Associations Between Adding a Radial Artery Graft to Single and Bilateral Internal Thoracic Artery Grafts and Outcomes: Insights From the Arterial Revascularization Trial

Multiarterial vs Single-Arterial Coronary Surgery: 10-Year Follow-up of 1 Million Patients

BACKGROUND

Although many options exist for multivessel coronary revascularization, controversy persists over whether multiarterial grafting (MAG) confers a survival advantage over single-arterial grafting (SAG) with saphenous vein in coronary artery bypass grafting (CABG). This study sought to compare longitudinal survival between patients undergoing MAG and those undergoing SAG.

METHODS

All patients undergoing isolated CABG with ≥2 bypass grafts in The Society of Thoracic Surgeons Adult Cardiac Surgery Database (2008-2019) were linked to the National Death Index. Risk adjustment was performed using inverse probability weighting and multivariable modeling. The primary end point was longitudinal survival. Subpopulation analyses were performed and volume thresholds were analyzed to determine optimal benefit.

RESULTS

A total of 1,021,632 patients underwent isolated CABG at 1108 programs (100,419 MAG [9.83%]; 920,943 SAG [90.17%]). Median follow-up was 5.30 years (range, 0-12 years). After risk adjustment, all characteristics were well balanced. At 10 years, MAG was associated with improved unadjusted (hazard ratio, 0.59; 95% CI 0.58-0.61) and adjusted (hazard ratio, 0.86; 95% CI, 0.85-0.88) 10-year survival. Center volume of ≥10 MAG cases/year was associated with benefit. MAG was associated with an overall survival advantage over SAG in all subgroups, including stable coronary disease, acute coronary syndrome, and acute infarction. Survival was equivalent to that with SAG for patients age ≥80 years and those with severe heart failure, renal failure, peripheral vascular disease, or obesity. Only patients with a body mass index ≥40 kg/m2 had superior survival with SAG.

CONCLUSIONS

Multiarterial CABG is associated with superior long-term survival and should be the surgical multivessel revascularization strategy of choice for patients with a body mass index of less than 40 kg/m2.

Randomized Clinical Trial of Hybrid vs. Surgical vs. Percutaneous Multivessel Coronary Revascularization: 5‑year Follow-up of HREVS Trial

Aim      To evaluate 5-year results of the HREVS (Hybrid REvascularization Versus Standarts) study.Material and methods  The study included 155 consecutive patients with multivessel coronary artery disease who were randomized into 3 groups: coronary artery bypass grafting (CABG) (n=50), hybrid coronary revascularization (HCR) (n=52) and percutaneous coronary intervention (PCI) (n=53) according to the consensus of the cardiology team on the technical and clinical feasibility of each of the three coronary revascularization strategies. The primary endpoint of the study was residual ischemia 12 months after revascularization according to data of single-photon emission computed tomography (SPECT). Secondary endpoints were major adverse cardiac and cerebrovascular events (MACCE) over 5 years of follow-up, which included all-cause death, myocardial infarction, stroke, and clinically determined repeat myocardial revascularization.Results Baseline characteristics of patients did not differ between study groups. Median residual ischemia determined by SPECT data after 12 months was not statistically significantly different in the CABG, HCR and PCI groups: 6.7 [4.6; 8.8]%, 6.4 [4.3; 8.5]% and 7.9 [5.9; 9.8]%, respectively (p=0.45). Mean follow-up period was 76.5 months (at least 60 months). There were no statistically significant differences in all-cause mortality between the CABG, HCR and PCI groups, 10.6, 12.8 and 8.2 %, respectively (p=0.23). Statistically significant differences between the groups of CABG, HCR and PCI in the incidence of myocardial infarction (12.8; 8.5 and 16.3 %; p=0.12), stroke (4.2; 6.4 and 10.2 % ; p=0.13), repeat revascularization for clinical indications (23.4; 23.4 and 34.7 %; p=0.11) were not observed either. However, the cumulative 5-year MACCE value was similar in the HCR group and the CABG group but significantly lower than in the PCI group (51.1, 51.1 and 69.4 %, respectively; p = 0.03).Conclusion      HCR that combines advantages of PCI and CABG is a promising strategy for coronary revascularization in multivessel coronary artery disease. HCR demonstrates satisfactory long-term results comparable to those of CABG but superior to PCI. To confirm the safety and efficacy of HCR, a large multicenter study is required that would have a sufficient power to evaluate clinical endpoints.

Multi-Omics Profiling of Human Endothelial Cells from the Coronary Artery and Internal Thoracic Artery Reveals Molecular but Not Functional Heterogeneity

Major adverse cardiovascular events occurring upon coronary artery bypass graft surgery are typically accompanied by endothelial dysfunction. Total arterial revascularisation, which employs both left and right internal thoracic arteries instead of the saphenous vein to create a bypass, is associated with better mid- and long-term outcomes. We suggested that molecular profiles of human coronary artery endothelial cells (HCAECs) and human internal mammary artery endothelial cells (HITAECs) are coherent in terms of transcriptomic and proteomic signatures, which were then investigated by RNA sequencing and ultra-high performance liquid chromatography-mass spectrometry, respectively. Both HCAECs and HITAECs overexpressed molecules responsible for the synthesis of extracellular matrix (ECM) components, basement membrane assembly, cell-ECM adhesion, organisation of intercellular junctions, and secretion of extracellular vesicles. HCAECs were characterised by higher enrichment with molecular signatures of basement membrane construction, collagen biosynthesis and folding, and formation of intercellular junctions, whilst HITAECs were notable for augmented pro-inflammatory signaling, intensive synthesis of proteins and nitrogen compounds, and enhanced ribosome biogenesis. Despite HCAECs and HITAECs showing a certain degree of molecular heterogeneity, no specific markers at the protein level have been identified. Coherence of differentially expressed molecular categories in HCAECs and HITAECs suggests synergistic interactions between these ECs in a bypass surgery scenario.

