1. CABG in diabetics: surgical aspects
Dr Raja Parvaiz Akhter
Head of Cardiac Surgery Department, PIC, Lahore.

3. Diabetic patients have a particularly high risk of cardiovascular mortality
Diabetes alone is a major risk factor
Diabetics may suffer from accelerated atherosclerosis and a high proportion demonstrates an extensive form of CAD
Diffuse peripheral involvement of the coronary circulation.

4. Patients suffering from diabetes have a higher mortality rate following myocardial infarction than those without diabetes
Reasons for this may be multiple:
Changes in the vascular endothelium under elevated blood glucose induce an impairment of the endothelium dependent vasodilatation
Due to a reduction of the synthesis or release of nitric oxide

5. Accelerated inactivation of nitric oxide by high levels of free radicals
Release of potent vasoconstrictors
Increased activation of protein kinase C
Decrease expression of inhibitory proteins causing abnormalities
in signal transduction
Reduced coronary flow reserve in diabetics and the diminished microvascular dilatation
Poorer development of collateral vessels in the coronary circulation of diabetic patients

6. Lifetime Risk of Coronary Artery Disease
Lifetime Risk of CAD Without Diabetes
CAD 5.4%
No CAD 93.8%
Lifetime Risk of CAD with Diabetes
No CAD 46%
CAD 54 %
Furnary, “Portland Continuous Intravenous Insulin Protocol: Laboratory Considerations,”

7. Diabetic Cardiac Surgery Population
Percentage of U.S. Population Without Diabetes Mellitus
Non-DM %
DM %
Percentage of Cardiac Surgery Population With Diabetes Mellitus
Non-DM %
DM %
Furnary, “Portland Continuous Intravenous Insulin Protocol: Laboratory Considerations,”

8. Revascularization in Diabetics
CABG and PTCA
do poorly in diabetics
CABG or PTCA
do not cure diabetes nor CAD

9. Diabetes mellitus, a major determinant of cardiovascular events, portends an adverse prognosis in patients with coronary artery disease regardless of treatment strategy.

10. Within the global CABG population, diabetic patients demonstrated the following particular characteristics:
They are older
The proportion of females is higher
Coronary circulation is more severely involved
Higher number of stenosis
Higher rate of prior myocardial infarction
Higher incidence of decreased left ventricular contractility and
Their overall cardiovascular risk profile is significantly
worse than in non-diabetic patients

11. Specific vascular biology in diabetes
DM have smaller vessels
Less plaque mass but greater neg. remodelling
Endothelial dysfunction
Altered platelet function and coagulation
DM have more plaque ruptures and different
plaque morphology

12. Patients with diabetes comprise 15 to 29% of surgical population
Associated with:
Longer stay
Greater infection rate
Higher operative mortality
Worse long-term prognosis

13. Specially true for patients with
In diabetic patients CABG using arterial conduits should be the preferred.
Specially true for patients with
Left main involvement,
Coronary three vessel disease with reduced LV-function and
Diffuse coronary involvement

14. Several studies demonstrate increased perioperative morbidity among diabetics, including
Neurologic Complications,
Renal dysfunction
Sternal wound infection

15. PTCA vs. CABG ARTS, arterial revascularisation therapy study
BARI, bypass angioplasty revascularisation investigation
CARDia, coronary artery revascularisation in diabetes
EAST, Emory angioplasty versus surgery trial
RITA, randomised intervention treatment of angina
SoS, stent or surgery

16. ARTS I MACCE (30 day follow-up)
CABG
(605)
Stent
(600)
Death
8+3*
1.8% 9
1.5%
CVA
7+1 *
1.3% 5
0.8%
AMI (Q)
13+4*
2.8%
15+1*
2.7%
Re-CABG 2
0.3% 12
2.0%
Re-PTCA 3
0.5% 10
1.7%
Total 41
6.8% 52
8.7%
*Events prior to assigned treatment

17. ARTS Trial (CABG v. PCI) Three year Follow-up 100 90 80 70 CABG 60 50
95.7%
87.8%
85.0%
83.6%
91.8%
CABG
Event Free Survival (%)
73.5%
69.5%
65.7%
PCI
p=0.005 Log Rank
p=0.006 Fisher
Death AMI CVA CABG Re-PCI
Days since randomization

18. Three year Follow-up (Diabetic subgroup)
ARTS Trial (CABG v. PCI)
Three year Follow-up (Diabetic subgroup)
100 90 80 70 60 50
CABG
92.7%
Death, AMI, CVA
PCI = CABG
Event Free Survival (%)
61.6%
PCI
p= Log Rank
p< Fisher
CABG Re-PCI
Days since randomization

23. BARI

25. Total No of Patients 795 Total Grafts 2309
Off - Pump VS On – Pump CABG Prospective Randomized Comparative Study From Jan to March 2007 at PIC, Lahore
Total No of Patients
Male (85.5 %)
Female (14.2 %)
On-Pump ( 41.3 %)
Off-Pump (58.7 %)
Total Grafts
Coronary Endarterectomy patients (15.8 %)

26. Diabetics Non diabetic 2 (1.0) 1 (0.3) 0.282 22 (11.2) 33 (10) 0.643
Off - Pump VS On – Pump CABG Prospective Randomized Comparative Study Complications in Diabetic CABG patients
Complications
Yes (%)
N= 242
No (%)
N = 331
p-value
Diabetics
Non diabetic
Neurological
2 (1.0)
1 (0.3)
0.282
Arrhythmias
22 (11.2)
33 (10)
0.643
Respiratory
19 (8.8)
29 (8.76)
0.986
Wound Infection
9 (3.7)
7 (2.1)
0.249
AMI
15 (6.19)
15 (4.53)
0.378
Low cardiac Output
6 (2.47)
0.019*
IABP
12 (4.95)
5 (1.5)
0.016*
Renal Failure
36 (14.87)
22 (6.64)
0.001*
Mortality
15 (6.2)
6 (1.8)
0.005*
Re-opening
5 (2.06)
0.612
Other complications
0.402

27. Low out put syndrome Diabetics VS Non- diabetics

28. Post CABG use of IABP Diabetics VS Non- diabetics

29. Post CABG Mortality Diabetics VS Non- diabetics

30. Our study – Complications in Diabetic patients

31. Recommendation
An aggressive secondary prophylaxis which is directed to correct all cardiovascular risk factors is recommended in all patients, especially in diabetics.
There are no difference to make in recommendations for long-term follow-up after PCI or CABG surgery.

32. Conclusions
Percutaneous treatment of diabetes associated coronary artery disease seems to remain challenging, despite advances in the stent technology and anti-thrombotic treatment
Acute results of PCI are comparable to those obtained in non-diabetic patients, the longterm results are in the majority of trials still Worse
There is great hope among cardiologists, that systematic use of clopidogrel, preloading, drug-eluted stents and treatment with GPIIb/IIIa inhibitors will improve the results
This may be partially true in the future, but nevertheless, all these strategies will never compete with exclusive arterial surgical revascularisation techniques with or without cardiopulmonary bypass