Multiple Arterial Grafts Improve Late Survival of Patients Undergoing CABG: Analysis of 8,622 Patients With Multivessel Disease
What is the impact of multiple arterial (MultArt) grafting on long-term survival compared with the conventional standard-of-care coronary artery bypass grafting (CABG) using the left internal mammary artery (LIMA ) to left anterior descending artery (LAD) with additional saphenous vein grafting (SVG)?
The investigators reviewed 8,622 Mayo Clinic patients who had isolated primary CABG for multivessel coronary artery disease from 1993 to 2009. Patients were stratified by number of arterial grafts: LIMA plus saphenous veins (LIMA/SV) group (n = 7,435), and MultArt group (n = 1,187). Cox regression models were used to find the univariate and multivariate predictors of late survival and overall survival.
Propensity score analysis matched 1,153 patients. Operative mortality was 0.8% (n = 10) in MultArt and 2.1% (n = 154) in LIMA/SV (p = 0.005); however, not statistically different (p = 0.996) in multivariate analysis, or in propensity-matched groups (p = 0.818). Late survival was greater for MultArt versus LIMA/SV (10-, and 15-year survival [y/s] were 84% and 71% vs. 61% and 36%, respectively [p < 0.001] in unmatched groups, and 83% and 70%, vs. 80% and 60%, respectively [p = 0.0025] in matched groups). MultArt subgroups, with bilateral internal mammary artery (BIMA)/SV (n = 589) and BIMA only (n = 271), had improved 15-y/s (86%, 76%, and 82%, 75% at 10-, and 15-years [p < 0.001]), and BIMA/radial artery (RA) (n = 147) and LIMA/RA (n = 169), had greater 10-y/s (84% and 78% [p < 0.001]) versus LIMA/SV. In multivariate analysis, MultArt grafts remained a strong independent predictor of survival (hazard ratio, 0.79; 95 % confidence interval, 0.66-0.94 [p = 0.007]).
The authors concluded that in patients undergoing isolated CABG with LIMA to LAD, arterial grafting of the non-LAD vessels conferred a survival advantage at 15 years compared with SVG.
This study of a large cohort of multivessel coronary artery disease patients reports that in isolated CABG performed more than 15 years ago with the use of LIMA to the LAD, bypassing the non-LAD targets with at least one additional arterial graft was an independent predictor of survival during the succeeding 15 years. The data suggest that MultArt grafting is a powerful surgical tool, and should be considered for all CABG patients, with the goal to substantially improve their long-term outcome. Additional prospective studies to further clarify subgroups of patients who benefit most from MultArt grafting in the contemporary era are indicated.
Keywords: Coronary Artery Disease, Propensity Score, Multivariate Analysis, Radial Artery, Incidence, Vascular Patency, Proportional Hazards Models, Saphenous Vein, Cardiovascular Diseases, Coronary Vessels, Confidence Intervals, Internal Mammary-Coronary Artery Anastomosis, Coronary Artery Bypass
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