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. 2022 May;15(5):875-887.
doi: 10.1016/j.jcmg.2021.11.030. Epub 2022 Feb 16.

Bypass Grafting and Native Coronary Artery Disease Activity

Jacek Kwiecinski  1 , Evangelos Tzolos  2 , Alexander J Fletcher  3 , Jennifer Nash  3 , Mohammed N Meah  3 , Sebastien Cadet  4 , Philip D Adamson  3 , Kajetan Grodecki  5 , Nikhil Joshi  3 , Michelle C Williams  3 , Edwin J R van Beek  6 , Chi Lai  7 , Adriana A S Tavares  3 , Mark G MacAskill  3 , Damini Dey  5 , Andrew H Baker  3 , Jonathon Leipsic  7 , Daniel S Berman  8 , Stephanie L Sellers  7 , David E Newby  6 , Marc R Dweck  3 , Piotr J Slomka  9
Affiliations

Bypass Grafting and Native Coronary Artery Disease Activity

Jacek Kwiecinski et al. JACC Cardiovasc Imaging. 2022 May.

Abstract

Objectives: The aim of this study was to describe the potential of 18F-sodium fluoride (18F-NaF) positron emission tomography (PET) to identify graft vasculopathy and to investigate the influence of coronary artery bypass graft (CABG) surgery on native coronary artery disease activity and progression.

Background: As well as developing graft vasculopathy, CABGs have been proposed to accelerate native coronary atherosclerosis.

Methods: Patients with established coronary artery disease underwent baseline 18F-NaF PET, coronary artery calcium scoring, coronary computed tomographic angiography, and 1-year repeat coronary artery calcium scoring. Whole-vessel coronary microcalcification activity (CMA) on 18F-NaF PET and change in calcium scores were quantified in patients with and without CABG surgery.

Results: Among 293 participants (mean age 65 ± 9 years, 84% men), 48 (16%) underwent CABG surgery 2.7 years [IQR: 1.4-10.4 years] previously. Although all arterial and the majority (120 of 128 [94%]) of vein grafts showed no 18F-NaF uptake, 8 saphenous vein grafts in 7 subjects had detectable CMA. Bypassed native coronary arteries had 3 times higher CMA values (2.1 [IQR: 0.4-7.5] vs 0.6 [IQR: 0-2.7]; P < 0.001) and greater progression of 1-year calcium scores (118 Agatston unit [IQR: 48-194 Agatston unit] vs 69 [IQR: 21-142 Agatston unit]; P = 0.01) compared with patients who had not undergone CABG, an effect confined largely to native coronary plaques proximal to the graft anastomosis. In sensitivity analysis, bypassed native coronary arteries had higher CMA (2.0 [IQR: 0.4-7.5] vs 0.8 [IQR: 0.3-3.2]; P < 0.001) and faster disease progression (24% [IQR: 16%-43%] vs 8% [IQR: 0%-24%]; P = 0.002) than matched patients (n = 48) with comparable burdens of coronary artery disease and cardiovascular comorbidities in the absence of bypass grafting.

Conclusions: Native coronary arteries that have been bypassed demonstrate increased disease activity and more rapid disease progression than nonbypassed arteries, an observation that appears independent of baseline atherosclerotic plaque burden. Microcalcification activity is not a dominant feature of graft vasculopathy.

Keywords: (18)F-NaF; CABG; PET/CT; coronary artery bypass graft; coronary artery disease.

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Conflict of interest statement

Funding Support and Author Disclosures This research was supported in part by grant R01HL135557 from the National Heart, Lung, and Blood Institute. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Dr Newby (CH/09/002, RE/18/5/34216, RG/16/10/32375), Dr Tzolos (FS/CRTF/20/24086), Dr Fletcher (FS/19/15/34155), Dr Baker (RG/20/5/34796), Dr Dweck (FS/14/78/31020), and Dr Williams (FS/ICRF/20/26002) are supported by the British Heart Foundation. Dr Adamson is supported by a Heart Foundation of New Zealand Senior Fellowship (1844). Dr van Beek is supported by the Scottish Imaging Network. Dr Tzolos was supported by a grant from the Dr Miriam and Sheldon G. Adelson Medical Research Foundation. Dr Newby is a recipient of a Wellcome Trust Senior Investigator Award (WT103782AIA). Dr Dweck is a recipient of the Sir Jules Thorn Award for Biomedical Research Award (2015). Dr Sellers is supported by fellowships from the Canadian Institutes of Health Research and the Michael Smith Foundation for Health Research. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Figures

