Publications by authors named "Usha Seshadri-Kreaden"

12 Publications

  • Page 1 of 1

Fertility and Symptom Relief following Robot-Assisted Laparoscopic Myomectomy.

Obstet Gynecol Int 2015 19;2015:967568. Epub 2015 Apr 19.

Nashville Fertility Center, 345 23rd Avenue, Nashville, TN 37203, USA.

Objective. To examine success of robot-assisted laparoscopic myomectomy (RALM) measured by sustained symptom relief and fertility. Methods. This is a retrospective survey of 426 women who underwent RALM for fibroids, symptom relief, or infertility at three practice sites across the US. We examined rates of symptom recurrence and pregnancy and factors associated with these outcomes. Results. Overall, 70% of women reported being symptom-free, with 62.9% free of symptoms after three years. At >3 years, 66.7% of women who underwent surgery to treat infertility and 80% who were also symptom-free reported achieving pregnancy. Factors independently associated with symptom recurrence included greater time after surgery, preoperative dyspareunia, multiple fibroid surgeries, smoking after surgery, and preexisting diabetes. Factors positively correlated with achieving pregnancy included desiring pregnancy, prior pregnancy, greater time since surgery, and Caucasian race. Factors negatively correlated with pregnancy were advanced age and symptom recurrence. Conclusions. This paper, the first to examine symptom recurrence after RALM, demonstrates both short- and long-term effectiveness in providing symptom relief. Furthermore, RALM may have the potential to improve the chance of conception, even in a population at high risk of subfertility, with greater benefits among those who remain symptom-free. These findings require prospective validation.
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http://dx.doi.org/10.1155/2015/967568DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4417601PMC
May 2015

The impact of robotics on the mode of benign hysterectomy and clinical outcomes.

Int J Med Robot 2016 Mar 4;12(1):114-24. Epub 2015 Mar 4.

Intuitive Surgical, Department of Clinical Affairs, Sunnyvale, CA, USA.

Background: The impact of robotics on benign hysterectomy surgical approach, clinical outcomes, and learning curve is still unclear.

Methods: Review of abdominal, vaginal, laparoscopic, or robotic cases in 156 US hospitals in the Premier Research Database.

Results: Of 289 875 hysterectomies, abdominal cases decreased from 2005-2010 (60-33%) and minimally invasive approaches increased (40-67%). Conversion rates were: 0.04% for vaginal, 2.5% for robotic, and 7.2% for laparoscopy (P < 0.001). Robotic surgery time was longest (3.4 h vs. 2.2 vaginal, 2.5 abdominal, 2.7 laparoscopy, P < 0.001). Robotic complication rate was lowest (14.8% vs. 16.2% vaginal, 18.6% laparoscopy, 28.9% abdominal, P < 0.001). Hospital stay was longer following abdominal surgery (3.5 days vs. 1.8 robotic, 1.9 vaginal, 1.8 laparoscopy, P < 0.001). Robotic surgery times and conversion and complication rates improved with experience (2.8 h, 2%, and 13.9%, respectively), even with increasing complexity.

Conclusions: Robotics was successfully incorporated without jeopardizing patient outcomes and increased the overall use of minimally invasive approaches.
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http://dx.doi.org/10.1002/rcs.1648DOI Listing
March 2016

The impact of different surgical modalities for hysterectomy on satisfaction and patient reported outcomes.

Interact J Med Res 2014 Jul 17;3(3):e11. Epub 2014 Jul 17.

Newark Beth Israel Medical Center, Minimally Invasive & Gynecologic Robotic Surgery, Newark, NJ, United States.

Background: There is an ongoing debate regarding the cost-benefit of different surgical modalities for hysterectomy. Studies have relied primarily on evaluation of clinical outcomes and medical expenses. Thus, a paucity of information on patient-reported outcomes including satisfaction, recovery, and recommendations exists.

Objective: The objective of this study was to identify differences in patient satisfaction and recommendations by approach to a hysterectomy.

Methods: We recruited a large, geographically diverse group of women who were members of an online hysterectomy support community. US women who had undergone a benign hysterectomy formed this retrospective study cohort. Self-reported characteristics and experiences were compared by surgical modality using chi-square tests. Outcomes over time were assessed with the Jonkheere-Terpstra trend test. Logistic regression identified independent predictors of patient satisfaction and recommendations.

