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Elsayed et al. Vessel Plus 2018;2:39 I http://dx.doi.org/10.20517/2574-1209.2018.65 Page 9 of 11

Two of our patients suffered from postoperative MI, one of them in the LAD region (3.3 percent). Our
[16]
results compared well to rates of perioperative MI mentioned in Schmitto et al. 3 percent, Byrne et al. [17]
[19]
[18]
[15]
3 percent, Myers et al. 4 percent, Sundt et al. 2 percent and Nishi et al. 2.9 percent. There was no
difference in our study between both groups LIMA and saphenous regarding MI and this was also the case
[15]
in Myers et al. study.
There was one case of mortality in our study (3.3). Our explanation that the delay in starting anticoagulation
for this patient who was bleeding led to a MI and started this vicious cascade of events leading to death.

[20]
Nishigawa et al. reported mortality of 1.1 percent, Schmitto et al. 5 percent, Takanashi et al. 2.7
[21]
[16]
[17]
[19]
percent, Byrne et al. 3 percent, Nishi et al. 2.9 percent. In comparing LIMA to saphenous group
mortality was 4.5 percent in the LIMA group and none in the saphenous group and was not statistically
significant. Myers et al. also had 4.1% mortality in the LIMA group, slightly higher than the saphenous
[15]
[14]
patch group (3%) and was not statistically significant. Owais et al. had a 13 percent mortality in each of his
groups, with no difference between both.
The CT coronary angiography done at 6 months postoperatively showed a patency rate of 93.1 percent,
with 2 patients found to have stenotic LIMA-LAD anastomosis. One patient belonged to the LIMA group
and the other to the saphenous patch group, with no statistical difference between both. Our explanation
for the patient with occlusion in the LIMA and saphenous patch group was attributed to bleeding in the
early postoperative hours which required reexploration in the operating room and delayed the start of the
anticoagulation. The second patient had an uneventful postoperative course and this unfortunate event was
not explained in his case.

[20]
In Nishigawa et al. study conventional angiography was done at a median of 7 days (range 0-85 days) and
[21]
showed a patency rate of 91.6 percent. Takanashi et al. showed early patency of 94 percent.
[19]
Nishi et al. had early and late angiographic control of his patients. He had a 92.1 percent early patency rate
and at midterm follow up at a mean of 21 months the patency rate was 89.1.

NYHA class significantly changed in our study following surgery, with 69 percent of patients falling in
[16]
NYHA class 1 as opposed to none of the patients being in class 1 preoperatively. Schmitto et al. also noted
an improvement in NYHA class after operation.

During follow up four of our patients reported recurrence of anginal pain (13.8 percent) and they belonged
[18]
to CCS 1. There was no difference related to the technique of reconstruction. Sundt et al. reported
[17]
recurrence of angina in 27 percent of their patients. Byrne et al. reported 90 percent freedom from anginal
[22]
pain at 1 year. Sergeant et al. in their analysis of 9600 patients undergoing primary CABG reported
recurrence of anginal pain in 8 percent of patients. Both authors attributed difference in recurrence of
symptoms between patients undergoing endarterectomy and those undergoing primary grafting may be due
to the diffuse and particularly severe nature of the coronary disease present among the population requiring
endarterectomy and insufficient endarterectomy done in LAD or other territories.

Our anticoagulation protocol started with unfractionated heparin in the ICU. Some surgeons preferred
[21]
DAPT and some triple therapy with DAPT in addition to warfarin. Takanashi et al. stated their
[15]
anticoagulation protocol to be low-molecular-weight heparin, followed by triple therapy. Myers et al. used
unfractionated heparin for 24 h and then switched to either warfarin (3 months) or clopidogrel (1 year) in
addition to aspirin for life.

[19]
Nishi et al. administered low molecular weight heparin 6 h after arrival in the ICU followed by low-dose
aspirin and warfarin (INR = 2.0), which were continued indefinitely.