Late effects of radial artery versus saphenous vein grafting in patients aged 70 years or older

Clinical application of individualized total arterial coronary artery bypass grafting in coronary artery surgery

BACKGROUND

Total arterial revascularization is associated with increased patency and long-term efficacy and decreased perioperative morbidity and mortality and incidence of cardiac-related events and sternal wound infection compared with conventional coronary artery bypass surgery (CABG), in which the left internal mammary artery (LIMA) is typically grafted to the left anterior descending artery with additional saphenous vein grafts often used. This study determined whether these favorable clinical results could be realized at the authors’ institute.

AIM

To summarize the early efficacy and clinical experience of individualized total arterial coronary artery bypass grafting surgery.

METHODS

CABG was performed on 35 patients with non-single-vessel coronary artery disease by adopting total arterial grafts at Fourth Affiliated Hospital of Harbin Medical University between April 2016 and December 2019. LIMA was used in 35 patients, radial artery (RA) was used in 35 patients, and right gastroepiploic artery (RGEA) was used in 9 patients. Perioperative complications were observed, short-term graft patency rate was followed-up, and quality of life was assessed.

RESULTS

All patients underwent off-pump coronary artery bypass and the surgeries were successful. All of them were discharged without any complications or deaths. During the follow-up, it was found that patients’ angina symptoms were relieved and New York Heart Association classification for cardiac function was class I to class II. A total of 90 vessels were grafted with no occlusion for internal mammary artery, three occlusions for RA, and one occlusion for RGEA.

CONCLUSION

The individualized total arterial strategy based on the vessels targeting individual anatomic characteristics can achieve complete revascularization with satisfactory short-term grafting patency rate.

Long-term graft patency after coronary artery bypass grafting: Effects of morphological and pathophysiological factors

OBJECTIVE

The aim of the present study was to identify morphological and pathophysiological factors associated with long-term patency of grafts used in coronary artery bypass grafting (CABG).

METHODS

A total of 127 patients who underwent CABG between 2000 and 2006 and presented for computed tomography evaluation of graft patency at 139.78±36.64 months post-CABG were analyzed. Patients received 340 grafts (2.68 grafts/patient), 399 distal anastomoses (3.14 anastomoses/ patient), 220 (55.14%) performed using arterial grafts, and 179 (44.86%) using saphenous vein grafts (SVGs).

RESULTS

Graft patency varied according to vessel type and coronary territory. Overall graft patency was 90.16% for the left internal thoracic artery (LITA), 75.55% for the right internal thoracic artery (RITA), 79.25% for the radial artery (RA), and 74.3% for the SVG. The maximum patency rate was obtained with the RA (80.65%) for the right coronary territory, RITA (92.86%) for the anterolateral territory, and SVG (82.54%) for the circumflex territory. The LITA-left anterior descending artery graft occluded in 13 (7.93%) cases, 7 due to competitive flow. The influence of graft length on patency rates after indexing to height was not significant. The target vessel degree of stenosis influenced arterial graft patency rates with an occlusion odds ratio (OR) of 3.02 when anastomosed to target vessels with <90% stenosis. Target vessel caliber also influenced patency rates with occlusion ORs of 2.63 for SVGs and 2.31 for arterial grafts when anastomosed to ≤1.5 mm target vessels.

CONCLUSION

Morphological parameters, such as graft type, target territory, target vessel caliber, and degree of stenosis, are important factors conditioning long-term graft patency.

Long-term Outcomes of Multiple Arterial Coronary Artery Bypass Grafting: A Population-Based Study of Patients in British Columbia, Canada

Importance

Although the long-term survival advantage of multiple arterial grafting (MAG) vs the standard use of left internal thoracic artery (LITA) supplemented by saphenous vein grafts (LITA+SVG) has been demonstrated in several observational studies, to our knowledge its safety and other long-term clinical benefits in a large, population-based cohort are unknown.

Objective

To compare the safety and long-term outcomes of MAG vs LITA+SVG among overall and selected subgroups of patients.