Results: There were 6262 women who met the study criteria; 41.74% (2614/6262) underwent an abdominal hysterectomy, 10.64% (666/6262) were vaginal, 27.42% (1717/6262) laparoscopic, 18.94% (1186/6262) robotic, and 1.26% (79/6262) single-incision laparoscopic. Most women were at least college educated (56.37%, 3530/6262), and identified as white, non-Hispanic (83.17%, 5208/6262). Abdominal hysterectomy rates decreased from 68.2% (152/223) to 24.4% (75/307), and minimally invasive surgeries increased from 31.8% (71/223) to 75.6% (232/307) between 2001 or prior years and 2013 (P<.001 all trends). Trends in overall patient satisfaction and recommendations showed significant improvement over time (P<.001).There were differences across the surgical modalities in all patient-reported experiences (ie, satisfaction, time to walking, driving and working, and whether patients would recommend or use the same technique again; P<.001). Significantly better outcomes were evident among women who had vaginal, laparoscopic, and robotic procedures than among those who had an abdominal procedure. However, robotic surgery was the only approach that was an independent predictor of better patient experience; these patients were more satisfied overall (odds ratio [OR] 1.31, 95% CI 1.13-1.51) and on six other satisfaction measures, and more likely to recommend (OR 1.64, 95% CI 1.39-1.94) and choose the same modality again (OR 2.07, 95% CI 1.67-2.57). Abdominal hysterectomy patients were more dissatisfied with outcomes after surgery and less likely to recommend (OR 0.36, 95% CI 0.31-0.40) or choose the same technique again (OR 0.29, 95% CI 0.25-0.33). Quicker return to normal activities and surgery after 2007 also were independently associated with better overall satisfaction, willingness to recommend, and to choose the same surgery again.

Conclusions: Consistent with other US data, laparoscopic and robotic hysterectomy rates increased over time, with a concomitant decline in abdominal hysterectomy. While inherent shortcomings of this retrospective Web-based study exist, findings show that patient experience was better for each of the major minimally invasive approaches than for abdominal hysterectomy. However, robotic-assisted hysterectomy was the only modality that independently predicted greater satisfaction and willingness to recommend and have the same procedure again.
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http://dx.doi.org/10.2196/ijmr.3160DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4129130PMC
July 2014

Docking of the da Vinci Si Surgical System® with single-site technology.

Int J Med Robot 2013 Mar 25;9(1):12-6. Epub 2013 Jan 25.

Division of Digestive Surgery, University Hospitals Geneva, Switzerland.

Background: Strategies to spare operating room (OR) times are crucial to limiting the costs involved in robotic surgery. Among other factors, the pre-operative set-up and docking phases have been incriminated at first to be time consuming. The docking process on the standard multiport da Vinci Surgical System has not been shown to significantly prolong the overall OR time. This study aims to analyse whether the length of the docking process on the new da Vinci Si Surgical System with Single-Site™ technology remains acceptable.

Methods: We prospectively analysed all of the robotic single-incision cholecystectomies performed at our institution for docking and operating times during 2011-2012. The docking task load was assessed each time in a self-administered fashion by the docking surgeon using the NASA TLX visual scale.

Results: Sixty-four robotic single-incision cholecystectomies were included and analysed. The mean operative time was 78 min. Two surgeons with previous robotic surgery experience and a group of three less experienced robotic surgeons were responsible for docking the system. They performed 45, 10 and nine dockings, respectively. The overall mean docking time was 6.4 min with no significant difference between the groups. The docking process represented approximately 8% of the operating time. The surgeon with the most procedures showed significant progress in his docking times. The different task load parameters did not show a statistical difference between the three groups, with the exception of the frustration parameter, which was higher in the group of less experienced surgeons. There were significant correlations between docking times and the assessment of the various task load parameters.

Conclusion: The docking process for a robotic single-incision cholecystectomy is learned rapidly and does not significantly increase the overall OR time.
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http://dx.doi.org/10.1002/rcs.1481DOI Listing
March 2013

Positive surgical margin and perioperative complication rates of primary surgical treatments for prostate cancer: a systematic review and meta-analysis comparing retropubic, laparoscopic, and robotic prostatectomy.

