1. CABG IN DIABETICS DR. SEYED SAEED FARZAM

2. Introduction Patients with diabetes mellitus Increased incidence of CAD More extensive disease at angiography Worse prognosis than non-diabetic CAD >20% of all revascularisation procedures

3. Atherosclerosis in Diabetes Mellitus: Pathophysiologic Considerations Abnormal platelet function  activation and adhesion in response to shear stress  expression of GpIIb/IIIa receptors   aggregation More diffuse atherosclerosis pattern Impaired coronary flow reserve  reduced tolerance of embolization  plaque burden and more lipid-rich plaques  predisposed to rupture Impaired ability to develop collaterals  larger MIs Increased response to vascular injury  rates of restenosis and reocclusion following both balloon angioplasty and bare stent implantation

4. Indications for Revascularization CABG :  Significant left main disease : Regardless of the severity of symptoms or LV dysfunction  Patients with 3 VD that Includes LAD proximal lesion & LV dysfunction  Patients with 2 VD with LAD proximal lesion & LV dysfunction or high risk non invasive tests

5. CABG in Patients with Diabetes CABG advantage depends on use of LIMA  rates of procedure related morbidity Renal failure Wound infection Sternal wound failure Possible increased stroke risk ARTS TRIAL

6. CABG Complications Mojor morbidity ( death, stroke, Renal failure sternal infection : 13.4% in 30 days MI : 3.9% Respiratory complications Bleeding : 2-6 % reparation for bleeding Wound infection Post operative HTN Cerebrovascular complication Stroke 2.6%

7. CABG Complications AF : One of the most frequent complications of CABG up to 40% Risk of stroke Use of beta blockers reoluces post operative AF Brady arrhythmia : 0.8% need for permanent pacemaker Renal dysfunction

8. 8 SVG Patency Early occlusion : 8 – 12 % 1 year occlusion : 15 – 30 % occlusion 1 – 6 y occlusion : 2% Annually 6 – 10 occlusion : 4% Annually At 10 y :50% SVG occlusion and 20 -40% significant stenosis in Remaining

9. Arterial graft patency IMA graft patency rate 95% 1 y 90% 5 y, 85% 10 y. FULL ARTERIAL

10. 0 10 20 30 0123456789101112 Months post-procedure Repeat Revascularization, % CABG PCI/DES 944887856818792PCI/DES N 911858836825806 CABG N Log rank P<0.0001 13% 5% PCI/DES CABG REPEAT REVASCULARIZATION

11. FREEDOM Diabetic patients with CABG had better survival at two years.

12. Discussion Patients undergoing CABG had significantly lower rates of the primary endpoint including death from any cause Results consistent with reports from smaller, retrospective, cohort, underpowered and subgroup analyses in the past Previous results had shown major adverse events were driven by rates of revascularization. This study shows CABG benefit driven by decreased MI and death from any cause. Increased rate of stroke consistent in almost all previous studies and meta-analyses

13. A=venous reservoir & blood filter B=membrane oxygenator C= heat exchanger coil Cardiopulmonary Bypass Components D= CPB console E=cardioplegia reservoir

15. CABG

16. LIMA,SVG BYPASS

17. ENDARTHRECTOMY

19. SEQUENTIAL GRAFT

20. 0PCAP

21. THANK YOU FULL ARTERIAL IS THE BEST CHOICE AND NEW LIMA OR BIMA REDIAL OR RIMA SKELTONISE OR PEDICLE WOUND CARE