Design, Setting, and Participants

In this population-based observational study, we included 20 076 adult patients with triple-vessel or left-main disease who underwent primary isolated coronary artery bypass grafting (MAG, n = 5580; LITA+SVG, n = 14 496) in the province of British Columbia, Canada, from January 2000 to December 2014, with follow-up to December 2015. We performed propensity-score analyses by weighting and matching and multivariable Cox regression to minimize treatment selection bias.

Exposures

Multiple arterial grafting or LITA+SVG.

Main Outcomes and Measures

Mortality, repeated revascularization, myocardial infarction, heart failure, and stroke.

Results

Of 5580 participants who underwent MAG, 586 (11%) were women and the mean (SD) age was 60 (8.7) years. Of 14 496 participants who underwent LITA+SVG, 2803 (19%) were women and the mean (SD) age was 68 (8.9) years. The median (interquartile range) follow-up time was 9.1 (5.1-12.6) years and 8.1 (4.5-11.7) years for the groups receiving MAG and LITA+SVG, respectively. Compared with LITA+SVG, MAG was associated with reduced mortality rates (hazard ratio [HR], 0.79; 95% CI, 0.72-0.87) and repeated revascularization rates (HR, 0.74; 95% CI, 0.66-0.84) in 15-year follow-up and reduced incidences of myocardial infarction (HR, 0.63; 95% CI, 0.47-0.85) and heart failure (HR, 0.79; 95% CI, 0.64-0.98) in 7-year follow-up. The long-term benefits were coherent by all 3 statistical methods and persisted among patient subgroups with diabetes, obesity, moderately impaired ejection fraction, chronic obstructive pulmonary disease, peripheral vascular disease, or renal disease. Multiple arterial grafting was not associated with increased morbidity or mortality rates at 30 days overall or within patient subgroups.

Conclusions and Relevance

Compared with LITA+SVG, MAG is associated with reduced mortality, repeated revascularization, myocardial infarction, and heart failure among patients with multivessel disease who are undergoing coronary artery bypass grafting without increased mortality or other adverse events at 30 days. The long-term benefits consistently observed across multiple outcomes and subgroups support the consideration of MAG for a broader spectrum of patients who are undergoing coronary artery bypass grafting in routine practice.

Optimal management of radial artery grafts in CABG: Patient and target vessel selection and anti-spasm therapy

The current literature on radial artery grafting is reviewed focusing on the optimal deployment of radial artery grafts in coronary artery bypass surgery with specific attention to the selection of patients and target vessels for radial artery grafting.

Coronary Artery Bypass Grafting with Arterial Conduits in the Elderly

Although improved long-term outcomes obtained with the use of arterial grafts for coronary revascularization in comparison with the traditional association of a single arterial and saphenous vein grafts have been demonstrated in the overall population, the efficacy of this newer technique in the elderly is difficult to prove because their shorter life expectancy due to advanced heart disease, associated with severe comorbidities. Moreover, more widespread use of this technique is limited by the concerns on the potential morbidity, particularly the longer time required to perform the operation and the possibility of deep sternal wound infection in case of bilateral internal thoracic artery harvesting due to the decreased blood supply to the sternum and surrounding tissues.The review of the recent literature indicates that the use of bilateral internal thoracic arteries in very elderly patients should not be considered routinely. It seems reasonable to avoid it in octogenarians in the presence of well-known predictors of sternal complications such as diabetes, morbid obesity, and severe chronic lung disease.There is also still controversy about the superiority of the radial artery over the saphenous vein graft as a second or third conduit for surgical myocardial revascularization, although the majority of recent studies seem to support more liberal use of the radial artery as second arterial conduit in the elderly. Although a clinical benefit of arterial graft revascularization cannot be formally excluded for elderly patients, the increased complexity of this technique suggests that careful clinical judgment is necessary to select grafts for individual patients.

The Surgical Treatment of Coronary Artery Occlusive Disease: Modern Treatment Strategies for an Age Old Problem

Coronary artery disease remains a formidable challenge to clinicians. Percutaneous interventions and surgical techniques for myocardial revascularization continue to improve. Concurrently, in light of emerging data, multiple practice guidelines have been published guiding clinicians in their therapeutic decisions. The multidisciplinary Heart Team concept needs to be embraced by all cardiovascular providers to optimize patient outcomes.