Eur Urol 2012 Jul 24;62(1):1-15. Epub 2012 Feb 24.

Institute of Prostate Cancer and LeFrak Center for Robotic Surgery, James Buchanan Brady Foundation Department of Urology, Weill Cornell Medical College-New York Presbyterian Hospital, New York, NY 10065, USA.

Context: Radical prostatectomy (RP) approaches have rarely been compared adequately with regard to margin and perioperative complication rates.

Objective: Review the literature from 2002 to 2010 and compare margin and perioperative complication rates for open retropubic RP (ORP), laparoscopic RP (LRP), and robot-assisted LRP (RALP).

Evidence Acquisition: Summary data were abstracted from 400 original research articles representing 167,184 ORP, 57,303 LRP, and 62,389 RALP patients (total: 286,876). Articles were found through PubMed and Scopus searches and met a priori inclusion criteria (eg, surgery after 1990, reporting margin rates and/or perioperative complications, study size>25 cases). The primary outcomes were positive surgical margin (PSM) rates, as well as total intra- and perioperative complication rates. Secondary outcomes included blood loss, transfusions, conversions, length of hospital stay, and rates for specific individual complications. Weighted averages were compared for each outcome using propensity adjustment.

Evidence Synthesis: After propensity adjustment, the LRP group had higher positive surgical margin rates than the RALP group but similar rates to the ORP group. LRP and RALP showed significantly lower blood loss and transfusions, and a shorter length of hospital stay than the ORP group. Total perioperative complication rates were higher for ORP and LRP than for RALP. Total intraoperative complication rates were low for all modalities but lowest for RALP. Rates for readmission, reoperation, nerve, ureteral, and rectal injury, deep vein thrombosis, pneumonia, hematoma, lymphocele, anastomotic leak, fistula, and wound infection showed significant differences between groups, generally favoring RALP. The lack of randomized controlled trials, use of margin status as an indicator of oncologic control, and inability to perform cost comparisons are limitations of this study.

Conclusions: This meta-analysis demonstrates that RALP is at least equivalent to ORP or LRP in terms of margin rates and suggests that RALP provides certain advantages, especially regarding decreased adverse events.
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http://dx.doi.org/10.1016/j.eururo.2012.02.029DOI Listing
July 2012

Clinical and cost comparisons for hysterectomy via abdominal, standard laparoscopic, vaginal and robot-assisted approaches.

S D Med 2011 Jun;64(6):197-9, 201, 203 passim

Introduction: The goal of this study was to compare outcomes and costs of four methods of hysterectomy: abdominal, standard laparoscopic, vaginal and robot-assisted approaches.

Methods: We conducted a retrospective medical chart review of 1474 consecutive hysterectomy patients with benign indications.

Results: Implementation of a robotics program at our institution resulted in reductions in abdominal (33 percent to 8 percent) and laparoscopic (29 percent to 5 percent) hysterectomies. Robotic surgery demonstrated the least blood loss and shortest hospital stays (both p < 0.0001), despite greater case complexity. Overall complication rates were highest for abdominal procedures (14 percent) and similar across minimally invasive approaches (8 to 9 percent). Conversion rates were four times greater in laparoscopic than vaginal or robotic hysterectomy (p = 0.01). Vaginal hysterectomy, performed in the least complex cases, had the lowest major complication rate (1.5 percent) and lowest costs. Costs for robotic surgery were similar to abdominal and laparoscopic approaches when robots were not depreciated as direct surgical expenses.

Conclusions: Vaginal hysterectomy was the least expensive surgical option. Robotic surgery reduced morbidity, conversions and hospital stays even in complex cases, without incurring additional costs beyond purchase of the robotic system.
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June 2011

Comparison of outcomes and cost for endometrial cancer staging via traditional laparotomy, standard laparoscopy and robotic techniques.

Gynecol Oncol 2008 Dec 1;111(3):407-11. Epub 2008 Oct 1.

Department of Obstetrics and Gynecology, Sanford Women's Health, Sanford Clinic, Sioux Falls, SD 57105, USA.

Objectives: The study purpose was to compare hysterectomy and lymphadenectomy completed via robotic assistance, laparotomy, and laparoscopy for endometrial cancer staging with respect to operative and peri-operative outcomes, complications, adequacy of staging, and cost.

