title: Coronary surgery in patients with peripheral vascular disease: effect of avoiding cardiopulmonary bypass.
abstract: BACKGROUND
  An increasing number of patients with peripheral vascular disease are undergoing coronary artery bypass grafting. Such patients have an increased risk of adverse outcomes. Our aim was to quantify the effect of avoiding cardiopulmonary bypass in this group of patients.
  
  
  METHODS
  Between April 1997 and March 2002, 3,771 consecutive patients underwent coronary artery bypass grafting performed by five surgeons. Four hundred and twenty-two (11.2%) had peripheral vascular disease and of these, 211 (50%) received off-pump surgery. We used multivariate logistic regression analysis to assess the effect of off-pump surgery on in-hospital mortality and morbidity, while adjusting for treatment selection bias. Treatment selection bias was controlled for by constructing a propensity score, which was the probability of receiving off-pump surgery and included core patient characteristics. The C statistic for this model was 0.8.
  
  
  RESULTS
  Off-pump patients were more likely to have preoperative renal dysfunction, previous gastrointestinal surgery, and less extensive disease. The left internal mammary artery was used more in off-pump compared to on-pump cases (90.1% vs 82.9%; p = 0.033). In the univariate analyses, off-pump patients were less likely to have a postoperative stroke (p = 0.007), and had shorter postoperative hospital stays (p < 0.001). However, the incidence of new atrial arrhythmia was higher (p = 0.028). After adjustment for differences in case-mix (propensity score), avoidance of cardiopulmonary bypass was still associated with a significant reduction in postoperative stroke (adjusted odds ratio 0.09 [95% confidence interval 0.02 to 0.50]; p = 0.005), and shorter postoperative hospital stay (p = 0.001).
  
  
  CONCLUSIONS
  Off-pump coronary surgery is safe in patients with peripheral vascular disease, with acceptable results. The incidence of postoperative stroke is substantially reduced when avoiding cardiopulmonary bypass in patients with peripheral vascular disease.
authors.affiliation: Department of Cardiothoracic Surgery, The Cardiothoracic Centre, Liverpool, United Kingdom.
authors.forename: Shishir
authors.initials: S
authors.lastname: Karthik
authors.forename: Ghassan
authors.initials: G
authors.lastname: Musleh
authors.forename: Antony D
authors.initials: AD
authors.lastname: Grayson
authors.forename: Daniel J M
authors.initials: DJ
authors.lastname: Keenan
authors.forename: D Mark
authors.initials: DM
authors.lastname: Pullan
authors.forename: Walid C
authors.initials: WC
authors.lastname: Dihmis
authors.forename: Ragheb
authors.initials: R
authors.lastname: Hasan
authors.forename: Brian M
authors.initials: BM
authors.lastname: Fabri
mesh_terms: D000368:Aged; D002315:Cardiopulmonary Bypass / Q000009:adverse effects*; D001026:Coronary Artery Bypass / Q000009:adverse effects*; D003327:Coronary Disease / Q000150:complications / Q000601:surgery; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016491:Peripheral Vascular Diseases / Q000150:complications; D011183:Postoperative Complications; D012307:Risk Factors; D020521:Stroke / Q000209:etiology