Bilateral versus Single Internal Thoracic Artery Grafting Strategies Supplemented by Radial Artery Grafting

PURPOSE

It is unclear if a second or third arterial graft can improve clinical outcomes in coronary artery bypass graft surgery. We compared the outcomes of bilateral internal thoracic artery (BITA) plus radial artery (RA) grafting versus left internal thoracic artery (LITA) plus RA grafting after off-pump coronary artery bypass grafting.

MATERIALS AND METHODS

Between January 2009 and December 2020, a total of 3007 patients with three-vessel coronary artery disease who underwent off-pump coronary artery bypass were analyzed. Among them, 971 patients received total arterial grafting using LITA. We divided the patients into two groups [group A, BITA+RA grafting (n=227) and group B, LITA+RA grafting (n=744)], and compared the survival and major adverse cardiac and cerebrovascular event (MACCE) rates between the two groups at 10 years.

RESULTS

After risk adjustment with inverse probability treatment weighting methods, the freedom from all-cause mortality was 93.1% and 88.3% in groups A and B, respectively (p=0.140). The freedom from MACCE rates were 68.3% and 89.0%, respectively (p<0.0001). LITA plus RA grafting [hazard ratio (HR): 1.3, 95% confidence interval (CI): 1.05-2.37, p=0.025] and incomplete revascularization (HR 1.2, 95% CI: 0.70-2.15, p=0.046) were significant risk factors for MACCEs in multivariable Cox regression analysis.

CONCLUSION

The rates of MACCEs were lower with LITA plus RA grafting than with BITA plus RA grafting in total arterial revascularization. Furthermore, complete revascularization improved long-term outcomes following total arterial grafting.

Radial artery versus saphenous vein versus right internal thoracic artery for coronary artery bypass grafting

OBJECTIVES

We used individual patient data from 4 of the largest contemporary coronary bypass surgery trials to evaluate differences in long-term outcomes when radial artery (RA), right internal thoracic artery (RITA) or saphenous vein graft (SVG) are used to complement the left internal thoracic artery-to-left anterior descending graft.

METHODS

Primary outcome was all-cause mortality. Secondary outcome was a composite of major adverse cardiac and cerebrovascular events (all-cause mortality, myocardial infarction and stroke). Propensity score matching and Cox regression were used to reduce the effect of treatment selection bias and confounders.

RESULTS

A total of 10 256 patients (1510 RITA; 1385 RA; 7361 SVG) were included. The matched population consisted of 1776 propensity score-matched triplets. The mean follow-up was 7.9 ± 0.1, 7.8 ± 0.1 and 7.8 ± 0.1 years in the RITA, RA and SVG cohorts respectively. All-cause mortality was significantly lower in the RA versus the SVG [hazard ratio (HR) 0.62, 95% confidence interval (CI): 0.51-0.76, P = 0.003] and the RITA group (HR 0.59, 95% CI 0.48-0.71, P = 0.001). Major adverse cardiac and cerebrovascular event rate was also lower in the RA group versus the SVG (HR 0.78, 95% CI 0.67-0.90, P = 0.04) and the RITA group (HR 0.75, 95% CI 0.65-0.86, P = 0.02). Results were consistent in the Cox-adjusted analysis and solid to hidden confounders.

CONCLUSIONS

In this pooled analysis of 4 large coronary bypass surgery trials, the use of the RA was associated with better clinical outcomes when compared to SVG and RITA.

Single Versus Multiple Arterial Revascularization in Patients With Reduced Renal Function: Long-term Outcome Comparisons in 23,406 CABG Patients From Ontario, Canada

OBJECTIVE

To compare the long-term outcomes of MAR versus SAR in patients with renal insufficiency.

SUMMARY OF BACKGROUND DATA

Previous studies have been insufficiently powered to address whether MAR confers long-term benefit over SAR in patients with renal dysfunction who require CABG.

METHODS

We conducted retrospective cohort study in Ontario, Canada of patients who underwent isolated CABG (n = 23,406). The primary outcome was MACE, defined as the composite of stroke, myocardial infarction, and repeat revascularization. We compared patients by matching them on the propensity to have received SAR versus MAR, within groups with preoperative glomerular filtration rate (GFR) ≥60 mL/min/1.73 m2; GFR between 30 and 60; and GFR <30.

RESULTS

In patients with GFR ≥60, the use of MAR versus SAR was associated with a lower rate of MACE [hazard ratio (HR) 0.87 (0.80-0.94)], and a lower rate of long-term mortality [HR 0.87 (0.79-0.97)]. In those with GFR between 30 and 60, MAR was not associated with a difference in MACE [HR 1.04 (0.87-1.26)], and a lower rate of long-term mortality [HR 0.75 (0.65-0.87)] was observed. In those with GFR <30, MAR was not associated with a difference in outcomes.

