Arterial Revascularization Trial - ART

Contribution To Literature:

The ART trial failed to show superiority of surgical bypass with a bilateral internal mammary artery versus a single internal mammary artery.

Description:

The goal of the trial was to evaluate the use of a bilateral internal mammary artery (BIMA) versus a single internal mammary artery (SIMA) during coronary artery bypass grafting (CABG).

Study Design

  • Randomized
  • Parallel

Patient Populations:

  • Patients undergoing CABG

    Number of enrollees: 3,102
    Duration of follow-up: Reported to 5 years, anticipated to 10 years
    Age range: Mean 64 years
    Percentage female: 15%

Primary Endpoints:

  • Survival at 10 years

Secondary Endpoints:

  • 30-day mortality
  • Reintervention
  • Clinical events
  • Quality of life
  • Cost-effectiveness

Drug/Procedures Used:

Patients undergoing CABG were randomized to BIMA (n = 1,548) versus SIMA (n = 1,554). Patients in either group could receive saphenous vein and/or radial artery grafts, and on-pump or off-pump surgery as needed.

Principal Findings:

Overall, 3,102 patients were randomized. In the BIMA group, the mean age was 64 years, 15% were women, 24% were diabetic, and 40% had prior myocardial infarction. Off-pump surgery was performed in 42%.

Three grafts were used in 50%, whereas four or more grafts were used in 31%. Duration of surgery was 222 minutes in the BIMA group versus 199 minutes in the SIMA group. Duration of ventilatory support was 968 minutes versus 863 minutes, duration of intensive care unit support was 41 hours versus 38 hours, and duration of postoperative care was 8 days versus 7.5 days, respectively, for BIMA versus SIMA groups.

At 30 days, mortality was 1.2% in the BIMA group versus 1.2% in the SIMA group. Stroke was 1.0% versus 1.2%, myocardial infarction was 1.4% versus 1.5%, revascularization was 0.7% versus 0.4%, and sternal wound reconstruction was 1.9% versus 0.6% (p < 0.05), respectively.

At 1 year, mortality was 2.5% in the BIMA group versus 2.1% in the SIMA group. Stroke was 1.5% versus 1.8%, myocardial infarction was 2.0% versus 2.0%, and revascularization was 1.8% versus 1.3%, respectively.

Costs at 1 year were $17,845 versus $16,398, respectively, for BIMA versus SIMA (p = 0.002).

At 5 years, mortality was 8.7% in the BIMA group versus 8.4% in the SIMA group (p = 0.77). Myocardial infarction was 3.4% for BIMA versus 3.5% for SIMA (p = 0.86). Stroke was 2.5% for BIMA versus 3.2% for SIMA (p = 0.24). Repeat revascularization was 6.5% with BIMA versus 6.6% with SIMA (p = 0.91).

Interpretation:

Among patients with multi-vessel coronary artery disease, the use of BIMA during CABG is feasible. BIMA is associated with slightly increased surgical time, increased duration of ventilatory support, increased duration of hospitalization, a 1.3% absolute increase in early sternal wound reconstruction, and higher 1-year costs. However, mortality, stroke, myocardial infarction, and need for repeat revascularization are similar up to 5 years.

A difference in these surgical techniques may not become evident until 10 years, during which time >95% of IMAs remain patent, in contrast to only 25-50% of saphenous veins. Regarding sternal wound reconstruction, post hoc analysis revealed that a “skeletonized” technique was associated with a lower rate of sternal wound complications, regardless of whether a SIMA or BIMA was harvested.

References:

Gray AM, Murphy J, Altman DG, et al. One-year costs of bilateral or single internal mammary grafts in the Arterial Revascularization Trial. Heart 2017;Apr 27:[Epub ahead of print].

Taggart DP, Altman DG, Gray AM, et al., on behalf of the ART Investigators. Randomized Trial of Bilateral versus Single Internal-Thoracic-Artery Grafts. N Engl J Med 2016;375:2540-9.

Presented by Dr. David P. Taggart at the American Heart Association Annual Scientific Sessions (AHA 2016), New Orleans, LA, November 14, 2016.

Taggart DP, Altman DG, Alastair MG, et al., on behalf of the ART Investigators. Randomized trial to compare bilateral vs. single internal mammary coronary artery bypass grafting: 1-year results of the Arterial Revascularisation Trial (ART). Eur Heart J 2010;31:2470-81.

Presented by Dr. David P. Taggart at the European Society of Cardiology Congress, Stockholm, Sweden, August 2010.


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