Multiple Versus Single Arterial Coronary Bypass Graft Surgery for Multivessel Disease

Is It Safe to Use Arterial Grafts in Patients with Acute Myocardial Infarction? Short-Mid-Term Propensity Analysis

INTRODUCTION

The use of multiple arterial grafts (MAGs) has an impact on patient survival; however, preference for its use in the acute phase of myocardial infarction (AMI) has not yet been established. This study aimed to compare the short-mid-term clinical results of AMI patients undergoing coronary artery bypass grafting (CABG) with a single arterial graft (SAG) vs. MAGs.

METHODS

This is a cross-sectional cohort study of 4,053 patients from the Registro Paulista de Cirurgia Cardiovascular II (REPLICCAR II). CABG in the AMI was considered when performed between one and seven days after diagnosis (n=238). Thirty-five patients underwent surgery with ≥ 2 arterial grafts (MAG group), population adjustment in SAG group was performed using the propensity score matching (PSM). Clinical follow-up was performed by telephone to assess need for readmission, new AMI, reoperation, and death.

RESULTS

After PSM, 70 patients were evaluated. During hospitalization, a significant statistical difference was observed in the surgery duration: the MAG group had a median of 4.78 hours while the SAG group had 4.11 hours (P=0.040). Within the MAG group, there was a predominance use of bilateral internal thoracic artery (62.86%), followed by radial graft associated with the use of left internal thoracic artery (28.57%) and the combination of the three grafts (8.57%). There were no significant differences between the groups in terms of outcomes up to 30 days after CABG or up to five years after CABG.

CONCLUSION

In REPLICCAR II, usage of MAGs in the AMI was not associated with clinical worsening of patients until the mid-term follow-up.

Long term follow-up of bilateral internal thoracic artery use in young coronary artery bypass grafting patients: 29 year single surgeon experience

BACKGROUND

Improved long term survival has demonstrated by grafting left internal thoracic artery (LITA) to the left anterior descending artery (LAD). This study investigated the prognostic benefits of BITA versus single LITA with common anastomotic configurations of BITA.

METHODS

Elective patients age below 60 years, undertaken by a single surgeon, between 1992 and 2014 were explored. Cox regression models were fitted to investigate prognostic benefits of BITA. Specific comparisons were made with BITA subgroups who received LITA to LAD or RITA to LAD to establish long-term prognostic difference with the use of the RITA to LAD as compared to the LITA to LAD anastomosis. Comparisons were made with other BITA configurations to establish long-term difference in survival as a result of the actual targets bypassed with BITA grafts.

RESULTS

Both groups had similar baseline patient characteristics. Following risk adjustment, the use of a second ITA conferred a significant 48% reduction in long-term mortality to BITA group [HR 0.52 (95%CI: 0.36-0.74) p < .001]. The use of the RITA to LAD, instead of LITA, resulted in no difference in the long-term prognostic benefit. The targets grafted with second ITA conferred a significant prognostic benefit for common configurations it was used in for bypass surgery.

CONCLUSIONS

The use of BITA confers long term prognostic benefit to patients. Grafting RITA to LAD instead of more common LITA to LAD made no difference in long term prognosis when compared to CABG patients with single ITA. The use of a second ITA conduit in common configurations for CABG confers prognostic benefits irrespective of distal target grafted.

A Comparative Analysis of Single Versus Multiple Arterial Grafts in Coronary Arterial Bypass Grafting: Initial Experience in Iraq

INTRODUCTION

The global recognition of multiple arterial grafting (MAG) and total arterial grafting (TAG) in coronary artery bypass grafting (CABG) is increasing. However, many centers have not yet adopted these procedures. Our study aims to examine the intraoperative, early postoperative, and two-year follow-up outcomes associated with MAG and TAG in candidates for CABG. The goal is to provide valuable insights into the role of these procedures.

METHODS

A prospective comparative study was conducted at Sulaimani Cardiac Hospital to analyze a cohort of 300 patients who underwent CABG surgery between January 2021 and April 2022. Convenience sampling was used to select participants. Prior to surgery, patients underwent comprehensive pre-operative evaluations, with certain CABG types being excluded. The patients were then categorized into three groups based on their surgical approach: single arterial conduit (SA), two arterial conduits (MA), and total arterial revascularization (TA). The standard bypass procedure was performed for all patients, and they were monitored for 30 days, six months, and two years after the surgery. A range of variables, including bypass and cross-clamp times, as well as postoperative complications such as bleeding and stroke, were recorded and analyzed. Statistical Product and Service Solutions (SPSS, version 25; IBM Corp., Armonk, NY) was used for this analysis, with a predetermined significance threshold of p ≤ 0.05.

RESULTS

The study included 300 participants who underwent CABG. The participants had an average age of 61.19 ± 4.67 years (95% CI: 36-81) and an average BMI of 27.40 ± 8.4 kg/m² (95% CI: 18-45). Diabetes was present in 40.3% of the patients, and the majority of the participants were male (77.7%). The number of vessels involved in the bypass varied, with two vessels in 21% of cases, three vessels in 65%, and four vessels in 14%. The left internal thoracic artery (LITA) was primarily used for arterial revascularization, and additional arterial conduits were used in 30.3% of cases. Statistical analysis showed significant differences in the number of grafts among patient groups (P = 0.042). However, there were no significant differences in bypass duration, cross-clamp duration, stroke incidence, or in-hospital mortality rates among the groups (P > 0.05). The rates of myocardial infarction (MI) approached significance (P = 0.05), and the mortality rates were comparable over a two-year period after CABG (4.7%) and at shorter intervals. These findings highlight the importance of age and the number of grafts in determining outcomes in CABG patients.

CONCLUSION

In a developing nation, the lack of a specialized center for MAG does not hinder the implementation of MAG or TAG. The overall occurrence of complications after CABG is similar across all groups, except for MI. Patients who undergo MAG have higher rates of overall survival compared to those who receive SA and TAG.

Radial artery vs right internal mammary artery as a second conduit during coronary artery bypass grafting

OBJECTIVE

To compare the clinical outcomes of radial artery (RA) grafts during CABG to those of right internal mammary artery (RIMA) grafts.

METHODS

This was a retrospective, single-institution cohort study of isolated CABG with multiple grafts between 2010-2022. To balance graft cohorts, propensity score matching (PSM) was performed using a 1:1 match ratio. Long-term postoperative survival was compared among RA and RIMA groups. Similarly, major adverse cardiac and cerebrovascular events (MACCE) were compared among both cohorts, with MACCE comprising death, myocardial infarction (MI), coronary revascularization, and stroke. Kaplan-Meier estimation was performed for mortality, while cumulative incidence estimation was utilized for MACCE.