CONCLUSIONS

MAR versus SAR does not correlate with a difference in MACE amongst patients with GFR between 30 and 60 and better survival raises the possibility of indication bias. Furthermore, MAR did not confer a benefit in those with severely reduced renal function. These data suggest that the potential long-term benefits of using MAR in CABG patients with renal insufficiency may be offset by competing health risks.

OUP accepted manuscript

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was ‘What is the best choice for third conduit when using bilateral internal mammary arteries for coronary artery bypass grafting—radial artery or saphenous vein graft?’. Altogether >525 papers were found using the reported search, of which 7 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Overall, there was no survival benefit demonstrated with the use of a radial artery over the use of a saphenous vein graft as a choice of third conduit following bilateral internal mammary artery grafts for coronary artery bypass grafting. The main limitation of the current evidence available is the restricted follow-up periods and the high attrition rates with small sample sizes affecting the strength of conclusions that can be drawn beyond 10 years of follow-up. We conclude that despite previous evidence supporting improved long-term patency of radial arterial grafts, there is no strong evidence that the use of a radial artery, over a saphenous vein graft, has any survival benefit when used as the third conduit following bilateral internal mammary artery grafts.

Additional survival benefit of bilateral in situ internal thoracic artery grafting with composite radial artery graft in total arterial off-pump coronary artery bypass grafting

OBJECTIVE

This study aimed to elucidate whether the use of bilateral internal thoracic arteries (BITAs) confers additional survival benefits compared with a single internal thoracic artery (SITA) in total arterial grafting with the radial artery.

METHODS

Between 2002 and 2016, 617 patients underwent a bilateral in situ internal thoracic artery grafting with the radial artery as a composite I-graft (BITA-I group) and 516 patients underwent single in situ internal thoracic artery grafting with the radial artery as a composite Y-graft (SITA-Y group). All anastomoses were performed without cardiopulmonary bypass and aortic manipulation. Propensity score matching was performed to adjust covariates and compared the outcomes between the 2 groups. Subanalysis was also performed to evaluate the effects of the BITA-I group on survival according to the covariates using Cox proportional hazards regression analysis.

RESULTS

Propensity score matching yielded 348 well-matched pairs. Early postoperative outcomes were similar in the 2 groups. The BITA-I group showed significantly better survival than the SITA-Y group (79.3% vs 70.2% at 10 years, P = .015). The subanalysis revealed a significantly better survival in the BITA-I group among overall patients (hazard ratio, 0.68; 95% confidence interval, 0.49-0.93). There was a significant positive effect on survival in the BITA-I group among patients without comorbidities or those aged <77 years.

CONCLUSIONS

BITA grafting with the radial artery provides better long-term survival than SITA grafting with the radial artery, which is enhanced among patients aged <77 years with minimum comorbidities.

Multiple arterial conduits for multi-vessel coronary artery bypass grafting in patients with mild to moderate left ventricular systolic dysfunction: a multicenter retrospective study

Background

Advantages of multiple arterial conduits for coronary artery bypass grafting (CABG) have been reported previously. We aimed to evaluate the mid-term outcomes of multiple arterial CABG (MABG) among patients with mild to moderate left ventricular systolic dysfunction (LVSD).

Methods

This multicenter study using propensity score matching took place from January 2013 to June 2019 in Jiangsu Province and Shanghai, China, with a mean and maximum follow-up of 3.3 and 6.8 years, respectively. We included patients with mild to moderate LVSD, undergoing primary, isolated multi-vessel CABG with left internal thoracic artery. The in-hospital and mid-term outcomes of MABG versus conventional left internal thoracic artery supplemented by saphenous vein grafts (single arterial CABG) were compared. The primary end points were death from all causes and death from cardiovascular causes. The secondary end points were stroke, myocardial infarction, repeat revascularization, and a composite of all mentioned outcomes, including death from all causes (major adverse events). Sternal wound infection was included with 6 months of follow-up after surgery.

Results

243 and 676 patients were formed in MABG and single arterial CABG cohorts after matching in a 1:3 ratio. In-hospital death was not significantly different (MABG 1.6% versus single arterial CABG 2.2%, p = 0.78). After a mean (±SD) follow-up time of 3.3 ± 1.8 years, MABG was associated with lower rates of major adverse events (HR, 0.64; 95% CI, 0.44–0.94; p = 0.019), myocardial infarction (HR, 0.39; 95% CI, 0.16–0.99; p = 0.045) and repeat revascularization (HR, 0.42; 95% CI, 0.18–0.97; p = 0.034). There was no difference in the rates of death, stroke, and sternal wound infection.

Conclusions

MABG was associated with reduced mid-term rates of major adverse events and cardiovascular events and may be the procedure of choice for patients with mild to moderate LVSD requiring CABG.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-021-01463-5.

Comparative Analysis Following Implementation of Two Types of Y-Composite Multiarterial Revascularization Strategies at a Single Academic Institution

Background

We compared early outcomes, at a single academic institution, of implementing full coronary revascularization in coronary artery bypass grafting using multiarterial Y‐composite grafts with multiple sequential anastomoses.

