Radial Artery Grafts Versus Saphenous Vein Grafts in Coronary Artery Bypass Surgery: VA Cooperative Study - Radial Artery vs. Saphenous Vein Grafts in Coronary Artery Bypass Surgery

Description:

The goal of the trial was to evaluate coronary artery bypass grafting (CABG) with radial artery grafts compared with saphenous vein grafts among patients with stable coronary artery disease (CAD).

Hypothesis:

Radial artery CABG would be more effective at improving long-term graft patency.

Study Design

  • Parallel

Patients Enrolled: 733
Mean Follow Up: 1 year. Angiography follow-up was funded at 5 years.
Mean Patient Age: 61 years
Female: 4%

Patient Populations:

Patients with stable CAD undergoing elective CABG

Primary Endpoints:

One-year angiographic graft patency defined as any opacification of the distal target by injection of the graft

Drug/Procedures Used:

All patients with stable CAD received a left internal mammary artery graft to the left anterior descending artery whenever possible. The best remaining recipient vessel was then randomized to a radial artery graft (n = 366) versus a saphenous vein graft (n = 367).

Principal Findings:

Overall, 733 patients were randomized and underwent surgery. Baseline characteristics were similar between the groups. In the radial artery group, the mean age was 61 years, 96% were men, 42% had diabetes, and mean low-density lipoprotein cholesterol was 104 mg/dl. The target artery was the circumflex in 55%, 53% of patients received three grafts, and on-pump surgery was performed in 89%. In the saphenous vein group, endoscopic vein harvest was used in 20%. Operative mortality was 0.8%.

The primary endpoint, graft patency at 1 year, was 89% for radial artery grafts versus 89% for saphenous vein grafts (p = 0.82). Graft patency was also similar between the groups with the following anastomoses: left anterior descending (83% vs. 85%), circumflex (93% vs. 90%), and right coronary artery (86% vs. 88%). Graft patency was lower among diabetics who received radial artery grafts (p for interaction = 0.04).

High-grade disease (string sign) in the graft was observed in 8% versus 1% (p < 0.001), and 75% to 100% stenosis was observed in 24% versus 16% (p = 0.03), respectively. In the saphenous vein graft group, patency was 78% among those who underwent endoscopic harvesting versus 91% among those who had vein harvesting by other techniques (p = 0.009). Also, in the saphenous vein graft group, patency was 90% among those who underwent on-pump procedures versus 78% among those who had off-pump procedures (p = 0.04).

One-year mortality was 2% in both groups, myocardial infarction was 1% in both groups, and stroke was 2% in both groups.

Interpretation:

Among patients undergoing elective CABG, the use of radial grafts was not superior to saphenous vein grafts. Angiographic graft patency was similar between the groups at 1 year; however, diabetics had lower patency with radial artery grafts. Endoscopic harvest of saphenous vein grafts and off-pump procedures appeared to lower saphenous vein graft patency. These results are in contradistinction to the RAPS trial, which documented higher patency with radial artery grafts compared with saphenous vein grafts. The effect of radial artery versus saphenous vein grafts in women is largely unknown.

References:

Goldman S, Sethi GK, Holman W, et al. Radial Artery Grafts vs Saphenous Vein Grafts in Coronary Artery Bypass Surgery: A Randomized Trial. JAMA 2011;305:167-174.

Presented by Dr. Steven Goldman at the ACC.10/i2 Summit, Atlanta, GA, March 2010.

Clinical Topics: Cardiac Surgery, Dyslipidemia, Invasive Cardiovascular Angiography and Intervention, Stable Ischemic Heart Disease, Cardiac Surgery and SIHD, Lipid Metabolism, Nonstatins, Chronic Angina

Keywords: Lipoproteins, LDL, Myocardial Infarction, Stroke, Angina, Stable, Cholesterol, LDL, Constriction, Pathologic, Coronary Artery Bypass, Diabetes Mellitus


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