Methods: One hundred and ten patients underwent hysterectomy with bilateral salpingo-oophorectomy, pelvic and para-aortic lymphadenectomy for endometrial cancer staging. All cases were performed by a single surgeon, at a single institution (40 robotic, 40 laparotomy, and 30 laparoscopic) and were retrospectively reviewed to compare demographics and peri-operative variables including, operative time, estimated blood loss, lymph node count, hospital stay, complications, and return to normal activity. Additionally, a cost comparison between all three modalities was performed.

Results: Patients undergoing robotic assisted hysterectomy and staging experienced longer operative time than the laparotomy cohort with no difference in comparison to the laparoscopic cohort (184 min, 108.6 min, 171 min, p<0.0001, p=0.14). Estimated blood loss was significantly reduced for the robotic cohort in comparison to the laparotomy cohort and comparable to laparoscopic cohort (166 cc, 316 cc, 253 cc, p=0.01, p=0.25). The complication rate was lowest in the robotic cohort (7.5%) relative to the laparotomy (27.5%) and laparoscopic cohorts (20%) (p=0.015, p=0.03). Average return to normal activity for the robotic patients was significantly shorter than those undergoing laparotomy (24.1 days versus 52 days, p<0.0001) and those undergoing laparoscopy (31.6 days, p=0.005). Lymph node retrieval did not differ between the 3 groups (robotic 17 nodes, laparotomy 14 nodes, laparoscopic 17 nodes). The total average cost for hysterectomy with staging completed via laparotomy was $12,943.60, for standard laparoscopy $7569.80, and for robotic assistance $8212.00. The difference in cost between laparotomy and robotic cohorts was significant p=0.0001 while there was no statistically significant difference in cost between laparoscopy and robotic cohorts p=0.06.

Conclusions: Robotic hysterectomy provides comparable node retrieval to laparotomy and laparoscopic procedures in the case of the experienced laparoscopic surgeon. While robotic hysterectomy takes longer to perform than hysterectomy completed via laparotomy, it is equivalent to laparoscopic hysterectomy and provides the patient with a more expeditious return to normal activity with reduced post-operative morbidity. Additionally, the average cost for hysterectomy and staging was highest for laparotomy, followed by robotic, and least for standard laparoscopy.
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http://dx.doi.org/10.1016/j.ygyno.2008.08.022DOI Listing
December 2008

What is the learning curve for robotic assisted gynecologic surgery?

J Minim Invasive Gynecol 2008 Sep-Oct;15(5):589-94

Tacoma Women's Specialists and Tacoma General Hospital, University of Washington, Tacoma WA 98405, USA.

Study Objective: The purpose of this study was to estimate the learning curve when using the da Vinci Surgical System (Intuitive Surgical Inc., Sunnyvale, CA) in benign gynecologic cases by a team of 2 gynecologic laparoscopists.

Design: Retrospective case series (Canadian Task Force classification II-1).

Setting: A private practice obstetrics/gynecology clinic.

Patients: Patients requiring major benign gynecologic surgery who were candidates for a laparoscopic approach.

Intervention: All patients who would have otherwise been offered a transabdominal or conventional laparoscopic procedure were offered the option of having their procedure performed laparoscopically with robotic assistance. Data that were collected included robot set-up times by the operative room staff, operative times for use of robot, total operative times, and perioperative outcome. We analyzed the learning curve defined as the number of cases required to stabilize operative time to perform the various procedures.

Measurements And Main Results: One hundred thirteen patients were treated over a 22-month period with the da Vinci Surgical System. Most procedures were hysterectomies, whereas other gynecologic procedures included supracervical hysterectomy, laparoscopic vaginal assisted hysterectomy, myomectomy, sacrocolpopexy, and oophorectomy. Total operative times for hysterectomies studied sequentially stabilized at approximately 95 minutes after 50 cases. The decrease in robotic time did not depend on uterine size. The mean length of hospital stay was 24 hours, and return to normal activities averaged 2.8 weeks.

Conclusions: Robotic assisted surgery is an enabling technology that allows gynecologic surgeons the ability to offer laparoscopic procedures to most of their patients. In the hands of surgeons with advanced laparoscopic skills, the learning curve to stabilize operative times for the various surgical procedures in women requiring benign gynecolologic interventions is 50 cases.
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http://dx.doi.org/10.1016/j.jmig.2008.06.015DOI Listing
January 2009

Robotically Assisted Beating Heart Totally Endoscopic Coronary Artery Bypass (TECAB). Is There a Future?