Methods and Results

Clinical records of 425 consecutive patients who underwent coronary artery bypass grafting using Y‐grafting with left internal mammary artery and radial artery (Y‐RA group) or right internal mammary artery (Y‐RIMA group) from 2015 to 2019, were reviewed. These were compared with the institutional experience of isolated coronary artery bypass grafting cases (in situ on pump/off pump) for the same period of time. When comparing the 4 groups, the Y‐RIMA/RA groups revealed a higher number of distal anastomosis than the in situ on‐ or off‐pump groups. When the number of distal arterial anastomosis was analyzed, there was a superiority of using the Y‐configuration compared with the in situ approach. Moreover, there were no significant differences among groups for mortality and/or major adverse cardiac and cerebrovascular events in hospital or at 30‐day follow‐up. A subanalysis comparing the Y‐RIMA group with the Y‐RA group showed that complementary grafts to the Y‐construct were required to accomplish full revascularization more frequently in the Y‐RIMA group. Full‐arterial revascularization was achieved in 92.2% of the Y‐RA group and 72.0% of the Y‐RIMA group (P<0.001). In 82.8% of the Y‐RA group and 30.8% of the Y‐RIMA group, revascularization was completed as an anaortic procedure (P<0.001).

Conclusions

The 2 types of arterial Y‐composite grafting were able to be introduced in the routine practice of our institution showing comparable results to the established institutional practice. This procedure allowed for more arterial distal anastomosis to be performed safely without compromising outcomes.

Survival benefit from a second arterial conduit to the circumflex circulation persists in elderly after coronary artery bypass surgery

BACKGROUND

This retrospective propensity matched study investigated the impact of age on the survival benefit from a second arterial conduit to the left-sided circulation.

METHODS

Data for isolated coronary artery bypass surgery were collected from October 2004 to March 2014. All patients with an internal mammary artery graft to left anterior descending artery and additional arterial or venous graft to the circumflex circulation were included. Propensity matching was used to balance co-variates and generate odds of death for each observation. Odds ratios (venous vs. arterial) were charted against age.

RESULTS

The in-hospital mortality rate was 1.12% (arterial) vs. 1.24% (venous) (p = 0.77). The overall 10-year survival was 74.6% (venous) vs. 82.6% (arterial) (p = 0.001). A total of 1226 patients were successfully matched to the venous or arterial (second conduit to circumflex territory after left internal mammary artery to left anterior descending artery) cohorts. Odds ratio for death (venous to arterial) showed a linear decremental overall survival benefit for the second arterial graft to circumflex circulation with increasing age.

CONCLUSIONS

The survival benefit of a second arterial graft persists through all age groups with a gradual decline with increasing age over the decades. Elderly patients should not be denied a second arterial graft to the circumflex circulation based on age criterion alone.

How decisive is the number of distal arterial anastomoses in coronary bypass surgery?

Background

The benefit of arterial revascularization in coronary surgery remains controversial. The incremental value of additional grafts to the left internal thoracic artery (ITA) has been mainly assessed according to the number of arterial grafts, possibly limiting the detection of its actual impact. We analyzed the influence of the number of distal arterial anastomoses (DAA) performed on late mortality in patients having received from one to three arterial grafts.

Methods

Retrospective review of 3685 primary isolated coronary artery bypass grafting (CABG) performed from 1989 to 2014 was conducted with a 13-year mean follow-up. One arterial graft (SITA) was used in 969 patients, two arterial grafts, ITA or gastroepiploic artery (GEA), in 1883 patients (BITA: 1644; SITA+GEA: 239), and three arterial grafts in 833 patients (BITA+GEA). Totally, 795 patients (22%) received one DAA, 1142 patients (31%) two, 1337 patients (36%) three, and 411 patients (11%) four or more. A sub-group analysis was done in the 2104 patients with 3-vessel disease who received at least 2 arterial grafts.

Results

In this series the early mortality was 1.6% and it was not influenced by the surgical technique. Late mortality was significantly influenced by age, gender, heart failure, LV ejection fraction, diabetes status, complete revascularization, number of arterial grafts, number of DAA, both ITA, sequential ITA graft, GEA graft. In multivariable analysis with Cox regression model, the number of DAA was the only technical significant independent prognosis factor of late survival (p < 0.0001), predominant over both ITA, complete revascularization and number of arterial grafts. The impact of the number of DAA on survival was found discriminant from 1 to 3; after 3 there was no more additional effect. In 3-vessel disease patients who received at least 2 arterial grafts, the number of DAA remained a significant independent prognosis factor of late survival (p < 0.0001).

Conclusions

The number of distal arterial anastomoses is an independent predictor of long-term survival, predominant over the number of arterial grafts and the completeness of the revascularization; higher the number, better the late survival. It is a strong support of the extensive use of arterial grafting in CABG.

Radial artery supply to the left mammary artery in a redo coronary bypass

BACKGROUND

Single-inflow coronary bypass through left internal thoracic artery and Y graft is effective in myocardial revascularization, but left sublavian diseases may affect its safety.

AIM OF THE STUDY

To assess that, in presence of a composite Y graft, issues involving the origin of the left internal thoracic artery are relatively easy to manage, even in reoperations.

METHODS

A critical stenosis of the subclavian artery involving the origin of a bilateral internal thoracic artery Y graft was bypassed using a free radial artery graft.