RESULTS

A total of 8,774 patients underwent CABG. Of those, 1,674 (19.1%) patients who underwent multiarterial CABG were included in this analysis. 326 (19.5%) patients received RA grafts and 1,348 (80.5%) received RIMA grafts. PSM yielded a cohort of 323 RA patients and 323 RIMA patients. After matching, groups were well-balanced across all baseline variables. No significant differences were observed in immediate postoperative complications or long-term survival, with 5-year survival estimates of 89.5% for the RA group vs 90.1% for the RIMA group. There was a nonsignificant trend toward a higher incidence of MACCE at 5 years in the RA group compared to the RIMA group (31.3% in the RA group vs 24.1% in the RIMA group), especially after 1-year follow-up (21.6% in the RA group vs 15.1% in the RIMA group). Specifically, for RA patients, there were higher rates of repeat revascularization in the 5-year postoperative period (14.7% in the RA group vs 5.3% in the RIMA group), particularly in the territory revascularized by the RA during the index operation (45.7% in the RA group vs 10.3% in the RIMA group).

CONCLUSION

Overall, RA and RIMA secondary conduits for CABG were associated with comparable immediate postoperative complications, 5-year MACCE, and 5-year survival after PSM. RA grafting was associated with significantly higher rates of repeat coronary revascularization at 5 years, specifically in the territory revascularized by the RA during the index operation.

Multiarterial vs Single-Arterial Coronary Surgery: 10-Year Follow-up of 1 Million Patients

BACKGROUND

Although many options exist for multivessel coronary revascularization, controversy persists over whether multiarterial grafting (MAG) confers a survival advantage over single-arterial grafting (SAG) with saphenous vein in coronary artery bypass grafting (CABG). This study sought to compare longitudinal survival between patients undergoing MAG and those undergoing SAG.

METHODS

All patients undergoing isolated CABG with ≥2 bypass grafts in The Society of Thoracic Surgeons Adult Cardiac Surgery Database (2008-2019) were linked to the National Death Index. Risk adjustment was performed using inverse probability weighting and multivariable modeling. The primary end point was longitudinal survival. Subpopulation analyses were performed and volume thresholds were analyzed to determine optimal benefit.

RESULTS

A total of 1,021,632 patients underwent isolated CABG at 1108 programs (100,419 MAG [9.83%]; 920,943 SAG [90.17%]). Median follow-up was 5.30 years (range, 0-12 years). After risk adjustment, all characteristics were well balanced. At 10 years, MAG was associated with improved unadjusted (hazard ratio, 0.59; 95% CI 0.58-0.61) and adjusted (hazard ratio, 0.86; 95% CI, 0.85-0.88) 10-year survival. Center volume of ≥10 MAG cases/year was associated with benefit. MAG was associated with an overall survival advantage over SAG in all subgroups, including stable coronary disease, acute coronary syndrome, and acute infarction. Survival was equivalent to that with SAG for patients age ≥80 years and those with severe heart failure, renal failure, peripheral vascular disease, or obesity. Only patients with a body mass index ≥40 kg/m2 had superior survival with SAG.

CONCLUSIONS

Multiarterial CABG is associated with superior long-term survival and should be the surgical multivessel revascularization strategy of choice for patients with a body mass index of less than 40 kg/m2.

Outcomes of Radial Artery Versus Saphenous Vein as A Second Conduit After Coronary Artery Bypass Grafting

Despite the advantages of multiarterial grafting, saphenous vein (SV) configurations predominate in coronary artery bypass grafting (CABG). In addition, the benefits of radial artery (RA) utilization in multivessel CABG remain unclear. This study aims to compare the clinical outcomes of patients who received RA grafts during CABG with those of patients who received SV grafts. A retrospective, single-institution cohort study was performed in 8,774 adults who underwent isolated CABG surgery with multiple grafts between 2010 and 2022. To balance graft cohorts, propensity score matching (PSM) was performed using a 1:2 (RA/SV) match ratio. Long-term postoperative survival was compared in RA and SV graft groups. Similarly, major adverse cardiac and cerebrovascular event (MACCE) rates were compared in the cohorts, with MACCE comprising death, myocardial infarction (MI), coronary revascularization, and stroke. Kaplan-Meier estimation was performed for both mortality and MACCE. A total of 7,218 patients (82.3%) who underwent multivessel CABG were included in this analysis. Of these patients, 341 (4.7%) received RA grafts, and 6,877 (95.3%) received SV grafts secondary to left internal mammary artery use. PSM yielded a cohort of 335 patients with RA and 670 patients with SV. After matching, groups were well balanced across all baseline variables. No significant differences were observed in either immediate postoperative morbidities or long-term survival. However, Kaplan-Meier estimates of long-term postoperative freedom from MACCE were significantly greater in matched patients with SV (73.3%) than in those with RA (67.4%) (p = 0.044, cluster log-rank), with patients with SV also possessing significantly greater freedom from coronary revascularization and MI. In conclusion, RA and SV secondary conduits for CABG were associated with comparable immediate postoperative complications and long-term survival after PSM. SV grafting was associated with significantly decreased rates of postoperative MACCE, likely owing to lower rates of coronary revascularization and MI than in RA grafting.

Percutaneous coronary intervention versus coronary artery by-pass grafting in premature coronary artery disease: What is the evidence? -A narrative review

Coronary artery disease (CAD) remains one of the leading causes of death globally. In the United States of America, in 2016, 19% of all patients under the age of 65 died of cardiovascular disease despite improvements in primary prevention. The premature clinical onset of symptoms in the young population (<60 years) is much more aggressive than in the older population, and the overall long-term prognosis is poor. CAD appears to have a rapidly progressive form in those under the age of 60 due to genetic predisposition, smoking, and substance abuse, however, the ideal management strategy is still yet to be established. The two primary methods of establishing coronary revascularization are percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG). Despite the increasing prevalence of CAD in the young population, they are consistently underrepresented in major randomized clinical trials of each revascularization strategy. Both CABG and PCI are known to have similar survival rates, but PCI is associated with higher repeat revascularization rate. Many argue this may be due to the progressive nature of CAD combined with the vessel patency time required in a patient under 60 with potentially another 20-30 years of life. There is little in literature regarding the outcomes of these various revascularization strategies in populations under 60 years with CAD. This review summarises the current evidence for each revascularisation strategy in patients under the age of 60 and suggests future avenues of research for this unique age group.

Impact of Graft Strategies on the Outcome of Octogenarians Undergoing Coronary Artery Bypass Grafting

PURPOSE

To analyse the outcome of coronary artery bypass grafting (CABG) in octogenarians with coronary multivessel disease and the impact of different graft strategies and other factors.