Is Bilateral Internal Mammary Arterial Grafting Beneficial for Patients Aged 75 Years or Older?

BACKGROUND

Although bilateral internal mammary artery (BIMA) grafting is performed with increasing regularity in elderly patients, whether it is truly beneficial, and therefore indicated, in these patients remains uncertain. We retrospectively investigated early and late outcomes of BIMA grafting in patients aged ≥75 years.

METHODS AND RESULTS

We identified 460 patients aged ≥75 years from among 2,618 patients who underwent either single internal mammary artery (SIMA) grafting (n=293) or BIMA grafting (n=107). Early outcomes did not differ between the SIMA and BIMA patients (30-day mortality: 1.7% vs. 0%, P=0.39; sternal wound infection: 1.0% vs. 4.7%; P=0.057). Late outcomes, 10-year survival in particular, were improved in the BIMA group (36.6% vs. 48.1%, P=0.033). In the analysis of the results in propensity score-matched groups (196 patients in the SIMA group, 98 patients in the BIMA group), improved 10-year survival was documented in the BIMA group (34.8% vs. 47.6%, P=0.030). Cox proportional regression analysis showed SIMA usage (non-use of BIMA) to be a predictor for late mortality (hazard ratio: 0.65, 95% confidence interval: 0.43-0.98, P=0.042). We further compared outcomes between the total non-elderly patients (n=2,158) and total elderly patients (n=460). BIMA usage was similar, as was 30-day mortality (1.0% vs. 1.3%, respectively).

CONCLUSIONS

A survival advantage, with no increase in early mortality, can be expected from BIMA grafting in patients aged ≥75 years. (Circ J 2016; 80: 1756-1763).

CABG Versus PCI: Greater Benefit in Long-Term Outcomes With Multiple Arterial Bypass Grafting

BACKGROUND

Treatment of multivessel coronary artery disease with traditional single-arterial coronary artery bypass graft (SA-CABG) has been associated with superior intermediate-term survival and reintervention compared with percutaneous coronary intervention (PCI) using either bare-metal stents (BMS) or drug-eluting stents (DES).

OBJECTIVES

This study sought to investigate longer-term outcomes including the potential added advantage of multiarterial coronary artery bypass graft (MA-CABG).

METHODS

We studied 8,402 single-institution, primary revascularization, multivessel coronary artery disease patients: 2,207 BMS-PCI (age 66.6 ± 11.9 years); 2,381 DES-PCI (age 65.9 ± 11.7 years); 2,289 SA-CABG (age 69.3 ± 9.0 years); and 1,525 MA-CABG (age 58.3 ± 8.7 years). Patients with myocardial infarction within 24 h, shock, or left main stents were excluded. Kaplan-Meier analysis and Cox regression were used to separately compare 9-year all-cause mortality and unplanned reintervention for BMS-PCI and DES-PCI to respective propensity-matched SA-CABG and MA-CABG cohorts.

RESULTS

BMS-PCI was associated with worse survival than SA-CABG, especially from 0 to 7 years (p = 0.015) and to a greater extent than MA-CABG was (9-year follow-up: 76.3% vs. 86.9%; p < 0.001). The surgery-to-BMS-PCI hazard ratios (HR) were as follows: versus SA-CABG, HR: 0.87; and versus MA-CABG, HR: 0.38. DES-PCI showed similar survival to SA-CABG except for a modest 0 to 3 years surgery advantage (HR: 1.06; p = 0.615). Compared with MA-CABG, DES-PCI exhibited worse survival at 5 (86.3% vs. 95.6%) and 9 (82.8% vs. 89.8%) years (HR: 0.45; p <0.001). Reintervention was substantially worse with PCI for all comparisons (all p <0.001).

CONCLUSIONS

Multiarterial surgical revascularization, compared with either BMS-PCI or DES-PCI, resulted in substantially enhanced death and reintervention-free survival. Accordingly, MA-CABG represents the optimal therapy for multivessel coronary artery disease and should be enthusiastically adopted by multidisciplinary heart teams as the best evidence-based therapy.