RESULTS

Bypass was performed between the left thoracic artery and the ascending aorta, off-pump and with excellent results.

CONCLUSIONS

In consideration of the excellent long term results of total arterial revascularization, radial artery is a feasible graft option, even in case of a composite Y graft in place.

Is the Use of BIMA in CABG Sub-Optimal? A Review of the Current Clinical and Economic Evidence Including Innovative Approaches to the Management of Mediastinitis

Bilateral internal mammary artery (BIMA) in coronary artery bypass grafting (CABG) has traditionally been limited. This review looks at the recent outcome data on BIMA in CABG focusing on the management of risk factors for mediastinitis, one of the potential barriers for more extensive BIMA utilization. A combination of pre-, intra- and postoperative strategies are essential to reduce mediastinitis. Limited data indicate that the incidence of mediastinitis can be reduced using closed incision negative-pressure wound therapy as a part of these strategies with the possibility of offering patients best treatment options by extending BIMA to those with a higher risk of mediastinitis. Recent economic data imply that the technology may challenge the current low uptake of BIMA by reducing the short-term cost differentials between single internal mammary artery and BIMA. Given that most published randomized controlled trials and meta-analyses of observational long-term outcome data favor BIMA, if short-term complications of BIMA including mediastinitis can be controlled adequately, there may be opportunities for more extensive use of BIMA leading to improved long-term outcomes. An ongoing study looking at BIMA in high-risk patients may provide evidence to support the hypothesis that mediastinitis should not be a factor in limiting the use of BIMA in CABG.

Active Participation in Outpatient Cardiac Rehabilitation Is Associated With Better Prognosis After Coronary Artery Bypass Graft Surgery - J-REHAB CABG Study

BACKGROUND

There is little evidence regarding the effect of outpatient cardiac rehabilitation (CR) on exercise capacity or the long-term prognosis in patients after coronary artery bypass graft surgery (CABG). This study aimed to determine whether participation in outpatient CR improves exercise capacity and long-term prognosis in post-CABG Japanese patients in a multicenter cohort.

METHODS AND RESULTS

We enrolled 346 post-CABG patients who underwent cardiopulmonary exercise testing during early (2-3 weeks) and late (3-6 months) time points after surgery. They formed the Active (n=240) and Non-Active (n=106) CR participation groups and were followed for 3.5 years. Primary endpoint was a major adverse cardiac event (MACE): all-cause death or rehospitalization for acute myocardial infarction/unstable angina/worsening heart failure. Peak oxygen uptake at 3-5 months from baseline was significantly more increased in Active than in Non-Active patients (+26±24% vs. +19±20%, respectively; P<0.05), and the MACE rate was significantly lower in Active than Non-Active patients (3.4% vs. 10.5%, respectively; P=0.02). Multivariate Cox proportional hazard analysis showed that participation in outpatient CR was a significant prognostic determinant of MACE (P=0.03).

CONCLUSIONS

This unique study showed that a multicenter cohort of patients who underwent CABG and actively participated in outpatient CR exhibited greater improvement in exercise capacity and better survival without cardiovascular events than their counterparts who did not participate.

Randomized Clinical Trial of Surgical vs. Percutaneous vs. Hybrid Revascularization in Multivessel Coronary Artery Disease: Residual Myocardial Ischemia and Clinical Outcomes at One Year-Hybrid coronary REvascularization Versus Stenting or Surgery (HREVS)

AIM

Optimal revascularization strategy in multivessel (MV) coronary artery disease (CAD) eligible for percutaneous management (PCI) and surgery remains unresolved. We evaluated, in a randomized clinical trial, residual myocardial ischemia (RI) and clinical outcomes of MV-CAD revascularization using coronary artery bypass grafting (CABG), hybrid coronary revascularization (HCR), or MV-PCI.

METHODS

Consecutive MV-CAD patients (n = 155) were randomized (1 : 1 : 1) to conventional CABG (LIMA-LAD plus venous grafts) or HCR (MIDCAB LIMA-LAD followed by PCI for remaining vessels) or MV-PCI (everolimus-eluting CoCr stents) under Heart Team agreement on equal technical and clinical feasibility of each strategy. SPECT at 12 months (primary endpoint of RI that the trial was powered for; a measure of revascularization midterm efficacy and an independent predictor of long-term prognosis) preceded routine angiographic control.

RESULTS

Data are given, respectively, for the CABG, HCR, and MV-PCI arms. Incomplete revascularization rate was 8.0% vs. 7.7% vs. 5.7% (p=0.71). Hospital stay was 13.8 vs. 13.5 vs. 4.5 days (p < 0.001), and sick-leave duration was 23 vs. 16 vs. 8 weeks (p < 0.001). At 12 months, RI was 5 (2, 9)% vs. 5 (3, 7)% vs. 6 (3, 10)% (median; Q1, Q3) with noninferiority p values of 0.0006 (HCR vs. CABG) and 0.016 (MV-PCI vs. CABG). Rates of angiographic graft stenosis/occlusion or in-segment restenosis were 20.4% vs. 8.2% vs. 5.9% (p=0.05). Clinical target vessel/graft failure occurred in 12.0% vs. 11.5% vs. 11.3% (p=0.62). Major adverse cardiac and cerebral event (MACCE) rate was similar (12% vs. 13.4% vs. 13.2%; p=0.83).