METHODS

Out of 1654 patients with multivessel disease who underwent CABG at our institution between January 2014 and March 2020, we investigated 225 consecutive patients with a median age of 82.1 years for survival prediction and need for coronary reintervention; a detailed outcome analysis was performed.

RESULTS

At mean follow-up of 3.3 years, the overall survival was 76.4%. An indication for emergency operation (p = 0.002), age (p <0.001), chronic pulmonary disease (p = 0.024), and reduced renal or ventricular function (p <0.001) had the highest impact on limited survival. The combination outcome of survival and coronary reintervention was 1.7-fold improved (p = 0.024) after use of the bilateral internal thoracic artery (BITA) (66.2%). Off-pump CABG (12%) revealed no impact on survival. Smokers showed a poorer outcome (p = 0.004). The logistic European System for Cardiac Operative Risk Evaluation was highly effective for evaluating long-term outcomes (p <0.001).

CONCLUSIONS

BITA grafting normalizes survival and reveals a better outcome in octogenarians with multivessel disease. However, patients at risk of poorer survival were operated under emergency conditions and those with pulmonary disease and reduced ventricular or renal function.

Multi-Omics Profiling of Human Endothelial Cells from the Coronary Artery and Internal Thoracic Artery Reveals Molecular but Not Functional Heterogeneity

Major adverse cardiovascular events occurring upon coronary artery bypass graft surgery are typically accompanied by endothelial dysfunction. Total arterial revascularisation, which employs both left and right internal thoracic arteries instead of the saphenous vein to create a bypass, is associated with better mid- and long-term outcomes. We suggested that molecular profiles of human coronary artery endothelial cells (HCAECs) and human internal mammary artery endothelial cells (HITAECs) are coherent in terms of transcriptomic and proteomic signatures, which were then investigated by RNA sequencing and ultra-high performance liquid chromatography-mass spectrometry, respectively. Both HCAECs and HITAECs overexpressed molecules responsible for the synthesis of extracellular matrix (ECM) components, basement membrane assembly, cell-ECM adhesion, organisation of intercellular junctions, and secretion of extracellular vesicles. HCAECs were characterised by higher enrichment with molecular signatures of basement membrane construction, collagen biosynthesis and folding, and formation of intercellular junctions, whilst HITAECs were notable for augmented pro-inflammatory signaling, intensive synthesis of proteins and nitrogen compounds, and enhanced ribosome biogenesis. Despite HCAECs and HITAECs showing a certain degree of molecular heterogeneity, no specific markers at the protein level have been identified. Coherence of differentially expressed molecular categories in HCAECs and HITAECs suggests synergistic interactions between these ECs in a bypass surgery scenario.

The effect of the multiple arterial grafts compared with single arterial graft for coronary artery bypass grafting on sternal wound complications: A meta-analysis

A meta-analysis investigation was executed to measure the influence of multiple arterial grafts (MAGs) compared with single arterial graft (SAG) for coronary artery bypass grafting (CABG) on sternal wound complications (SWCs). A comprehensive literature inspection till February 2023 was applied and 1048 interrelated investigations were reviewed. The seven chosen investigations enclosed 11 201 individuals with CABG in the chosen investigations' starting point, 4870 of them were using MAGs, and 6331 were using SAG. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were utilised to compute the value of the effect of the MAGs compared with SAG for CABG on SWCs by the dichotomous approaches and a fixed or random model. MAGs had significantly higher SWC (OR, 1.38; 95% CI, 1.10-1.73, P = .005) compared with those with SAG in CABG. MAGs had significantly higher SWC compared with those with SAG in CABG. However, care must be exercised when dealing with its values because of the low number of selected investigations for the meta-analysis.

Expert systematic review on the choice of conduits for coronary artery bypass grafting: endorsed by the European Association for Cardio-Thoracic Surgery (EACTS) and The Society of Thoracic Surgeons (STS)

PREAMBLE

The finalized document was endorsed by the EACTS Council and STS Executive Committee before being simultaneously published in the European Journal of Cardio-thoracic Surgery (EJCTS) and The Annals of Thoracic Surgery (The Annals) and the Journal of Thoracic and Cardiovascular Surgery (JTCVS).

Coronary artery bypass with single versus multiple arterial grafts in women: A meta-analysis

OBJECTIVE

The study objective was to investigate the impact of multiple arterial grafting on long-term all-cause mortality in women undergoing isolated coronary artery bypass grafting.

METHODS

A comprehensive search was performed to identify observational studies reporting outcomes after coronary artery bypass grafting reported by sex and stratified into multiple arterial grafting versus single arterial grafting strategies. Articles were considered for inclusion if they were written in English and were propensity-matched observational studies. Included studies were then pooled in a meta-analysis performed using the generic inverse variance method. The primary outcome was long-term all-cause mortality. Secondary outcomes were operative mortality and spontaneous myocardial infarction. Meta-regression was used to explore the effects of preoperative and intraoperative variables on the primary outcome.

RESULTS

A total of 6 studies with 32,793 women (25,714 single arterial grafting and 7079 multiple arterial grafting) were included. Women who received multiple arterial grafting had lower long-term mortality (incidence rate ratio, 0.86; 95% confidence interval, 0.76-0.96; P = .007) and spontaneous myocardial infarction (incidence rate ratio, 0.80; 95% confidence interval, 0.68-0.93; P = .003) compared with women who received single arterial grafting, but the difference in mortality disappeared when including only the 3 largest studies. There was no difference between groups in operative mortality (odds ratio, 0.99; 95% confidence interval, 0.84-1.17; P = .91). Meta-regression did not identify any associations with the incidence rate ratio for long-term mortality.

CONCLUSIONS

The use of multiple arterial grafting in women undergoing coronary artery bypass grafting is associated with lower long-term mortality, although the difference is mostly driven by small series. Further studies, including randomized trials, are needed to evaluate the efficacy of multiple arterial grafting in women undergoing coronary artery bypass grafting.

Immediate Results after Multiple Arterial Grafts in Coronary Artery Bypass Graft Surgery in the São Paulo State: Cross Cohort Study

BACKGROUND

The short-term results after using arterial grafts still raise questions and doubts for medical society.

OBJECTIVE

To compare the immediate outcomes of patients undergoing single arterial graft versus multiple arterial grafts coronary artery bypass grafting surgery.

METHODS

Cross-sectional cohort study in the São Paulo Registry of Cardiovascular Surgery II (REPLICCAR II). Perioperative data from 3122 patients were grouped by the number of arterial grafts used, and their outcomes were compared: reoperation, deep sternal wound infection (DSWI), stroke, acute kidney injury, prolonged intubation (>24 hours), short hospital stay (<6 days), prolonged hospital stay (>14 days), morbidity and mortality. Propensity Score Matching (PSM) matched 1062 patients, adjusted for the mortality risk.