Are all forms of total arterial revascularization equal? A comparison of single versus bilateral internal thoracic artery grafting strategies

OBJECTIVE

Total arterial revascularization (TAR) with internal thoracic arteries (ITAs) and radial arteries (RA) is associated with greater long-term survival compared with the use of a single internal thoracic artery supplemented by veins. The optimal conduit choice and configuration in achieving TAR remains controversial, with uncertainty regarding the individual prognostic impact of ITAs and RAs. As such, among patients solely undergoing TAR, we compared long-term survival between patients receiving single thoracic arteries and those receiving bilateral ITAs.

METHODS

From 1995 to 2010, 2821 patients with 3-vessel coronary artery disease at 8 centers underwent primary isolated coronary artery bypass with TAR using ITAs and RAs. Bilateral ITAs were used in 912 patients. In 380 cases, bilateral in situ ITAs were grafted to the left coronary system. RAs were used in 848 patients (93%) receiving bilateral ITAs and 1906 patients (99.8%) receiving single ITAs. Survival data were obtained using the National Death Index. Separate 1:1 propensity score-matched analyses were performed for (1) bilateral ITA versus single ITA and (2) bilateral ITA incorporating a free right ITA versus single ITA and RAs. Among the 912 patients with bilateral ITAs, those receiving an in situ right ITA to the left coronary system were compared with those receiving a free right ITA.

RESULTS

In the propensity score-matched analysis comparing bilateral versus single ITAs (591 matched pairs), there were similar rates of 30-day mortality and deep sternal wound infection. Bilateral ITA use was associated with greater 15-year survival (79% ± 3.9% vs 67% ± 4.7%, P < .001). In the analysis between bilateral ITA incorporating a free right ITA versus single ITA + RAs (380 matched pairs), bilateral ITA use demonstrated comparable survival at 15 years (79% ± 4.7% vs 67% ± 5.7%, P = .09). Among patients receiving bilateral ITAs, comparison between in situ right ITA versus free right ITA recipients (206 matched pairs) revealed comparable 15-year survival (84% ± 6.1% vs 79% ± 6.7%, P = .13). Multivariable Cox regression found bilateral ITA use to be protective from mortality (hazard ratio, 0.73; 95% confidence interval, 0.59-0.90, P = .004).

CONCLUSIONS

The use of bilateral ITAs as an in situ or free conduit is associated with greater survival and seems to offer a prognostic advantage over the use of only a single ITA supplemented by RAs. Therefore, all configurations of TAR are not equivalent.

Multi Versus Single Arterial Coronary Bypass Graft Surgery Across the Ejection Fraction Spectrum

BACKGROUND

Left internal thoracic artery (LITA) and radial artery (RA) multi-arterial CABG (MABG) is generally associated with improved long-term survival compared with traditional LITA and saphenous vein single arterial CABG (SABG). We examined the hypothesis that this multi-arterial survival advantage persists irrespective of left ventricular ejection fraction (LVEF).

METHODS

We retrospectively analyzed the primary, non-salvage multi-graft CABG experience (n = 11,261; 64.4 ± 10.4 years, 70.4% men) from 2 institutions (1995 to 2011). Risk-adjusted 15-year survival was pairwise compared for the MABG versus SABG grafting approaches within 3 LVEF subcohorts (>0.50, n = 4,833 [44% MABG]; 0.36 to 0.50, n = 4,465 [39% MABG]; and ≤ 0.35, n = 1,963 [35% MABG]) using propensity-matched and covariate adjusted Cox regression (all patients) comparisons.

RESULTS

Propensity matching yielded 1,317 (LVEF > 0.50), 1,179 (LVEF, 0.36 to 0.50), and 470 (LVEF ≤ 0.35) well-matched grafting method pairs. Acute perioperative mortality was equivalent between MABG and SABG within each LVEF group, but increased with decreasing LVEF. MABG was uniformly associated with better 15-year survival compared with SABG for all LVEF categories. The associated matched-adjusted hazard ratios (95% confidence intervals) were consistent across EF groups at 0.79 (0.68 to 0.93), 0.80 (0.69 to 0.93), and 0.82 (0.66 to 1.0), respectively. Covariate adjusted HR in all patients concurred with matched results.