CONCLUSION

In this first randomized controlled study comparing CABG, HCR, and MV-PCI, residual myocardial ischemia and MACCE were similar at 12 months. There was no midterm indication of any added value of HCR. Hospital stay and sick-leave duration were shortest with MV-PCI. While longer-term follow-up is warranted, these findings may impact patient and physician choices and healthcare resources utilization. This trial is registered with NCT01699048.

Radial Artery Versus Right Internal Thoracic Artery Versus Saphenous Vein as the Second Conduit for Coronary Artery Bypass Surgery: A Network Meta-Analysis of Clinical Outcomes

Background

There remains uncertainty regarding the second‐best conduit after the internal thoracic artery in coronary artery bypass grafting. Few studies directly compared the clinical results of the radial artery (RA), right internal thoracic artery (RITA), and saphenous vein (SV). No network meta‐analysis has compared these 3 strategies.

Methods and Results

MEDLINE and EMBASE were searched for adjusted observational studies and randomized controlled trials comparing the RA, SV, and/or RITA as the second conduit for coronary artery bypass grafting. The primary end point was all‐cause long‐term mortality. Secondary end points were operative mortality, perioperative stroke, perioperative myocardial infarction, and deep sternal wound infection (DSWI). Pairwise and network meta‐analyses were performed. A total of 149 902 patients (4 randomized, 31 observational studies) were included (RA, 16 201, SV, 112 018, RITA, 21 683). At NMA, the use of SV was associated with higher long‐term mortality compared with the RA (incidence rate ratio, 1.23; 95% CI, 1.12–1.34) and RITA (incidence rate ratio, 1.26; 95% CI, 1.17–1.35). The risk of DSWI for SV was similar to RA but lower than RITA (odds ratio, 0.71; 95% CI, 0.55–0.91). There were no differences for any outcome between RITA and RA, although DSWI trended higher with RITA (odds ratio, 1.39; 95% CI, 0.92–2.1). The risk of DSWI in bilateral internal thoracic artery studies was higher when the skeletonization technique was not used.

Conclusions

The use of the RA or the RITA is associated with a similar and statistically significant long‐term clinical benefit compared with the SV. There are no differences in operative risk or complications between the 2 arterial conduits, but DSWI remains a concern with bilateral ITA when skeletonization is not used.

The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights from 2019

This highlights in our specialty for 2019 begin with the ongoing major developments in transcatheter valve interventions. Thereafter, the advances in left ventricular assist devices are reviewed. The recent focus on conduit selection and robotic options in coronary artery bypass surgery are then explored. Finally, this special articles closes with a discussion of pulmonary hypertension in noncardiac surgery, anesthetic technique in cardiac surgery, as well as postoperative pneumonia and its outcome consequences.

Arterial Grafts for Coronary Bypass

Observational and randomized evidence shows that arterial grafts have better patency rates than saphenous vein grafts (SVGs) in coronary artery bypass grafting. Observational studies suggest that the use of multiple arterial grafts is associated with longer postoperative survival, but this must be interpreted in the context of treatment allocation bias and hidden confounders intrinsic to the study designs. Recently, a pooled analysis of 6 randomized trials comparing the radial artery with the SVG as the second conduit and the largest randomized trial comparing the use of single and bilateral internal thoracic arteries have provided apparently divergent results about a clinical benefit with the use of >1 arterial conduit. However, both analyses have methodological limitations that may have influenced their results. At present, it is unclear whether the well-documented increased patency rate of arterial grafts translates into clinical benefits in the majority of patients undergoing coronary artery bypass grafting. A large randomized trial testing the arterial grafts hypothesis (ROMA [Randomized Comparison of the Clinical Outcome of Single Versus Multiple Arterial Grafts]) is underway and will report the results in a few years.

Multiarterial coronary artery bypass grafting: is the radial artery fulfilling the unkept promise of the right internal thoracic artery?

PURPOSE OF REVIEW

The debate on the second best conduit for CABG is still intense. In this review, we discuss the role of the radial artery and the right internal thoracic artery (RITA) compared with saphenous vein grafts (SVG).

RECENT FINDINGS

The recent RADIAL STUDY has been the first evidence based on randomized trials of a clinical benefit using a second arterial graft in CABG.On the other hand, the definitive 10-year results of the ART trial failed to show a clinical advantage associated with the use of bilateral internal thoracic artery (BITA). A thorough and contextualized analysis of this and other studies, however, may offer a different perspective.

SUMMARY

Arterial conduits in CABG have shown better patency rates than SVG. Whether this leads to better clinical outcomes is still debated. In this setting, the radial artery and the RITA seem to offer a similar advantage, although with different indications and contraindications.

Long-term Outcomes of Multiple Arterial Coronary Artery Bypass Grafting: A Population-Based Study of Patients in British Columbia, Canada

Importance

Although the long-term survival advantage of multiple arterial grafting (MAG) vs the standard use of left internal thoracic artery (LITA) supplemented by saphenous vein grafts (LITA+SVG) has been demonstrated in several observational studies, to our knowledge its safety and other long-term clinical benefits in a large, population-based cohort are unknown.

Objective

To compare the safety and long-term outcomes of MAG vs LITA+SVG among overall and selected subgroups of patients.

