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Vein Graft Use and Long-Term Survival After CABG
Quick Takes
- Among patients who underwent isolated CABG with a single arterial graft (SAG-CABG), Medicare and Medicaid claims data revealed differences between surgeons who tended to be more liberal versus more conservative users of saphenous vein grafts (SVGs).
- There was no difference in survival after SAG-CABG based on whether the surgeon was characterized as a conservative or liberal user of SVGs.
Study Questions:
Among patients undergoing coronary artery bypass grafting (CABG) with a single arterial graft (SAG-CABG), does the use of more saphenous vein grafts (SVGs) affect long-term survival?
Methods:
In a retrospective, observational study, data from the Centers for Medicare and Medicaid Services administrative claims database between 2001 and 2015 were reviewed for patients undergoing isolated SAG-CABG (including patients who underwent coronary endarterectomy and/or atrial fibrillation ablation procedures, and including patients who underwent CABG with 0 SVGs). Surgeons were stratified by number of SVGs utilized per SAG-CABG into conservative (≥1 standard deviation below mean), average (within 1 standard deviation of mean), and liberal (≥1 standard deviation above mean). Long-term survival was estimated using Kaplan-Meier analysis and compared among surgeon groups before and after augmented inverse-probability weighting.
Results:
There were 1,028,264 Medicare beneficiaries undergoing SAG-CABG from 2001 to 2015 (mean age 72.0 ± 7.9 years, 68.3% male); the median duration of follow-up was 6.1 years (interquartile range, 2.7-9.6 years). Over time, 1-vein and 2-vein SAG-CABG utilization increased, while 3-vein and ≥4-vein SAG-CABG utilization decreased (p < 0.001). On average, there were 2.3 ± 0.4 SVGs per SAG-CABG procedure. Of 5,356 surgeons performing ≥1 SAG-CABG, 1,132 were conservative SVG users (146,365 procedures, 1.7 ± 0.2 SVG/procedure), 3,272 were average (727,624 procedures, 2.3 ± 0.2 SVG/procedure), and 952 were liberal SVG users (154,275 procedures, 2.9 ± 0.2 SVG/procedure). SAG-CABG procedures associated with liberal SVG users were more often with high-volume surgeons at high-volume centers, and were less often off-pump CABG. Weighted analysis demonstrated no difference in median survival among patients undergoing SAG-CABG by liberal versus conservative vein graft users (adjusted median survival difference, 27 days); the same held true for subanalysis after excluding 199,757 patients who underwent off-pump CABG (adjusted median survival difference, 6 days).
Conclusions:
Among Medicare beneficiaries undergoing SAG-CABG, there was no association between surgeon proclivity for vein graft utilization and long-term survival, suggesting that a conservative approach to vein graft utilization is reasonable.
Perspective:
Among patients who undergo CABG, use of the left internal mammary artery is associated with improved short-term and long-term outcomes, and complete revascularization is associated with improved long-term outcomes. However, there is not consensus on the definition of complete revascularization. This large, retrospective, observational study based on Medicare and Medicaid claims data shows that there was no difference in survival after SAG-CABG based on whether the surgeon was characterized as a conservative or liberal user of SVGs. In addition to limitations inherent to the retrospective use of administrative claims data, the completeness of coronary revascularization, outcomes other than all-cause mortality, and any potential impact of post-CABG percutaneous coronary revascularization are unknown. Additional studies would be required to address these issues, as well as whether these findings can be extrapolated to a younger (non-Medicare) population.
Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Cardiovascular Care Team, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias
Keywords: Atrial Fibrillation, Cardiac Surgical Procedures, Catheter Ablation, Coronary Artery Bypass, Endarterectomy, Geriatrics, Myocardial Revascularization, Saphenous Vein, Survival
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