Figure 1.
Figure 1.. Measurement of 18F-sodium fluoride uptake and calculation of the coronary microcalcification activity in patients with prior coronary artery bypass graft surgery.
Three-dimensional rendering of coronary computed tomography (CT) angiography with superimposed tubular whole vessel volumes of interest (light green) employed for evaluation of 18F-sodium fluoride (18F-NaF) uptake (blue and red). The coronary microcalcification activity (CMA) is a summary measure of 18F-NaF activity across the entire coronary vasculature. (A) 63-year-old male with prominent uptake in stented saphenous vein bypass grafts (orange arrows) and native coronary arteries (green arrows) who experienced a non-fatal non-ST segment elevation myocardial infarction during follow-up. (B) 70-year old male with evident uptake in native coronary arteries (green arrows) and subtle 18F-NaF activity within coronary bypasses (orange arrows).
Figure 2.
Figure 2.. Case examples of increased 18F-sodium fluoride uptake in saphenous vein bypass grafts.
Green arrows indicate the areas of increased 18F-sodium fluoride (18F-NaF) uptake within saphenous bypass grafts (top row) and computed tomography angiography of the corresponding saphenous vein bypass grafts (bottom row). We observed increased 18F-NaF activity both in grafts with advanced atherosclerosis (Patient 2 and 3) and in the absence of such lesions (Patient 1).
Figure 3.
Figure 3.. 18F-Sodium fluoride positive saphenous vein graft.
The samples were obtained at heart transplant from a 61-year-old male patient 4 years after coronary artery bypass grafting to left circumflex artery (A) and a 72-year-old male patient 12 years after coronary artery bypass grafting to right coronary artery (B). Both patients underwent surgical revascularization due to obstructive coronary artery disease. Magnified and matched to H+E as well as Movat’s Pentachrome staining demonstrating co-localization of 18F-sodium fluoride uptake with elastin as part of fibro-intimal thickening and microcalcification (black staining on von Kossa).
Figure 4.
Figure 4.. Coronary 18F-sodium fluoride uptake in native coronary arteries in patients with or without prior coronary artery bypass graft.
Case examples of 18F-sodium fluoride (18F-NaF) activity within native coronary segments proximal to a graft (A-D) and non-grafted coronary arteries with a similar plaque burden (E-H). While all the bypassed native vessels demonstrate intense 18F-NaF uptake (CMA > 2.0), the non-bypassed vessels showed no (CMA = 0), or only very subtle 18F-NaF activity (CMA = 0.32 and 0.47 in G and H respectively).
Central Figure:
Central Figure:. Bypassed native coronary arteries demonstrate increased disease activity and faster disease progression.
Co-registered coronary CT angiography with 18F-sodium fluoride (18F-NaF) positron emission tomography (PET) and non-contrast CT at baseline and after 12 months of follow-up in a patient with (top row) and without (bottom row) a history of surgical revascularization. Despite similar co-morbidities and plaque burdens bypassed native coronary vessels demonstrate both greater disease activity (coronary microcalcification activity [CMA] on 18F-NaF PET) and more rapid disease progression (change in the coronary calcium score on CT) than non-bypassed coronary arteries.
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References

    1. Goldman S, Sethi G, Holman W, et al. Radial artery grafts vs saphenous vein grafts in coronary artery bypass surgery: A randomized trial. JAMA. 2011. 305, 167–174. doi:10.1001/jama.2010.1976. - DOI - PubMed
    1. Desai ND, Cohen EA, Naylor CD, Fremes SE. Radial Artery Patency Study Investigators. A randomized comparison of radial-artery and saphenous-vein coronary bypass grafts. N Engl J Med. 2004;351:2302–9. doi: 10.1056/NEJMoa040982. - DOI - PubMed
    1. Gaudino M, Benedetto U, Fremes S, Biondi-Zoccai Sedrakyan A, et al., for the RADIAL Investigators. Radial-artery or saphenous-vein grafts in coronary-artery bypass surgery. N Engl J Med. 2018; 378:2069–2077 DOI: 10.1056/NEJMoa171602 - DOI - PubMed
    1. Goldman S, Zadina K, Moritz T, et al. Long-term patency of saphenous vein and left internal mammary artery grafts after coronary artery bypass surgery: Results from a Department of Veterans Affairs Cooperative Study. J Am Coll Cardiol 2004;44:2149–2156. - PubMed
    1. Fitzgibbon GM, Kafka HP, Leach AJ, Keon WJ, Hooper GD, Burton JR. Coronary bypass graft fate and patient outcome: Angiographic follow-up of 5,065 grafts related to survival and reoperation in 1,388 patients during 25 years. J Am Coll Cardiol 1996;28:616–626. - PubMed

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