Home » Coronary artery bypass grafting, does the operation pose greater risks for women?

Coronary artery bypass grafting, does the operation pose greater risks for women?

by admin
Coronary artery bypass grafting, does the operation pose greater risks for women?

by Marco Agrifoglio

Women have worse mortality and morbidity in both the short and long term because, at the time of diagnosis and possible surgery, they have greater pre-operative risk factors

I read that coronary bypass is a procedure that carries risks for women: is this true?

Marco Agrifoglio, associate professor of cardiac surgery, University of Milan, responds; Monzino IRCCS Cardiology Center (GO TO THE FORUM)

Coronary artery bypass surgery (CABG) is considered the treatment of choice in patients suffering from multivessel coronary artery disease, because it restores blood flow in the diseased coronary arteries. Obstructions are “bypassed” thanks to the use of arteries taken from the patient himself, located in the chest (mammary arteries) or in the forearm (radial artery) and/or in the patients’ legs (saphenous vein). However, the number of CABG operations has decreased in recent years, accompanied by the significant growth in percutaneous coronary angioplasty (PCI) procedures, including multi-district ones, performed by interventional cardiologists.

Risk factors

Recent studies evaluating the impact of sex on CABG outcomes have shown that women have worse short- and long-term mortality and morbidity. These differences can be explained by the fact that at the time of diagnosis and possible surgery, female patients have greater pre-operative risk factors (previous myocardial infarction, arterial hypertension, diabetes, peripheral vascular and cerebrovascular disease). Furthermore, these patients present themselves late in the emergency room with different and more serious symptoms and long-lasting pain. Anatomically, the coronary vessels have a smaller caliber and therefore are more difficult to operate.

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Multifactorial approach

It was also found that fewer arterial and venous CABGs are performed and that the risk of bypass closure is increased compared to men. Such differences are also observed after PCI, where women show a greater risk of adverse cardiovascular events at 5 years compared to men after the cardiac procedure. The reduction of mortality in women after CABG probably requires a multifactorial approach evaluating risk, clinical presentation, diagnosis, pathology of coronary artery disease and operative therapy for differences in anatomy (small caliber coronary arteries), microcirculation (coronary arteries with greater vasospasm).

The experience of surgeons

Furthermore, to improve results in women it is essential that the CABG procedure is scrupulously performed by cardiac surgeons expert in coronary surgery and especially in the use of arterial conduits (mammary arteries, radial) compared to the saphenous vein, which has higher closure rates ( 50% at 10 years). Many studies highlight that bypass with left internal mammary artery, considered the gold standard (98% patency at 10 years), bypass with bilateral internal mammary artery or with radial artery, are performed more rarely, with the effect that arterial revascularization is obtained less frequently and less completely in female patients.

Studies conducted on men

In conclusion, the current diagnostic and therapeutic protocols for coronary revascularization are all based on studies conducted predominantly in male patients (>80%), proving inadequate for women. It is hoped that prospective studies such as ROMA («Randomization of single vs. multiple arterial grafts in women») will provide important data on the optimal surgical strategy for women undergoing CABG and a definitive answer to this debate.

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March 5, 2024

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