Innovations (Phila) 2008 Mar;3(2):52-8

From the *Alliance Hospital; †Cardiac Surgical Associates of West Texas, Odessa, TX; ‡Intuitive Surgical Inc, Sunnyvale, CA; and §The University of Chicago Medical Center, Chicago, IL.

Objective: : Since the introduction of beating heart totally endoscopic coronary artery bypass (TECAB), approximately 400 patients have undergone the procedure worldwide. Despite satisfactory results and reduced morbidity, the procedure has not gained wide acceptance. This report describes the authors' experience of beating heart TECAB with robotic assistance and the potential adoption of this technique for the future.

Methods: : Between July 2004 and December 2005, 93 patients underwent successful for beating heart TECAB (47 males and 46 females). Mean age was 67.4 + 12.3 years. Fifteen (13.8%) were excluded or converted intraoperatively to thoracotomy for completion of procedure. The procedure was performed through port incisions for the robotic arms and the endostabilizer. Single or bilateral internal thoracic arteries were used as conduits. Anastomoses were done using surgical U-clips. Eighteen (19.4%) patients underwent planned hybrid revascularization. Eighty-four (90.3%) patients underwent computed tomography or conventional angiography.

Results: : Details of 93 completed revascularization cases are summarized in the tables. No in-hospital mortality, myocardial infarction, or CVA was noted. Mean operative time was 272.6 + 128.9 minutes (median, 270 minutes). Mean anastomotic time was 13.8 + 3.7 minutes. Mean length of hospital stay was 3.4 + 2.0 days (median, 3 days). At the time of study, 122 of 122 (100%) grafts were found to be patent.

Conclusions: : Single- and multivessel beating heart TECAB with or without hybrid revascularization may offer a less invasive approach in a selected group of patients.
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http://dx.doi.org/10.1097/IMI.0b013e318176778aDOI Listing
March 2008

Feasibility, safety, and efficacy of totally endoscopic coronary artery bypass grafting: multicenter European experience.

J Thorac Cardiovasc Surg 2007 Sep;134(3):710-6

Department of Cardiac Surgery at Erasme University Hospital, Brussels, Belgium.

Objective: The invention of robotic systems has begun a new era of endoscopic cardiac surgery. Reports on totally endoscopic coronary artery bypass grafting are limited, however, and data regarding feasibility, safety, and efficacy are needed to determine this technique's position in the therapeutic armamentarium. This study describes the largest multicenter experience in the literature with robotic totally endoscopic coronary artery bypass grafting specifically addressing procedural feasibility, safety, and efficacy.

Methods: Between September 1998 and November 2002, a total of 228 patients with coronary artery disease were scheduled for totally endoscopic coronary artery bypass grafting with the da Vinci Surgical System (Intuitive Surgical Inc, Sunnyvale, Calif.) at five European institutions. Patients underwent totally endoscopic coronary artery bypass grafting with either an on-pump (group A, n = 117) or an off-pump approach (group B, n = 111). Patients underwent postoperative angiography or stress electrocardiography and were followed up for 6 months.

Results: Procedural feasibility was demonstrated through the completion of 164 successful totally endoscopic cases. Sixty-four patients (group C, 28%) had conversion to nonrobotic procedures. Conversion rates decreased with time. The overall procedural efficacy, as defined by angiographic patency or lack of ischemic signs on stress electrocardiography, was 97%. The incidence of major adverse cardiac events within 6 months was 5%.

Conclusion: Both on- and off-pump totally endoscopic coronary artery bypass grafting are feasible, with a conversion rate that diminishes with increasing experience. Conversion does not adversely affect outcome and thus constitutes a safe alternative. Although target vessel reintervention may be slightly higher than that reported for open coronary artery bypass grafting, graft patency and major adverse cardiac events for both approaches are comparable to those reported in the Society of Thoracic Surgeons database, demonstrating the safety and efficacy of the totally endoscopic coronary artery bypass grafting procedure.
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http://dx.doi.org/10.1016/j.jtcvs.2006.06.057DOI Listing
September 2007

Multicenter mitral valve study: a lateral approach using the da vinci surgical system.

