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Multiple Arterial Grafts Improve Late Survival of Patients Undergoing CABG: Analysis of 8,622 Patients With Multivessel Disease
Study Questions:
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)?
Methods:
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.
Results:
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]).
Conclusions:
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.
Perspective:
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.
Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Atherosclerotic Disease (CAD/PAD), Interventions and Coronary Artery Disease
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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