Late Clinical Outcomes of Total Arterial Revascularization or Multiple Arterial Grafting Compared to Conventional Single Arterial with Saphenous Vein Grafting for Coronary Surgery

Abstract

Coronary surgery provides better long-term outcomes than percutaneous coronary intervention. Conventional practice is to use a single arterial conduit supplemented by saphenous vein grafts. The use of multiple arterial revascularization (MAG), or exclusive arterial revascularization (TAR), however, is reported as having improved late survival. Survival is a surrogate for graft failure that may lead to premature death, and improved survival reflects fewer graft failures in the non-conventional strategy groups. The reasons for not using MAG or TAR may be due to perceived technical difficulties, a lack of definitive large-scale randomized evidence, a lack of confidence in arterial conduits, or resources or time constraints. Most people consider radial artery (RA) grafting to be new, with use representing approximately 2-5% worldwide, despite select centers reporting routine use in most patients for decades with improved results. In conclusion, the current body of evidence supports more extensive use of total and multiple arterial revascularization procedures in the absence of contraindications.

Keywords: coronary artery bypass grafting; internal mammary artery; multiple arterial grafting; radial artery; total arterial revascularization.

Figure 1

Total arterial revascularization vs. non-total arterial revascularization: combined literature review and expanded multicenter collaborative data set meta-analysis. Reproduced with permission [23] Royse A, et al., J Am Coll Cardiol. 2022; 80(19):1833–1843. Data from individual publications or registries were pooled using a meta-analysis methodology. A total of 4 studies from the literature review section were removed because they included, or potentially included, duplicate patients from the expanded multicenter collaborative data set. A combined cohort of 127,565 propensity-score-matched or propensity-score-adjusted patients allocated to total arterial revascularization or non-total arterial revascularization were compared for late all-cause mortality at 8.3 years (95% CI: 6.2–10.4 years). An HR < 1 indicates a survival benefit. Almost all studies found a survival benefit favoring total arterial revascularization. Meta-analysis for the combined cohort found a significant survival advantage for total arterial revascularization by both random-effect and fixed-effect models.

Figure 2

Survival advantage for total arterial revascularization in coronary bypass grafting. Reproduced with permission [23] Royse A, et al., J Am Coll Cardiol. 2022; 80(19): 1833–1843. From a combination of literature and expanded current international registry data in matched patients. Survival for those exclusively receiving arterial coronary grafts (TAR) was greater than those that received supplementary saphenous vein grafts (non-TAR).

Figure 3

A summary of our retrospective study. Reproduced with permission [34] Ren, J. Long-term observational angiographic patency and perfect patency of radial artery compared with saphenous vein or internal mammary artery in coronary bypass surgery, J Thoracic Cardiovasc Surg 2022, 10.1016/j.jtcvs.2022.08.047. Abbreviations: OR, odds ratio; RA, radial artery; IMA, internal mammary artery; SVG, saphenous vein graft; CABG, coronary artery bypass grafting; Cx, circumflex artery; IMA, internal mammary artery; IQR, interquartile range; LAD, left anterior descending artery; OR, odds ratio; PCI, percutaneous coronary intervention.

Figure 4

Rate of patency and perfect patency of unique individual grafts. Reproduced with permission [34] Ren, J. Long-term observational angiographic patency and perfect patency of radial artery compared with saphenous vein or internal mammary artery in coronary bypass surgery, J Thoracic Cardiovasc Surg 2022, 10.1016/j.jtcvs.2022.08.047. Lighter colors represent patency, and darker colors represent perfect patency. All observations are directly measured without statistical estimation. For example, the bar of 5 to 10 years postoperative captures all angiograms taken within this time frame. Additional analysis up to 1 year postoperative shows that reductions in patency are evident within 3 months of surgery and that patency and perfect patency remains similar in later periods. Abbreviations: RA, radial artery; IMA, internal mammary artery; SVG, saphenous vein graft.