RESULTS

After PSM, the single arterial graft group showed patients with advanced age, more former smokers, hypertension, diabetes, stable angina, and previous myocardial infarction. In the multiple arterial grafts, there was a predominance of males, recent pneumonia, and urgent surgeries. After the procedure, there was a higher incidence of pleural effusion (p=0.042), pneumonia (p=0.01), reintubation (p=0.006), DSWI (p=0.007), and sternal debridement (p=0.015) in the multiple arterial grafts group, however, less need for blood transfusion (p=0.005), extremity infections (p=0.002) and shorter hospital stays (p=0.036). Bilateral use of the internal thoracic artery was not related to increased DSWI rate, but glycosylated hemoglobin >6.40% (p=0.048).

CONCLUSION

Patients undergoing the multiarterial technique had a higher incidence of pulmonary complications, and DSWI, where glycosylated hemoglobin ≥6.40%, had a greater influence on the infectious outcome than the choice of grafts.

Bibliometric and visual analysis of cerebral revascularization from 1999 to 2022

Background

Cerebral revascularization is a neurosurgical procedure used to restore the cerebral collateral circulation channel. This study examines the countries, institutions, authors, journals, keywords, and references related to the disease in the field of cerebral revascularization from 1999 to 2022 from a bibliometrics perspective, evaluates the changes of knowledge structure clustering and identifies the new hot spots and new research directions in this field.

Methods

The Web of Science Core Collection (WOSCC) database and the PICOS retrieval method were used to conduct a comprehensive search for articles and reviews pertaining to cerebral revascularization. The final filtered data were bibliometrically and visually drawn using Microsoft office 365, CiteSpace (v.6.1.R2), and VOSviewer (v.1.6.18).

Results

From 1999 to 2022, a total of 854 articles pertaining to cerebral revascularization, which originated from 46 nations, 482 institutions, and 686 researchers, were extracted from the WOSCC database, and the number of publications in this field of study was rising. The United States held the highest proportion in the ranking analysis of countries, institutions, authors, and journals. By analyzing co-citations, the scientific organization of this field and the development status of frontier fields were realized. Cerebral revascularization, moyamoya disease, extracranial intracranial bypass, and occlusion are the current research focal points in the field of cerebral revascularization. Hyperperfusion and vascular disorder may also become a new study focus in this discipline in the near future.

Conclusion

Using the method of bibliometrics, this study analyzed and reviewed the articles in the field of cerebral revascularization, which enabled scholars to better comprehend the dynamic process in this field and provided a foundation for future in-depth research.

Single versus multiple arterial grafting in diabetic patients at 10 years: the Arterial Revascularization Trial

AIMS

To evaluate the impact of multiple arterial grafting (MAG) vs. single arterial grafting (SAG) in a post hoc analysis of 10-year outcomes in patients with diabetes mellitus (DM) from the Arterial Revascularization Trial (ART).

METHODS AND RESULTS

The primary endpoint was all-cause mortality and the secondary endpoint was a composite of major adverse cardiac events (MACE) at 10-year follow-up. Patients were stratified by diabetes status (non-DM and DM) and grafting strategy (MAG vs. SAG). A total of 3020 patients were included in the analysis; 716 (23.7%) had DM. Overall, 55.8% non-DM patients received MAG and 44.2% received SAG, while 56.6% DM patients received MAG and 43.4% received SAG. The use of MAG compared with SAG was associated with lower 10-year mortality for both non-DM [17.7 vs. 21.0%, adjusted hazard ratio (HR) 0.87, 95% confidence interval (CI) 0.72-1.06] and DM patients (21.5 vs. 29.9%, adjusted HR 0.65, 95% CI 0.48-0.89; P for interaction = 0.12). For both groups, the rate of 10-year MACE was also lower for MAG vs. SAG. Overall, deep sternal wound infections (DSWIs) were uncommon but more frequent in the MAG vs. SAG group in both non-DM (3.3 vs. 2.1%) and DM patients (7.9 vs. 4.8%). The highest rates of DSWI were in insulin-treated patients receiving MAG (9.6 vs. 6.3%, when compared with SAG).

CONCLUSION

In this post hoc analysis of the ART, MAG was associated with substantially lower mortality rates at 10 years after coronary artery bypass grafting in patients with DM. Patients with DM receiving MAG had a higher incidence of DSWI, especially if insulin dependent.

Volume-Outcome Relationship of Resternotomy Coronary Artery Bypass Grafting

BACKGROUND

We assessed volume-outcome relationships of resternotomy coronary artery bypass grafting (CABG).

METHODS

We studied 1,362,218 first-time CABG and 93,985 resternotomy CABG patients reported to The Society of Thoracic Surgeons Adult Cardiac Surgery Database between 2010 and 2019. Primary outcomes were in-hospital mortality and mortality and morbidity (M&M) rates calculated per hospital and per surgeon. Outcomes were compared across 6 total cardiac surgery volume categories. Multivariable generalized linear mixed-effects models were used considering continuous case volume as the main exposure, adjusting for patient characteristics and within-surgeon and hospital variation.

RESULTS

We observed a decline in resternotomy CABG unadjusted mortality and M&M from the lowest to the highest case-volume categories (hospital-level mortality, 3.9% ± 0.6% to 3.3% ± 0.1%; M&M, 18.5% ± 1.1% to 15.7% ± 0.4%, P < .001; surgeon-level mortality, 4.1% ± 0.3% to 4.1% ± 1.3%; M&M, 18.5% ± 0.6% to 14.5% ± 2.2%, P < .001). Looking at outcomes vs continuous volume showed that beyond a minimum annual volume (hospital 200-300 cases; surgeon 100-150 cases, approximately), mortality and M&M rates did not further improve. Using individual-level data and adjusting for patient characteristics and clustering within surgeon and hospital, we found higher procedural volume was associated with improved surgeon-level outcomes (mortality adjusted odds ratio, 0.39/100 procedures; 95% CI, 0.24-0.61; M&M adjusted odds ratio, 0.37/100 procedures; 95% CI, 0.28-0.48; P < .001 for both). Hospital-level adjusted volume-outcomes associations were not statistically significant.

CONCLUSIONS

We observed an inverse relationship between total cardiac case volume and resternotomy CABG outcomes at the surgeon level only, indicating that individual surgeon's experience, rather than institutional volume, is the key determinant.

