Total Arterial Revascularization With Internal Thoracic and Radial Artery Grafts in Triple-Vessel Coronary Artery Disease Is Associated With Improved Survival | Journal Scan

Study Questions:

Is coronary artery bypass grafting (CABG) using total arterial revascularization associated with better survival compared to CABG using a single internal thoracic artery and saphenous veins?

Methods:

From 1995 to 2010, 6,059 patients with three-vessel coronary artery disease underwent primary isolated CABG at eight centers. A study cohort of 3,774 patients was formed, with 2,988 (79%) undergoing total arterial revascularization and 786 (21%) receiving only saphenous veins to supplement a single in situ internal thoracic artery. In the total arterial revascularization group, bilateral internal thoracic arteries were used in 1,079 patients (36%) and at least one radial artery was used in 2,916 patients (97%). Propensity-score matching was used for risk adjustment.

Results:

Patients undergoing total arterial revascularization were younger (65.0 ± 10.4 years vs. 71.3 ± 7.9 years, p < 0.001) and less likely to have diabetes, cerebrovascular disease, recent myocardial infarction, and severe left ventricular impairment. At 15 years, patients who underwent total arterial revascularization experienced superior unadjusted survival (62% ± 1.1% vs. 35% ± 1.9%, p < 0.001). Multivariable Cox regression in the entire study cohort showed that the total arterial group had improved survival with a hazard ratio of 0.79 (95% confidence interval, 0.70-0.90; p < 0.001). After propensity-score matching yielded 384 patient pairs, total arterial revascularization was associated with improved survival at 15 years compared to patients who underwent single arterial revascularization (54% ± 3.3% vs. 41% ± 3.0%, p = 0.0004).

Conclusions:

This large multicenter study suggests that a strategy of total arterial revascularization is associated with improved long-term survival compared with the use of a single arterial graft plus saphenous vein grafts. Total arterial revascularization should be encouraged in patients with a reasonable life expectancy.

Perspective:

CABG with total arterial revascularization requires increased operative time for harvesting the conduits. At least in part because of this, its use might be limited to less complicated patients with lower anticipated perioperative risk. However, the finding in multivariable regression and propensity-score matched analyses of improved survival associated with total arterial revascularization compared to an isolated internal thoracic artery plus vein grafts suggests that it should be considered more often among patients with a reasonable life expectancy after CABG. Decades ago, demonstration of improved survival led to a demand that CABG is performed when feasible with the use of an internal thoracic artery, despite the added operative time and surgeon effort. In an analogous situation, these data should support increased demand for total arterial revascularization when feasible among appropriate patients.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Atherosclerotic Disease (CAD/PAD), Interventions and Coronary Artery Disease

Keywords: Coronary Artery Bypass, Coronary Artery Disease, Diabetes Mellitus, Life Expectancy, Mammary Arteries, Myocardial Infarction, Operative Time, Radial Artery, Risk Adjustment, Saphenous Vein


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