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Rustenbach CJ, Reichert S, Salewski C, Schano J, Berger R, Nemeth A, Zdanyte M, Häberle H, Caldonazo T, Saqer I, Saha S, Schnackenburg P, Djordjevic I, Krasivskyi I, Serna-Higuita LM, Doenst T, Hagl C, Wahlers T, Schlensak C, Sandoval Boburg R. Influence of Obesity on Short-Term Surgical Outcomes in HFrEF Patients Undergoing CABG: A Retrospective Multicenter Study. Biomedicines 2024; 12:426. [PMID: 38398028 PMCID: PMC10887226 DOI: 10.3390/biomedicines12020426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 02/05/2024] [Accepted: 02/12/2024] [Indexed: 02/25/2024] Open
Abstract
Background: This retrospective multicenter study investigates the impact of obesity on short-term surgical outcomes in patients with heart failure and reduced ejection fraction (HFrEF) undergoing coronary artery bypass grafting (CABG). Given the rising global prevalence of obesity and its known cardiovascular implications, understanding its specific effects in high-risk groups like HFrEF patients is crucial. Methods: The study analyzed data from 574 patients undergoing CABG across four German university hospitals from 2017 to 2023. Patients were stratified into 'normal weight' (n = 163) and 'obese' (n = 158) categories based on BMI (WHO classification). Data on demographics, clinical measurements, health status, cardiac history, intraoperative management, postoperative outcomes, and laboratory insights were collected and analyzed using Chi-square, ANOVA, Kruskal-Wallis, and binary logistic regression. Results: Key findings are a significant higher mortality rate (6.96% vs. 3.68%, p = 0.049) and younger age in obese patients (mean age 65.84 vs. 69.15 years, p = 0.003). Gender distribution showed no significant difference. Clinical assessment scores like EuroScore II and STS Score indicated no differences. Paradoxically, the preoperative left ventricular ejection fraction (LVEF) was higher in the obese group (32.04% vs. 30.34%, p = 0.026). The prevalence of hypertension, COPD, hyperlipidemia, and other comorbidities did not significantly differ. Intraoperatively, obese patients required more packed red blood cells (p = 0.026), indicating a greater need for transfusion. Postoperatively, the obese group experienced longer hospital stays (median 14 vs. 13 days, p = 0.041) and higher ventilation times (median 16 vs. 13 h, p = 0.049). The incidence of acute kidney injury (AKI) (17.72% vs. 9.20%, p = 0.048) and delirium (p = 0.016) was significantly higher, while, for diabetes prevalence, there was an indicating a trend towards significance (p = 0.051) in the obesity group, while other complications like sepsis, and the need for ECLS were similar across groups. Conclusions: The study reveals that obesity significantly worsens short-term outcomes in HFrEF patients undergoing CABG, increasing risks like mortality, kidney insufficiency, and postoperative delirium. These findings highlight the urgent need for personalized care, from surgical planning to postoperative strategies, to improve outcomes for this high-risk group, urging further tailored research.
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Affiliation(s)
- Christian Jörg Rustenbach
- Department of Thoracic and Cardiovascular Surgery, German Cardiac Competence Center, Eberhard-Karls-University, 72076 Tuebingen, Germany; (S.R.); (C.S.); (J.S.); (R.B.); (A.N.); (C.S.); (R.S.B.)
| | - Stefan Reichert
- Department of Thoracic and Cardiovascular Surgery, German Cardiac Competence Center, Eberhard-Karls-University, 72076 Tuebingen, Germany; (S.R.); (C.S.); (J.S.); (R.B.); (A.N.); (C.S.); (R.S.B.)
| | - Christoph Salewski
- Department of Thoracic and Cardiovascular Surgery, German Cardiac Competence Center, Eberhard-Karls-University, 72076 Tuebingen, Germany; (S.R.); (C.S.); (J.S.); (R.B.); (A.N.); (C.S.); (R.S.B.)
| | - Julia Schano
- Department of Thoracic and Cardiovascular Surgery, German Cardiac Competence Center, Eberhard-Karls-University, 72076 Tuebingen, Germany; (S.R.); (C.S.); (J.S.); (R.B.); (A.N.); (C.S.); (R.S.B.)
| | - Rafal Berger
- Department of Thoracic and Cardiovascular Surgery, German Cardiac Competence Center, Eberhard-Karls-University, 72076 Tuebingen, Germany; (S.R.); (C.S.); (J.S.); (R.B.); (A.N.); (C.S.); (R.S.B.)
| | - Attila Nemeth
- Department of Thoracic and Cardiovascular Surgery, German Cardiac Competence Center, Eberhard-Karls-University, 72076 Tuebingen, Germany; (S.R.); (C.S.); (J.S.); (R.B.); (A.N.); (C.S.); (R.S.B.)
| | - Monika Zdanyte
- Department of Cardiology, German Cardiac Competence Center, Eberhard-Karls-University, 72076 Tuebingen, Germany;
| | - Helene Häberle
- Department of Anesthesiology and Intensive Care Medicine, Eberhard-Karls-University, 72076 Tuebingen, Germany;
| | - Túlio Caldonazo
- Department of Cardiothoracic Surgery, Jena University Hospital, 07747 Jena, Germany; (T.C.); (I.S.); (T.D.)