Treatment of Complex Two-Vessel Coronary Heart Disease with Single Left Internal Mammary Artery as T-Graft with Itself—A Retrospective Double Center Analysis of Short-Term Outcomes

Background and Objectives: The strategy of revascularization may be constrained in patients with insufficient bypass grafts and with increased risk of wound healing disorders. Among those with complex left-sided double-vessel disease in whom a percutaneous coronary intervention (PCI), as well as the surgical procedure of minimally invasive coronary artery bypass grafting via left minithoracotomy (MICS CABG), is not a treatment option, CABG using the left internal mammary artery as a T-graft with itself may be an effective treatment strategy. Materials and Methods: We reviewed the data from patients treated in Cologne and Tuebingen from 2019 to 2022. We included 40 patients who received left internal mammary artery (LIMA) grafting, and additional T-graft with the LIMA itself. The objective was focused on intraoperative and short-term outcomes. Results: A total of 40 patients were treated with the LIMA-LIMA T-graft procedure with a Fowler score calculated at 20.1 ± 3.0. A total of 37.5% of all patients had lacking venous graft material due to prior vein stripping, and 21 patients presented severe vein varicosis. An overall of 2.6 ± 0.5 distal anastomoses (target vessels were left anterior descending, diagonal, intermediate branch, and/or left marginal ramus) were performed, partly sequentially. Mean flow of LIMA-Left anterior descending (LAD) anastomosis was 59.31 ± 11.04 mL/min with a mean PI of 1.21 ± 0.18. Mean flow of subsequent T-Graft accounted for 51.31 ± 3.81 mL/min with a mean PI of 1.39 ± 0.47. Median hospital stay was 6.2 (5.0; 7.5) days. No incidence of postoperative wound healing disorders was observed, and all patients were discharged. There was one 30-day readmission with a diagnosis of pericardial effusion (2.5%). There was no 30-day mortality within the cohort. Conclusions: Patients requiring surgical myocardial revascularization due to complex two-vessel coronary artery disease (CAD) can be easily managed with LIMA alone, despite an elevated Fowler score and a promising outcome. A prospective study needs to be conducted, as well as longer term surveillance, to substantiate and benchmark the long-term results, as well as the patency rates.

Immediate impact of coronary artery bypass graft surgery on regional myocardial perfusion: Results from the Collaborative Pilot Study to Determine the Correlation Between Intraoperative Observations Using Spy Near-Infrared Imaging and Cardiac Catheterization Laboratory Physiological Assessment of Lesion Severity

Objectives

Coronary artery bypass grafting (CABG) is performed using anatomic guidance. Data connecting the physiologic significance of the coronary vessel stenosis to the acute physiologic response to grafting are lacking. The Collaborative Pilot Study to Determine the Correlation Between Intraoperative Observations Using Spy Near-Infrared Imaging and Cardiac Catheterization Laboratory Physiological Assessment of Lesion Severity study is the first to compare preintervention coronary physiology with the acute regional myocardial perfusion change (RMP-QC) at CABG in a per-graft analysis.

Methods

Non-emergent patients undergoing diagnostic catheterization suitable for multivessel CABG were enrolled. Synergy between Percutaneous Coronary Intervention with Taxus score, fractional flow reserve (FFR), instantaneous wave free ratio (iFR), and quantitative coronary angiography was documented in 75 epicardial coronary arteries, with 62 angiographically intermediate and 13 severe stenoses. At CABG, near-infrared fluorescence analysis quantified the relative change (post- vs pregrafting, termed RMP-QC) in the grafted vessel's perfusion territory. Scatter plots were constructed for RMP-QC versus quantitative coronary angiography and RMP-QC versus FFR/iFR. Exact quadrant randomization test for randomness was used.

Results

There was no relationship between RMP-QC and quantitative coronary angiography percent diameter stenosis, whether all study vessels were included (P = .949) or vessels with core-lab quantitative coronary angiography only (P = .922). A significant nonrandom association between RMP-QC and FFR (P = .025), as well as between RMP-QC and iFR (P = .008), was documented. These associations remained when excluding vessels with assigned FFR and iFR values (P = .0092 and P = .0006 for FFR and iFR, respectively).

Conclusions

The Collaborative Pilot Study to Determine the Correlation Between Intraoperative Observations Using Spy Near-Infrared Imaging and Cardiac Catheterization Laboratory Physiological Assessment of Lesion Severity study demonstrates there is no association between angiographic coronary stenosis severity and the acute perfusion change after grafting; there is an association between functional stenosis severity and absolute increase in regional myocardial perfusion after CABG.

Risk factors associated with in-hospital mortality for patients with ECLS due to post cardiotomy cardiogenic shock after isolated coronary surgery

OBJECTIVES

Extracorporeal membrane oxygenation (ECMO) or extracorporeal life support (ECLS) in patients after cardiac surgery and post cardiotomy cardiogenic shock (PCS) is known to be associated with high mortality. Especially in patients after coronary artery bypass grafting (CABG) and PCS, ECLS is frequently established. Aim of this analysis was to evaluate factors associated with in-hospital mortality in patients treated with ECLS due to PCS after CABG.

METHODS

Between August 2006 and January 2017, 92 consecutive patients with V-A ECLS due to PCS after isolated CABG were identified and included in this retrospective analysis. Patients were divided into survivors (S) and non-survivors (NS) and analysed in regard of risk factors of in-hospital mortality.

RESULTS

In-hospital mortality added up to 61 patients (66 %). Non-survivors were significantly older (60±12 (S) vs. 67±10 (NS); p=0.013). Bilateral internal mammary artery graft was significantly more frequently used in S (23% (S) vs. 2% (NS); p=0.001). After 24 hours of ECLS support, median lactate levels were significantly higher in NS (1.9(1.3;3.5) mmol/L (S) vs. 3.5(2.1;6.3) mmol/L (NS); p=0.001). NS suffered more often acute kidney injury requiring dialysis (42% (S) vs. 74% (NS); p=0.002).

CONCLUSION

Mortality in patients with refractory PCS after CABG and consecutive ECLS support remains high. Failing end-organ recovery under ECLS despite optimized concomitant medical therapy is an indicator of adverse outcomes in this specific patient cohort. Moreover, total-arterial revascularization might be beneficial for cardiac recovery in patients suffering PCS after CABG and following ECLS.

Multiple Grafting with Single Left Internal Mammary Artery as T-Graft with Itself

BACKGROUND

 Revascularization strategies might be limited in patients with lack of sufficient bypass graft material and increased risk of wound healing disturbances. In this regard, we present first results of patients treated with left internal mammary artery (LIMA) as T-graft with itself due to left-sided double-vessel disease, elevated risk of wound healing infection, and lack of graft material.

METHODS

 Eighteen patients were retrospectively analyzed in this study. All patients received LIMA grafting, and additional T-graft with itself during off-pump coronary artery bypass surgery. The investigation was focused on intraoperative and postoperative outcomes.

