title: Impact of extracardiac vascular disease on vein graft failure and outcomes after coronary artery bypass surgery.
abstract: BACKGROUND
  While extracardiac vascular disease (ECVD), defined as a history of peripheral vascular disease (PVD) or cerebrovascular disease (CBVD), is common in patients undergoing coronary artery bypass graft (CABG) surgery, there are limited data available on the association between ECVD, vein graft failure (VGF), and clinical outcomes.
  
  
  METHODS
  Using data from the Project of Ex-vivo Vein Graft Engineering via Transfection IV (PREVENTIV) trial (n = 3,014), 1-year angiographic follow-up and 5-year clinical outcomes (death, myocardial infarction, and revascularization) were determined in patients with and without ECVD. Logistic regression was used to assess risk of VGF. Generalized estimating equations methods were used to account for correlations in a graft-level analysis. Kaplan-Meier estimates and Cox hazards regression were used to compare clinical outcomes. We similarly explored the association of the individual components CBVD and PVD with both VGF and clinical outcomes in an additive model.
  
  
  RESULTS
  Patients with ECVD (n = 634, 21%) were older, more commonly female, and had more comorbidities, lower use of internal thoracic artery grafting, and overall worse graft quality than patients without ECVD. VGF rates tended to be higher (patient-level: odds ratio [OR]: 1.23, 95% confidence interval [CI] 0.96 to 1.58, p = 0.099; graft-level: OR: 1.23, 95% CI: 1.00 to 1.53, p = 0.053) in patients with ECVD. VGF rates were significantly higher among CBVD patients (OR: 1.42, 95% CI: 1.03 to 1.97, p = 0.035; graft-level: OR: 1.40, 95% CI: 1.06 to 1.85, p = 0.019). Patients with ECVD had a higher risk of death, myocardial infarction, or revascularization 5 years after CABG surgery (hazard ratio [HR]: 2.96, 95% CI: 2.02 to 4.35, p < 0.001). This relationship was driven by the subset of patients with PVD (HR = 3.32, 95% CI: 2.16 to 5.09, p < 0.001) and not by those with CBVD (HR = 1.10, 95% CI: 0.88 to 1.37, p = 0.40).
  
  
  CONCLUSIONS
  ECVD is common among patients undergoing CABG surgery and is associated with similar short-term but increasingly worse long-term clinical outcomes. This higher risk may be partly, but not exclusively, due to higher rates of VGF among these patients.
authors.affiliation: Duke Clinical Research Institute, Durham, North Carolina; Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
authors.forename: Ralf E
authors.initials: RE
authors.lastname: Harskamp
authors.affiliation: Duke Clinical Research Institute, Durham, North Carolina.
authors.forename: John H
authors.initials: JH
authors.lastname: Alexander
authors.affiliation: Duke Clinical Research Institute, Durham, North Carolina.
authors.forename: Phillip J
authors.initials: PJ
authors.lastname: Schulte
authors.affiliation: Duke University Medical Center, Durham, North Carolina.
authors.forename: W Schuyler
authors.initials: WS
authors.lastname: Jones
authors.affiliation: Duke University Medical Center, Durham, North Carolina.
authors.forename: Judson B
authors.initials: JB
authors.lastname: Williams
authors.affiliation: Cardiopulmonary Research Science and Technology Institute, Dallas, Texas.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Mack
authors.affiliation: Duke Clinical Research Institute, Durham, North Carolina.
authors.forename: Eric D
authors.initials: ED
authors.lastname: Peterson
authors.affiliation: PERFUSE Angiographic Laboratory, Boston, Massachusetts.
authors.forename: C Michael
authors.initials: CM
authors.lastname: Gibson
authors.affiliation: Duke Translational Medicine Institute, Durham, North Carolina.
authors.forename: Robert M
authors.initials: RM
authors.lastname: Califf
authors.affiliation: Missouri Baptist Medical Center, St. Louis, Missouri.
authors.forename: Nicholas T
authors.initials: NT
authors.lastname: Kouchoukos
authors.affiliation: East Carolina University, Greenville, North Carolina.
authors.forename: T Bruce
authors.initials: TB
authors.lastname: Ferguson
authors.affiliation: Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
authors.forename: Robbert J
authors.initials: RJ
authors.lastname: de Winter
authors.affiliation: Duke Clinical Research Institute, Durham, North Carolina. Electronic address: renato.lopes@duke.edu.
authors.forename: Renato D
authors.initials: RD
authors.lastname: Lopes
mesh_terms: D000368:Aged; D002561:Cerebrovascular Disorders / Q000150:complications*; D001026:Coronary Artery Bypass; D003327:Coronary Disease / Q000150:complications* / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D016491:Peripheral Vascular Diseases / Q000150:complications*; D012189:Retrospective Studies; D012307:Risk Factors; D017211:Treatment Failure; D016896:Treatment Outcome; D014680:Veins / Q000637:transplantation*