CONCLUSIONS

MABG results in significantly enhanced long-term survival compared with LITA/SVG SABG regardless of the degree of LV dysfunction. These results favor MABG as the therapy of choice in patients with LV dysfunction.

Mid-Term Patency in Radial Artery and Saphenous Vein After Coronary Artery Bypass Grafting in Asymptomatic Patients Using 128-Slice CT Coronary Angiography

Background:

Patency of the revascularization conduit is an essential predictor of long-standing survival after coronary artery bypass grafting.

Objectives:

We have conducted this study to compare the mid-term patency rates of radial artery (RA), left internal thoracic artery (LITA) and also saphenous vein (SV) grafts in asymptomatic patients following coronary artery bypass graft surgery (CABG) undergoing total IV anesthesia.

Patients and Methods:

In this study, 30 three-vessel disease patients with 104 RA, LITA, and SV grafts used concomitantly for primary isolated non-emergent CABG surgery were assessed. The primary end point was CT angiographic graft patency rate. After 53.5 (24-97) months’ follow-up, graft patency was assessed using 128-slice CT coronary angiography. Logistic regression analysis was used to detect the independent predictors of graft failure.

Results:

A total of 104 grafts, including 30 LITA, 44 SV, and 30 RA grafts, were studied. Cumulative graft patency rates were 93.3% in LITA, 83.3% in RA, and 70.5% in SV grafts. Statistically significant difference was found between the LITA and the SV graft patency rates (P = 0.019), whereas the difference between the RA conduit patency and the LITA or SV graft patency rates did not have any statistical significance (P = 0.424 and P = 0.273, respectively). Independent predictors of RA grafts occlusion were native coronary stenosis < 70% and female gender.

Conclusions:

In our patients, the RA grafts had an acceptable patency rate in 2 to 5 years’ follow-up. Although the SV grafts had a relatively higher patency rate than RA grafts in our asymptomatic patients, the patency rates in RA and SV grafts were close to each other. The RA graft function was poor in the patients with a higher number of risk factors and in the females.

Saphenous vein graft vs. radial artery graft searching for the best second coronary artery bypass graft

Coronary artery bypass grafting (CABG) was first used in the late 1960s. This revolutionary procedure created hope among ischemic heart disease patients. Multiple conduits are used and the golden standard is the left internal mammary artery to the left anterior descending artery. Although all approaches were advocated by doctors, the use of saphenous vein grafts became the leading approach used by the majority of cardiac surgeons in the 1970s. The radial artery graft was introduced at the same time but was not as prevalent due to complications. It was reintroduced into clinical practice in 1989. The procedure was not well received initially but it has since shown superiority in patency as well as long-term survival after CABG. This review provides a summary of characteristics, technical features and patency rates of the radial artery graft in comparison with venous conduits. Current studies and research into radial artery grafts and saphenous vein grafts for CABG are explored. However, more studies are required to verify the various findings of the positive effects of coronary artery bypass grafting with the help of radial arteries on mortality and long-lasting patency.

A meta-analysis of randomized controlled trials on mid-term angiographic outcomes for radial artery versus saphenous vein in coronary artery bypass graft surgery

BACKGROUND

Currently, saphenous vein (SV) and radial artery (RA) are the most commonly used conduits in combination with the left internal mammary artery for conventional coronary artery bypass graft surgery (CABG). The present meta-analysis aimed to assess the existing evidence from randomized controlled trials (RCTs) to compare the angiographic outcomes of these two conduits at mid-term follow-up.

METHODS

Four relevant and updated RCTs with follow-up beyond 3 years were identified using five electronic databases. Angiographic endpoints included complete occlusion, 'string sign', graft failure and complete patency.