Design, Setting, and Participants

In this population-based observational study, we included 20 076 adult patients with triple-vessel or left-main disease who underwent primary isolated coronary artery bypass grafting (MAG, n = 5580; LITA+SVG, n = 14 496) in the province of British Columbia, Canada, from January 2000 to December 2014, with follow-up to December 2015. We performed propensity-score analyses by weighting and matching and multivariable Cox regression to minimize treatment selection bias.

Exposures

Multiple arterial grafting or LITA+SVG.

Main Outcomes and Measures

Mortality, repeated revascularization, myocardial infarction, heart failure, and stroke.

Results

Of 5580 participants who underwent MAG, 586 (11%) were women and the mean (SD) age was 60 (8.7) years. Of 14 496 participants who underwent LITA+SVG, 2803 (19%) were women and the mean (SD) age was 68 (8.9) years. The median (interquartile range) follow-up time was 9.1 (5.1-12.6) years and 8.1 (4.5-11.7) years for the groups receiving MAG and LITA+SVG, respectively. Compared with LITA+SVG, MAG was associated with reduced mortality rates (hazard ratio [HR], 0.79; 95% CI, 0.72-0.87) and repeated revascularization rates (HR, 0.74; 95% CI, 0.66-0.84) in 15-year follow-up and reduced incidences of myocardial infarction (HR, 0.63; 95% CI, 0.47-0.85) and heart failure (HR, 0.79; 95% CI, 0.64-0.98) in 7-year follow-up. The long-term benefits were coherent by all 3 statistical methods and persisted among patient subgroups with diabetes, obesity, moderately impaired ejection fraction, chronic obstructive pulmonary disease, peripheral vascular disease, or renal disease. Multiple arterial grafting was not associated with increased morbidity or mortality rates at 30 days overall or within patient subgroups.

Conclusions and Relevance

Compared with LITA+SVG, MAG is associated with reduced mortality, repeated revascularization, myocardial infarction, and heart failure among patients with multivessel disease who are undergoing coronary artery bypass grafting without increased mortality or other adverse events at 30 days. The long-term benefits consistently observed across multiple outcomes and subgroups support the consideration of MAG for a broader spectrum of patients who are undergoing coronary artery bypass grafting in routine practice.

Immediate results of bypass grafting of the territory of the right coronary artery using the 'Penza Coronary Technology'

Coronary artery bypass grafting (CABG) is known to be an effective method of treatment for multivessel obstructive coronary disease with low rates of reintervention and excellent long-term survival and freedom from angina. Graft patency lies at the heart of its procedural success and durability, which in its turn largely depends on the appropriate choice of the conduit, as well as the target coronary artery (CA). It should be mentioned that patency of one and the same conduit used for bypass grafting of the territory of either the left or right coronary artery (LCA and RCA, respectively) may differ, which is probably determined by differences in physiology, size, territory of runoff, and local flow characteristics between different coronary targets. Previous reports have supported the use of bilateral internal thoracic arteries to revascularize the left coronary circulation. If this becomes standardized practice, the optimal conduit for the right coronary system remains to be established. Proposed in the present article is a variant of bypass grafting of the RCA territory using a composite I-graft formed from the proximal portion of the right internal thoracic artery (ITA) in situ and the great saphenous vein (GSV) harvested by the 'no-touch' technique. This technique is part of a CABG schematic algorithm worked out in our Clinic and called the 'Penza Coronary Technology'.

The radial artery in coronary surgery, 2018

It is now 25 years since the radial artery (RA) was reintroduced in coronary surgery. It has evolved into being a significant coronary artery bypass conduit and ranks third in usage after the internal thoracic artery (ITA) and saphenous vein grafts (SVG). Its advantages are that it can be readily and efficiently harvested, is of good length and appropriate size for coronary artery bypass graft (CABG) surgery, is robust and easy to handle, and remains free of atheroma, and there is minimal wound morbidity. The RA must be used judiciously with attention to spasm prophylaxis because of its muscular wall, and by avoiding competitive flow. Its patency is equivalent to the ITAs when placed to similar coronary territories and under similar conditions (stenosis, size, quality) and RA patencies are always superior to those of SVG in both observational and randomized studies-88-90% versus 50-60% at 10 years, and 80-87% versus 25-40% at 20 years. Its use and excellent patencies result in survival results equivalent to bilateral internal thoracic artery (BITA) grafting and always superior to left internal thoracic artery (LITA) +SVG. Typical radial artery multiarterial bypass grafting (RA-MABG) 10-year survivals are 80-90% versus 70-80% for LITA-SVG. In general, for every 100 patients undergoing CABG, 10 more patients will be alive at 10 years post-operatively. The RA also is important in achieving total arterial revascularization, and several reports indicate a further survival advantage for patients having three arterial grafts over two. The RAs are especially useful in diabetic, morbidly obese patients, those with conduit shortage, and leg pathology, and in coronary reoperations. Although the RA has equivalent patencies to the right internal thoracic artery (RITA), it is much more versatile. RAs that have been instrumented by angiography or percutaneous coronary intervention should be avoided. The radial artery has proved to be an excellent arterial conduit, is equivalent to but more versatile than the RITA, and is always superior to SVG. Its use should be part of every coronary surgeon's skill set.