RESULTS

 LIMA-LIMA T-graft was performed in a total of 18 patients. Mean Fowler score accounted for 18.2 ± 2.9. Severe vein varicosis was present in 9 patients, and 38.9% of patients had lacking venous graft material due to prior vein stripping. A total of 2.5 ± 0.5 distal anastomoses were performed. Mean flow of LIMA-left anterior descending anastomosis was 41.72 ± 12.11 mL/min with a mean pulsatility index (PI) of 1.01 ± 0.21. Mean flow of subsequent T-graft accounted for 26.31 ± 4.22 mL/min with a mean PI of 1.59 ± 0.47. Median hospital stay was 7(6.75;8) days. No incidence of postoperative wound healing disorders was observed and all patients were discharged off hospital.

CONCLUSIONS

 LIMA as T-graft with itself to treat left-sided double-vessel disease is feasible and safe in patients with missing bypass graft material and increased risk of deep sternal wound infection. Further prospective studies are necessary to confirm our results.

Impact of Bilateral versus Single Internal Thoracic Artery Grafting on the Long-Term Survival in Adults: A Systematic Review

Objective

To analyse the survival of patients who had undergone bilateral internal thoracic artery grafting versus those with single internal thoracic artery grafting from the available literature. Moreover, this study will review the available literature regarding which of the two techniques seems to be the safest with long-term survival and reduced mortality rates.

Methods

A literature search of the databases was conducted to retrieve studies that fall under the study design of cohort and randomized controlled clinical trials in English from January 2015 to July 2021. Finally, seven studies were selected: four cohort studies and three other from a randomized trial.

Results

The cohort studies revealed that bilateral internal thoracic artery grafting is associated with lower mortality rates and better long-term survival outcomes than single internal thoracic artery grafting, while the ART randomized controlled clinical trials showed that there is no significant difference in mortality rates between both the coronary artery bypass grafting techniques. However, all studies concluded that bilateral internal thoracic artery grafting is associated with a higher frequency of deep sternal wound infections.

Conclusion

The discrepancy in results between the cohort studies and randomized controlled clinical trial remains persistent. However, the stated advantages of bilateral internal thoracic artery grafting are not strong enough to convince surgeons to alter their practice and the wide magnitude of expectations from the ART study was reckoned as inadequate. This may well be due to the presence of limited criteria for bilateral internal thoracic artery grafting in identifying the impact on survival of extended arterial revascularization, and there is a new colossal expectation from the ongoing randomized trial based on multiple arterial grafting versus single arterial grafting.

Does Age Affect the Short- and Long-Term Outcomes of Coronary Bypass Grafting?

The etiology of coronary artery disease (CAD) is multifactorial, stemming from both modifiable and nonmodifiable risk factors such as age. Several studies have reported the effects of age on various outcomes of coronary artery bypass grafting (CABG). This article reviews age-related outcomes of CABG and offers direction for further studies in the field to create comprehensive, evidence-based guidelines for the treatment of CAD. Ninety-two primary sources were analyzed for relevance to the subject matter, of which 17 were selected for further analysis: 14 retrospective cohort studies, 2 randomized clinical trials, and 1 meta-analysis. Our review revealed four broad age ranges into which patients can be grouped: those with CAD (1) below the age of 40 years, (2) between the ages of 40 and 60 years, (3) between the ages of 60 and 80 years, and (4) at or above 80 years. Patients below the age of 40 years fare best overall with total arterial revascularization (TAR). Patients between the ages of 40 and 60 years also fare well with the use of multiarterial grafts (MAGs) whereas either MAGs or single-arterial grafts may be of significant benefit to patients at or above the age of 60 years, with younger and diabetic patients benefitting the most. Arterial grafting is superior to vein grafting until the age of 80 years, at which point there is promising evidence supporting the continued use of the saphenous vein as the favored graft substrate. Age is a factor affecting the outcomes of CABG but should not serve as a barrier to offering patients CABG at any age from either a cost or a health perspective. Operative intervention starts to show significant mortality consequences at the age of 80 years, but the increased risk is countered by maintenance or improvement to patients' quality of life.

Multiarterial coronary grafting using the radial artery as a second arterial graft: how far does the survival benefit extend?

OBJECTIVES

Despite the 10-year results of the Arterial Revascularization Trial, the controversy regarding the survival benefit of multiarterial grafting (MAG) remains. Our goal was to present our long-term survival data in this propensity-matched observational study.

METHODS

A primary unmatched population of 4303 patients with first-time isolated coronary artery bypass grafts operated on between 2000 and 2018 were included. A total of 1187 post-matched patients were compared with matched controls. Multivariate logistic regression and Cox proportional hazard analyses were undertaken to assess the contribution of MAG and other covariates to the long-term survival of unmatched and propensity-matched populations.

RESULTS

MAG was associated with increased median survival in both the unmatched and the matched groups; difference: 962 and 1459 days, log-rank tests; P = 0.029 and 0.0004, respectively. MAG was associated with a reduced hazard of death in the unmatched as well as in the matched groups: hazard ratio [95% confidence interval (CI)]: 0.72 (0.62-0.83); P < 0.0001 and 0.75 (0.64-0.88); P ≤ 0.0001, respectively. In the matched group, the prosurvival factors were low logistic EuroSCORE, obesity, no intra-aortic balloon pump, an ejection fraction >30%, age 50-69 years, operation by an experienced surgeon, with and without diabetes, on-pump surgery and 3 distal anastomoses. In a cohort of 242 late-presenting patients with reinfarction or recurrent angina, both MAG and control populations were associated with reduced median survival; median (95% CI): MAG: 3026 (1138-3503); control: 3035 (2134-3991), log-rank P = 0.217 with superior patency of the left internal mammary artery but no difference between radial artery and saphenous vein grafts.

CONCLUSIONS

Multiarterial revascularization, especially using the radial artery as a second arterial conduit, is associated with a significant survival benefit and a lack of in-hospital morbidity.

Myocardial Revascularization Surgery: JACC Historical Breakthroughs in Perspective

Coronary artery bypass grafting (CABG) was introduced in the 1960s as the first procedure for direct coronary artery revascularization and rapidly became one of the most common surgical procedures worldwide, with an overall total of more than 20 million operations performed. CABG continues to be the most common cardiac surgical procedure performed and has been one of the most carefully studied therapies. Best CABG techniques, optimal bypass conduits, and appropriate patient selection have been rigorously tested in landmark clinical trials, some of which have resolved controversy and most of which have stoked further debate and trials. The evolution of CABG cannot be properly portrayed without presenting it in the context of the parallel development of percutaneous coronary intervention. In this Historical Perspective, we a provide a broad overview of the history of coronary revascularization with a focus on the foundations, evolution, best evidence, and future directions of CABG.