RESULTS

The incidence of complete occlusion was significantly lower after using RA compared to SV [6.7% vs. 17.2%; odd ratio (OR), 0.36; 95% confidence interval (CI), 0.23-0.58; P<0.0001]. The angiographic 'string sign' was significantly more likely to be identified after using RA compared to SV (3.1% vs. 0%; OR, 5.65; 95% CI, 1.21-26.39; P=0.03). Graft failure was significantly lower after RA compared to SV (9.6% vs. 18.8%; OR, 0.47; 95% CI, 0.30-0.72; P=0.0005). Complete graft patency was found to be significantly higher after RA compared to SV (88.6% vs. 75.8%; OR, 3.19; 95% CI, 1.42-7.16; P=0.005).

CONCLUSIONS

Results of the present meta-analysis suggest that selected patients with severe, proximal stenosis may have superior angiographic outcomes at mid-term follow-up after using RA compared to SV for CABG. However, RA is associated with a significantly higher incidence of the 'string sign'. Future studies should aim to collect additional data on symptomatic outcomes.

Radial artery as a second arterial graft in the elderly and both sexes

BACKGROUND

Use of multiple arterial grafts for surgical coronary revascularization remains limited in scope worldwide, and is disproportionately low in two growing segments of coronary artery disease patients-women and the elderly. While a prevailing practice, this trend is not supported by objective data. This report discusses two recent reports that support the liberal use of the radial artery (RA) as a second arterial conduit, in the elderly and irrespective of sex, instead of the conventional operation based on a single internal thoracic artery (ITA) with additional vein grafts.

METHODS

From 1996 to 2007, 6,384 patients underwent primary, non-salvage emergency coronary artery bypass grafting with at least 2 complete grafts (including one ITA graft) were included in the present analysis. Those with bilateral ITA, ITA-only grafts, or concomitant valve/aortic surgery were excluded. 2,605 patients aged 70 or greater were further included in a subsequent analysis. Patients were further matched on propensity score models based on ITA/RA versus ITA/saphenous vein (SV) grafts.

RESULTS

69% of all included patients were male. Propensity models yielded 1,416 ITA/RA and ITA/SV matched pairs in men and 567 pairs in women. Operative mortality was similar for both graft combinations in men and women, while late mortality was significantly lower for ITA/RA subcohorts in both sexes. Matched Kaplan-Meier cumulative mortality was significantly better for ITA/RA irrespective of sex (men: risk reduction (RR) =0.65, P<0.001; women: RR=0.75, P=0.045). In patients aged 70 years or older, operative death was essentially identical for ITA/RA vs. ITA/SV (2.31% vs. 2.31%; P=0.880). Patients undergoing ITA/RA grafting had significantly better unadjusted 12-year survival. In 480 elderly matched pairs, cumulative mortality at 1, 5, and 10 years was significantly better for the ITA/RA cohort.

CONCLUSION

The discussed data showed a clinically significant improvement in intermediate (1-5 years) and late (>5 years) survival with multiple arterial grafts in female and male patients and in the elderly. The latter was true for both the septuagenarian and octogenarian subgroups. Importantly, the choice of the RA as the second arterial conduit seems to be associated with low associated perioperative risks, and avoids the potential for sternal healing complications due to bilateral ITA dissection in certain patients.

Conduits for Coronary Bypass: Arteries Other Than the Internal Thoracic Artery's

This is the third in a series on coronary artery bypass which reviews three alternative arterial conduits. The radial artery has become the most widely used of the three and accumulating experience demonstrates better patency at 10 years versus saphenous vein. Drawbacks are a long incision on the forearm, the propensity for spasm and persistent sensory disturbance in about 10%. The first is answered by endoscopic harvest which may yield a shorter conduit but reduces sensory nerve injury. Spasm is managed pharmacologically and by less harvest trauma. The gastroepiploic artery is used in situ and free and although the abdominal cavity is entered complications are minimal and patency compares favorably with the radial artery. Use of the inferior epigastric artery remains minimal and its similar length often requires composite use but limited patency data are supportive. Other arteries have had rare use and this is unlikely to change because the three presented here have significant advantages and acceptance.