Clinical Validation of a Coronary Surgery Technique That Minimizes Aortic Manipulation

BACKGROUND

To minimize aortic manipulation and maximize use of arterial conduits are aims of modern coronary surgery.

METHODS

From March 2012 to October 2016, 890 consecutive patients with multivessel coronary disease underwent isolated coronary operations using both internal thoracic arteries (ITAs). In 205 (23%; mean age, 67.6 ± 9.2 years), the right ITA was proximally transected and used as a free graft, while its in situ stump was elongated with a saphenous vein graft. The new arteriovenous I conduit was directed to the inferolateral cardiac wall. Operative data and early outcomes of these patients (I group) were compared with the remaining 685 patients (control [C] group). Early and late outcomes were also compared in 184 pairs identified with propensity score matching.

RESULTS

Between the I and C groups there was no significant difference in expected operative risk (European System for Cardiac Operative Risk Evaluation II, p = 0.28), although diseased ascending aorta (p < 0.0001) and critical preoperative state (p = 0.027) were more frequent in the I group. Despite a higher number of coronary anastomoses (mean, 4 ± 0.9 vs 3.7 ± 1, p < 0.0001), cardiopulmonary bypass time was shorter in the I group both in overall (86.7 ± 23.7 vs 105.7 ± 34.2 minutes, p < 0.0001) and matched series (86.8 ± 24.1 vs 108.8 ± 31.9 minutes, p < 0.0001). In-hospital mortality (1% vs 1.9%, p = 0.54) and the rates of postoperative complications were similar. During the follow-up period, no intergroup difference was found in matched patients in the nonparametric estimates of freedom from all-cause death (p = 0.39) and major adverse cardiac and cerebrovascular events (p = 0.44).

CONCLUSIONS

Surgery using this arteriovenous I conduit is safe, minimizes aortic manipulation, shortens cardiopulmonary bypass time, and aids complete revascularization.

Historical Milestones in the Management of Stable Coronary Artery Disease over the Last Half Century

Coronary revascularization for coronary artery disease dates back to the introduction of coronary bypass by Favaloro in 1967 and coronary angioplasty by Gruentzig in 1977 (first published in 1968 and 1978, respectively). There have been many technical improvements over the ensuing 5 decades, studied in clinical trials. This article reviews the history of coronary revascularization (the development of optimal medical therapy) and points the way to the future of stable coronary artery disease management.

The Incremental Value of Three or More Arterial Grafts in CABG: The Effect of Native Vessel Disease

BACKGROUND

We investigated whether extended arterial grafting with three or more arterial grafts in patients with a left internal thoracic artery to left anterior descending artery graft improves survival in coronary artery bypass graft surgery patients and whether its effects will depend on the extent of coronary artery disease; specifically three-vessel disease (3VD) versus two-vessel disease (2VD).

METHODS

Fifteen-year mortality was analyzed in 11,931 patients with multivessel disease and primary isolated left internal thoracic artery to left anterior descending artery coronary artery bypass graft surgery with 2 or more grafts. Patients were aged 64.3 ± 10.5 years; 3,484 (29.2%) were women; 2,532 (21.2%) had 2VD and 9,399 (78.8%) had 3VD. Patients were grouped into one single-artery group (n = 6,782, 56.9%; reference group), and two multiple artery groups: two arteries (n = 3,678, 30.8%) and three arteries (n = 1,471, 12.3%). Long-term survival was compared by Kaplan-Meier estimates. Risk-adjusted mortality hazard ratio (HR) with 95% confidence interval (CI) were derived by covariate adjusted Cox regression to quantify multiple artery effects versus one artery in the overall cohort and separately among patients with 2VD and 3VD.

RESULTS

Radial artery (94%) and right internal thoracic artery (6%) conduits were used for additional arterial grafts. For the entire multivessel cohort, increasing number of arterial grafts was associated with incrementally improved 15-year survival (two arteries HR 0.85, 95% CI: 0.78 to 0.92; three arteries HR 0.75, 95% CI: 0.65 to 0.85). The three arteries versus two arteries comparison was consistent, even if not significant (HR 0.89, 95% CI: 0.77 to 1.03). The benefits derived from additional arterial grafts were more pronounced in case of 3VD (two arteries HR 0.84 95% CI: 0.76 to 0.92; three arteries HR 0.73, 95% CI: 0.63 to 0.84), without survival benefit with 2VD.

CONCLUSIONS

Our results support the use of extended arterial grafting to maximize long-term coronary artery bypass graft surgery patient survival, especially for 3VD patients.

Hybrid Revascularization: A Review

Hybrid coronary revascularization (HCR) combines surgical bypass with percutaneous coronary intervention (PCI) performed either during the same procedure or in a staged approach within 60 days. Coronary artery bypass grafting using the left internal mammary artery (LIMA) has shown excellent long-term patency with improved patient survival. It remains the gold standard treatment for the majority of patients with multivessel coronary artery disease. However, saphenous vein grafts have poor long-term patency. Advances in stent technology have resulted in reduced rates of thrombosis and restenosis, making PCI a viable alternative to coronary surgery in selected patients. HCR is attractive as a less invasive method of coronary revascularization which preserves the benefits of the LIMA performed with less invasive surgical techniques with the efficacy of newer generation stents.