Innovations (Phila) 2007 Mar;2(2):56-61

From *St. Joseph Hospital, Atlanta, GA; the †Department of Surgery, Good Samaritan Hospital, Cincinnati, OH; ‡Cardiac, Vascular, and Thoracic Surgeons, Inc, Cincinnati, OH; §Sacred Heart Medical, Spokane, WA; ‖Intuitive Surgical, Sunnyvale, CA; and ¶E. Kenneth Hatton, MD, Institute for Research and Education, Cincinnati, OH.

Objective: : The purpose of this study was to demonstrate the feasibility of simple to complex endoscopic robotic mitral valve repair, using a lateral approach.

Methods: : Data were retrospectively collected on 201 patients undergoing a lateral "ports only" endoscopic robotic mitral valve repair at three institutions. Techniques of aortic occlusion included the endoaortic balloon or a transthoracic clamp. The efficacy of the repair was measured intraoperatively by transesophageal echocardiogram.

Results: : Two hundred one patients with a mean age of 55.2 ± 14.2 were intended to undergo elective robotic mitral valve surgery. One hundred eighty-six (92.5%) were scheduled for a repair procedure and 15 (7.5%) were scheduled for replacement. The repair was accomplished in 179 of 186 (96.2%) of patients. Eight patients (4.3%) required a conversion to sternotomy incision. Seven converted patients received a mitral valve repair and one received a replacement mitral valve. Mitral valve pathology included 10% isolated anterior leaflet involvement, 43% isolated posterior leaflet involvement, and 6% bileaflet pathology, and the remaining patients had dilated annulus, chordal rupture, or elongation. One hundred seventy-nine patients (96.2%) had regurgitation grade of 0 to 1 after repair. Two patients (1%) died. Other adverse events included reoperation for valve-related complications, 2 of 201 (1%); reoperation for cardiac-related complications, 3 of 201 (1.5%); and new onset of atrial fibrillation, 35 of 201 (17.4%).

Conclusions: : A lateral endoscopic robotic approach to mitral valve repair is safe, feasible, and can be performed consistently with acceptable postoperative results. Further follow-up is required to determine the long-term efficacy of this approach to robotic mitral valve repair.
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http://dx.doi.org/10.1097/IMI.0b013e31803c9b2aDOI Listing
March 2007

Integrated coronary revascularization: percutaneous coronary intervention plus robotic totally endoscopic coronary artery bypass.

Circulation 2006 Jul;114(1 Suppl):I473-6

Cardiac & Thoracic Surgical Associates (M.R.K.), Richmond, VA, USA.

Background: Robotic totally endoscopic coronary artery bypass (TECAB) of the left anterior descending artery (LAD) coupled with percutaneous coronary intervention (PCI) of a second coronary artery has been investigated in patients with multivessel disease to provide a minimally invasive therapeutic option.

Methods And Results: TECAB of the LAD was performed using the left internal mammary artery (LIMA). A second lesion was treated with PCI before surgery, simultaneously, or after surgery. Three-month angiographic follow-up was performed in all patients and was subject to independent review. A total of 27 patients requiring double vessel revascularization were treated at 7 centers. Eleven patients underwent PCI before surgery, 12 patients underwent PCI after surgery, and 4 patients underwent simultaneous surgical and percutaneous intervention. Ten patients (37%) were treated with bare metal stents, whereas 17 patients (63%) were treated with drug-eluting stents. Postoperative angiographic evaluation demonstrated an overall LIMA anastomotic patency of 96.3% and PCI vessel patency of 66.7%. There were no deaths or strokes. One patient experienced a perioperative myocardial infarction. Eight of 27 patients (29.6%) required reintervention, 1 LIMA anastomotic stenosis (3.7%), 3 after bare metal stent (30%), and 4 after drug-eluting stent placement (23.5%).

Conclusions: Integrated revascularization treatment plans provide minimally invasive options for patients with multivessel coronary artery disease. This approach may be accomplished with no mortality, low perioperative morbidity, and excellent angiographic LIMA patency. The reintervention rate after PCI in this series was higher than that reported elsewhere and should be investigated further. The choice of suitable vessel, type of stent and timing of the treatment must be carefully considered before implementing this hybrid strategy.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.105.001537DOI Listing
July 2006
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