Differences in Long-term Outcomes After Coronary Artery Bypass Grafting Using Single vs Multiple Arterial Grafts and the Association With Sex

Importance

Sex-related differences in the outcome of using multiple arterial grafts during coronary artery bypass grafting (CABG) remain uncertain.

Objective

To compare the outcomes of the use of multiple arterial grafts vs a single arterial graft during CABG for women and men.

Design, Setting, and Participants

This statewide cohort study used data from New York's Cardiac Surgery Reporting System and New York's Vital Statistics file on 63 402 patients undergoing CABG from January 1, 2005, to December 31, 2014. Statistical analysis was performed from January 10 to August 20, 2020.

Exposures

Multiple arterial grafting or single arterial grafting.

Main Outcomes and Measures

Mortality, acute myocardial infarction (AMI), stroke, repeated revascularization, major adverse cardiac and cerebrovascular event (composite of mortality, AMI, and stroke), and major adverse cardiac event (composite of mortality, AMI, or repeated revascularization) were compared among propensity-matched patients and stratified by the risk of long-term mortality.

Results

Of the 63 402 patients (48 155 men [76.0%]; mean [SD] age, 69.9 [10.5] years) in the study, women had worse baseline characteristics than men for most of the explored variables. Propensity matching yielded a total of 9512 male pairs and 1860 female pairs. At 7 years of follow-up, mortality was lower among men who underwent multiple arterial grafting (adjusted hazard ratio, 0.80; 95% CI, 0.73-0.87) but not women who underwent multiple arterial grafting (adjusted hazard ratio, 0.99; 95% CI, 0.84-1.15). When stratified by the estimated risk of death, the use of multiple arterial grafts was associated with better survival and a lower rate of a major adverse cardiac event among low-risk, but not high-risk, patients of both sexes, and the risk cutoff was different for men and women.

Conclusions and Relevance

This study suggests that women have a worse preoperative risk profile than men. Multiple arterial grafting is associated with better outcomes among low-risk, but not high-risk, patients, and the risk cutoffs differ between sexes. These data highlight the need for new studies on the outcome of multiple arterial grafts in women.

Does the Addition of a Gastroepiploic Artery to Bilateral Internal Thoracic Artery Improve Survival?

It is unclear whether the additional conduit to supplement bilateral internal thoracic arteries (BITA) influences the patient outcome in coronary surgery. This retrospective study compared long-term survival of patients undergoing left-sided BITA grafting in which the third conduit to the right coronary system (RCA) was either vein graft (SVG) or gastroepiploic artery (GEA). From 1989 to 2014, 1432 consecutive patients underwent left-sided revascularization with BITA associated with SVG (n = 599) or GEA (n = 833) to RCA. Propensity score was calculated by logistic regression model and patients were matched 1 to 1 leading to 2 groups of 320 matched patients. The primary end point was the overall mortality from any cause. GEA was used in significantly lower risk patients. The 30-day mortality was 1.6% without influence of the graft configuration. Postoperative follow-up was 13.6 ± 6.6 years and was 94% complete. The significant difference in patients' survival observed at 20 years in favor of GEA in unmatched groups (48 ± 4% vs 33 ± 6%, P < 0.001) was not confirmed in matched groups (41 ± 7% vs 36 ± 7%, P = 0.112). In multivariable Cox model analysis, the conduit used to RCA did not influence the long-term survival in matched groups, like no other graft configuration or operative parameter. Only complete revascularization remained predictor of survival (P = 0.016), with age (P < 0.0001), diabetes status (P = 0.007), and left ventricle ejection fraction (P < 0.0001). Long-term survival in patients undergoing BITA grafting is not affected by using GEA as third arterial conduit in alternative to SVG. Further studies are necessary to assess its impact on long-term cardiac events.

Kidney-Pancreas Transplant Recipients Experience Higher Risk of Complications Compared to the General Population after Undergoing Coronary Artery Bypass Grafting

This retrospective analysis aims to identify differences in surgical outcomes between pancreas and/or kidney transplant recipients compared with the general population undergoing coronary artery bypass grafting (CABG). Using Nationwide Inpatient Sample (NIS) data from 2005 to 2014, patients who underwent CABG were stratified by either no history of transplant, or history of pancreas and/or kidney transplant. Multivariate analysis was used to calculate odds ratio (OR) to evaluate in-hospital mortality, morbidity, length of stay (LOS), and total hospital charge in all centers. The analysis was performed for both nonemergency and emergency CABG. Overall, 2,678 KTx (kidney transplant alone), 184 PTx (pancreas transplant alone), 254 KPTx (kidney-pancreas transplant recipients), and 1,796,186 Non-Tx (nontransplant) met inclusion criteria. KPTx experienced higher complication rates compared with Non-Tx (78.3 vs. 47.8%, p  < 0.01). Those with PTx incurred greater total hospital charge and LOS. On weighted multivariate analysis, KPTx was associated with an increased risk for developing any complication following CABG (OR 3.512, p  < 0.01) and emergency CABG (3.707, p  < 0.01). This risk was even higher at transplant centers (CABG OR 4.302, p  < 0.01; emergency CABG OR 10.072, p  < 0.001). KTx was associated with increased in-hospital mortality following emergency CABG, while PTx and KPTx had no mortality to analyze. KPTx experienced a significantly higher risk of complications compared with the general population after undergoing CABG, in both transplant and nontransplant centers. These outcomes should be considered when providing perioperative care.

How decisive is the number of distal arterial anastomoses in coronary bypass surgery?

Background

The benefit of arterial revascularization in coronary surgery remains controversial. The incremental value of additional grafts to the left internal thoracic artery (ITA) has been mainly assessed according to the number of arterial grafts, possibly limiting the detection of its actual impact. We analyzed the influence of the number of distal arterial anastomoses (DAA) performed on late mortality in patients having received from one to three arterial grafts.

Methods

Retrospective review of 3685 primary isolated coronary artery bypass grafting (CABG) performed from 1989 to 2014 was conducted with a 13-year mean follow-up. One arterial graft (SITA) was used in 969 patients, two arterial grafts, ITA or gastroepiploic artery (GEA), in 1883 patients (BITA: 1644; SITA+GEA: 239), and three arterial grafts in 833 patients (BITA+GEA). Totally, 795 patients (22%) received one DAA, 1142 patients (31%) two, 1337 patients (36%) three, and 411 patients (11%) four or more. A sub-group analysis was done in the 2104 patients with 3-vessel disease who received at least 2 arterial grafts.

