasty versus Minimally Invasive Bypass Surgery. New England Journal of Medicine 347:8, 551-552
Full Text
- Letters
