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Multicenter Study
. 2020 May 1;5(5):507-514.
doi: 10.1001/jamacardio.2019.6104.

Long-term Outcomes Associated With Total Arterial Revascularization vs Non-Total Arterial Revascularization

Rodolfo V Rocha  1 , Derrick Y Tam  1   2 , Reena Karkhanis  1   2 , Xuesong Wang  3 , Peter C Austin  2   3 , Dennis T Ko  3   4 , Mario Gaudino  5 , Alistair Royse  6   7 , Stephen E Fremes  1   2
Affiliations
Multicenter Study

Long-term Outcomes Associated With Total Arterial Revascularization vs Non-Total Arterial Revascularization

Rodolfo V Rocha et al. JAMA Cardiol. .

Abstract

Importance: The optimal conduits for coronary artery bypass grafting (CABG) remain controversial in multivessel coronary artery disease.

Objective: To compare the long-term clinical outcomes of total arterial revascularization (TAR) vs non-TAR (CABG with at least 1 arterial and 1 saphenous vein graft) in a multicenter population-based study.

Design, setting, and participants: This multicenter population-based cohort study using propensity score matching took place from October 2008 to March 2017 in Ontario, Canada, with a mean and maximum follow-up of 4.6 and 9.0 years, respectively. Individuals with primary isolated CABG were identified, with at least 1 arterial graft. Exclusion criteria were individuals from out of province and younger than 18 years. Patients undergoing a cardiac reoperation or those in cardiogenic shock were also excluded because these conditions would potentially bias the surgeon toward not performing TAR. Analysis began April 2019.

Exposures: Total arterial revascularization.

Main outcomes and measures: Primary outcome was time to first event of a composite of death, myocardial infarction, stroke, or repeated revascularization (major adverse cardiac and cerebrovascular events). Secondary outcomes included the individual components of the primary outcome.

Results: Of 49 404 individuals with primary isolated CABG, 2433 (4.9%) received TAR, with the total number of bypasses being 2, 3, and 4 or more vessels in 1521 (62.5%), 865 (35.6%), and 47 individuals (1.9%), respectively. The mean (SD) age was 61.2 (10.4) years and 1983 (81.5%) were men. After propensity score matching, 2132 patient pairs were formed, with equal total number of bypasses (mean [SD], 2.4 [0.5]) but with more arterial grafts in the TAR group (mean [SD], 2.4 [0.5] vs 1.2 [0.4]; P < .01). In-hospital death (15 [0.7%] vs 21 [1.0%]; P = .32) did not differ between TAR vs non-TAR groups after propensity score matching. Throughout 8 years, TAR was associated with improved freedom from major adverse cardiac and cerebrovascular events (hazard ratio, 0.78; 95% CI, 0.68-0.89), death (hazard ratio, 0.80; 95% CI, 0.66-0.97), and myocardial infarction (hazard ratio, 0.69; 95% CI, 0.51-0.92). There was no difference in stroke and repeated revascularization.

Conclusions and relevance: Total arterial revascularization was associated with improved long-term freedom from major adverse cardiac and cerebrovascular events, death, and myocardial infarction and may be the procedure of choice for patients with reasonable life expectancy requiring CABG.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Tam is supported by the Ontario Ministry of Health Clinician Investigator’s Program. Drs Austin and Ko are supported by a Mid-Career Award from the Heart and Stroke Foundation. Dr Fremes reports grants from Randomization of Single vs Multiple Arterial Grafts (ROMA) trial and serves as the Bernard S. Goldman Chair in Cardiovascular Surgery outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Freedom From MACCE Curves for Propensity Score–Matched TAR vs Non-TAR Groups Up to 8-Year Follow-up
HR indicates hazard ratio; MACCE, major adverse cardiac and cerebrovascular event; TAR, total arterial revascularization.
Figure 2.
Figure 2.. Survival Curves for 8-Year All-Cause Survival for Propensity Score–Matched TAR vs Non-TAR Groups
HR indicates hazard ratio; TAR, total arterial revascularization.
See this image and copyright information in PMC

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