Results

In this series the early mortality was 1.6% and it was not influenced by the surgical technique. Late mortality was significantly influenced by age, gender, heart failure, LV ejection fraction, diabetes status, complete revascularization, number of arterial grafts, number of DAA, both ITA, sequential ITA graft, GEA graft. In multivariable analysis with Cox regression model, the number of DAA was the only technical significant independent prognosis factor of late survival (p < 0.0001), predominant over both ITA, complete revascularization and number of arterial grafts. The impact of the number of DAA on survival was found discriminant from 1 to 3; after 3 there was no more additional effect. In 3-vessel disease patients who received at least 2 arterial grafts, the number of DAA remained a significant independent prognosis factor of late survival (p < 0.0001).

Conclusions

The number of distal arterial anastomoses is an independent predictor of long-term survival, predominant over the number of arterial grafts and the completeness of the revascularization; higher the number, better the late survival. It is a strong support of the extensive use of arterial grafting in CABG.

Training for Multiple Arterial Grafting: A Thoracic Surgery Resident Survey

BACKGROUND

Utilization of multiple arterial grafting (MAG) in the United States is less than 10%. Trainee experience with MAG has not previously been examined.

METHODS

A total of 497 thoracic surgery residents in accredited training programs in March 2019 and 115 who completed residency in 2018 were electronically surveyed regarding their experience with MAG using a radial artery (RA) graft or bilateral internal mammary artery (BIMA) grafts with a skeletonized mammary (SM).

RESULTS

Eighty-four (14%) trainees responded: 54% had completed 2+ years of training and 87% declared their focus as cardiac, undecided, or both cardiac and thoracic (CUB). Of all 84 respondents, 76% (n = 64 of 84) had no experience with RA harvest. A total of 35% (n = 29 of 84) had no experience with SM harvest. The majority, 68% (n = 57 of 84), used BIMA grafting in 0% to 5% of cases. A total of 61% (n = 51 of 84) used RA conduit in 0% to 5% of cases. Among trainees with 2+ years of experience, 56% (n = 25 of 45) had performed more than 6 SM takedowns, 18% (n = 8 of 45) had no experience. In trainees with 2+ years, 20% (n = 9 of 45) performed more than 5 RA harvests, while 80% (n = 36 of 45) had no experience. Examining integrated 6-year residents with greater than 3 years of experience, only 33% (n = 5 of 15) performed more than 5% RA grafting. A total of 90% of CUB trainees wanted to perform MAG in practice and 75% felt prepared to do so.

CONCLUSIONS

Despite substantial variation in MAG training, respondents expressed an overwhelming interest in performing MAG. These data and the reality of MAG utilization in the United States indicate that a more rigorous, standardized approach to MAG training may be required.

Percutaneous Coronary Intervention or Surgery for Unprotected Left Main Disease: EXCEL Trial at 5 Years

Although coronary artery bypass graft (CABG) surgery traditionally has been considered the gold standard for left main revascularization, percutaneous coronary intervention has evolved in the past decades so that it now represents a valid alternative to CABG in a large proportion of cases. The landmark Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL) trial is the largest contemporary randomized comparison assessing the impact of revascularization strategies for left main disease. This review discusses the background, rationale, design, results, and implications of the EXCEL trial.

Meta-Analysis Comparing Multiple Arterial Grafts Versus Single Arterial Graft for Coronary-Artery Bypass Grafting

Observational studies and randomized controlled trials (RCTs) have shown conflicting outcomes for multiple arterial graft (MAG) coronary artery bypass graft surgery compared with single arterial grafts (SAGs). The predominant evidence supporting the use of MAGs is observational. The aim of this meta-analysis of RCTs is to compare outcomes following MAG and SAG. We searched multiple databases for RCTs comparing MAG versus SAG. The clinical outcomes studied were all-cause mortality, cardiac mortality, myocardial infarction (MI), revascularization, stroke, sternal wound complications, and major bleeding. We used hazard ratio (HR), relative risk (RR), and corresponding 95% confidence interval (CI) for measuring outcomes. Ten RCTs (6392 patients) were included. The average follow-up in the studies was 4.2 years. The average age of the patients in the studies ranged from 56.3 years to 74.6. No significant difference was seen between MAG and SAG groups for all-cause mortality (11.8% vs 12.7%, HR 0.94, 95% CI 0.81 to 1.09, p 0.36), cardiac mortality (4.1% vs 4.5%, HR 0.96 95% CI 0.74 to 1.26, p 0.77), MI (3.5% vs 5.1%, HR 0.87 95% CI 0.67 to 1.12, p 0.28), and major bleeding (3.3% vs 4.9%, RR 0.85 95% CI 0.64 to 1.13, p 0.26). Repeat revascularization in MAG showed a lower RR than SAG when one of the confounding studies was excluded (RR 0.63, 95% CI 0.4 to 0.99, p 0.04). The incidence of stroke was lower in MAG than SAG (2.9% vs 3.9%, RR 0.74 95% CI 0.56 to 0.98, p 0.03). MAG had higher incidence of sternal wound complications than SAG (2.9% vs 1.7%, RR 1.75 95% CI 1.19 to 2.55, p 0.004). In conclusion, MAG does not have a survival advantage compared with SAG but is better in revascularization and risk of stroke. This benefit may be set off by a higher incidence of sternal wound complications in MAG.

Radial artery harvesting in coronary artery bypass grafting surgery-Endoscopic or open method? A meta-analysis

We analyzed the clinical outcomes of open radial artery harvesting (OAH) and endoscopic radial artery harvesting (EAH) undergoing coronary artery bypass grafting (CABG). We designed this meta-analysis conducted using Pubmed, Medline, the Cochrane Library, and EMBASE. Articles with comparisons of OAH and EAH undergoing CABG were included. Primary outcomes included the wound infection rate, the wound complication rate, neurological complications of the forearm, in-hospital mortality, long-term survival, and the patency rate. The results of our study included six randomized controlled trials (RCTs), two non-randomized controlled trials (NRCTs) with matching, and 10 NRCTs. In total, 2919 patients were included in 18 studies, while 1187 (40.7%) and 1732 (59.3%) patients received EAH and OAH, respectively. EAH was associated with a lower incidence of wound infection (RR = 0.29, 95% confidence interval (CI) = 0.14 to 0.60, p = 0.03), and neurological complications over the harvesting site (RR = 0.41, 95% CI = 0.27 to 0.62, p < 0.0001). There was no significant difference in 30-day mortality, long-term survival (over one year), and the graft patency rate. According to our analysis, endoscopic radial artery harvesting can improve the outcome of the harvesting site, without affecting the mortality, long-term survival, and graft patency.