| | - Ibrahim Saqer
- Department of Cardiothoracic Surgery, Jena University Hospital, 07747 Jena, Germany; (T.C.); (I.S.); (T.D.)
| | - Shekhar Saha
- Department of Cardiac Surgery, Ludwig-Maximilians-University, 80539 Munich, Germany (P.S.); (C.H.)
| | - Philipp Schnackenburg
- Department of Cardiac Surgery, Ludwig-Maximilians-University, 80539 Munich, Germany (P.S.); (C.H.)
| | - Ilija Djordjevic
- Department of Cardiothoracic Surgery, Heart Center, University of Cologne, 50923 Köln, Germany; (I.D.); (I.K.); (T.W.)
| | - Ihor Krasivskyi
- Department of Cardiothoracic Surgery, Heart Center, University of Cologne, 50923 Köln, Germany; (I.D.); (I.K.); (T.W.)
| | - Lina María Serna-Higuita
- Institute for Clinical Epidemiology and Applied Biostatistics, Eberhard-Karls-University, 72076 Tuebingen, Germany;
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, Jena University Hospital, 07747 Jena, Germany; (T.C.); (I.S.); (T.D.)
| | - Christian Hagl
- Department of Cardiac Surgery, Ludwig-Maximilians-University, 80539 Munich, Germany (P.S.); (C.H.)
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, Heart Center, University of Cologne, 50923 Köln, Germany; (I.D.); (I.K.); (T.W.)
| | - Christian Schlensak
- Department of Thoracic and Cardiovascular Surgery, German Cardiac Competence Center, Eberhard-Karls-University, 72076 Tuebingen, Germany; (S.R.); (C.S.); (J.S.); (R.B.); (A.N.); (C.S.); (R.S.B.)
| | - Rodrigo Sandoval Boburg
- Department of Thoracic and Cardiovascular Surgery, German Cardiac Competence Center, Eberhard-Karls-University, 72076 Tuebingen, Germany; (S.R.); (C.S.); (J.S.); (R.B.); (A.N.); (C.S.); (R.S.B.)
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2
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Ren J, Tian DH, Gaudino M, Fremes S, Reid CM, Vallely M, Smith JA, Srivastav N, Royse C, Royse A. Survival Benefit of Multiple Arterial Revascularization With and Without Supplementary Saphenous Vein Graft. J Am Heart Assoc 2023; 12:e031986. [PMID: 37947115 PMCID: PMC10727302 DOI: 10.1161/jaha.123.031986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 10/11/2023] [Indexed: 11/12/2023]
Abstract
Background It is unknown if the presence of saphenous vein grafting (SVG) adversely affects late survival following coronary surgery with multiple arterial grafting (MAG) versus single arterial grafting. Methods and Results A retrospective, observational, multicenter cohort study from 2001 to 2020 was conducted using the Australian and New Zealand Society of Cardiac and Thoracic Surgeons Database linked to the National Death Index. Patients undergoing primary isolated coronary artery bypass grafting with ≥2 grafts were included, and exclusions were patients aged <18 years, reoperations, concomitant or previous cardiac surgery, and the absence of arterial grafting. Demographics, comorbidities, medication, and operative configurations were propensity score matched between cohorts. The primary outcome was all-cause late death. Of 59 689 eligible patients, 35 113 were MAG (58.8%), and 24 576 were single arterial grafting (41.2%). Of the MAG cohort, 17 055 (48.6%) patients did not receive supplementary SVG (total arterial revascularization). Matching separately generated 22 764 patient pairs for MAG versus single arterial grafting, and 11 137 patient pairs for MAG with total arterial revascularization versus MAG with ≥1 supplementary vein grafts. At a median follow-up duration of 5.0 years postoperatively, the mortality rate was significantly lower for MAG than single arterial grafting (hazard ratio [HR], 0.79 [95% CI, 0.76-0.83]; P<0.001). The stratified MAG analysis found that MAG with total arterial revascularization had a lower risk of late death (HR, 0.85 [95% CI, 0.80-0.91]; P<0.001) compared with MAG with ≥1 supplementary vein grafts. Sensitivity analyses produced consistent outcomes as the primary analysis. Following adjustment for the presence of SVG in the Cox model, the survival advantage of incremental number of arteries was lost. Conclusions Multiple arterial grafting has significantly improved long-term survival compared with single arterial grafting. A further incremental survival benefit exists when no SVG is used.
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Affiliation(s)
- Justin Ren
- SurgeryUniversity of MelbourneMelbourneAustralia
| | - David H. Tian
- SurgeryUniversity of MelbourneMelbourneAustralia
- Anesthesia, Westmead HospitalSydneyAustralia
| | - Mario Gaudino
- Cardiothoracic Surgery, Weill Cornell MedicineNew YorkNY
| | | | | | - Michael Vallely
- Cardiothoracic SurgeryVictorian Heart Hospital and Monash UniversityMelbourneAustralia
| | - Julian A. Smith
- Cardiothoracic SurgeryVictorian Heart Hospital and Monash UniversityMelbourneAustralia
| | | | - Colin Royse
- SurgeryUniversity of MelbourneMelbourneAustralia
- Outcomes Research ConsortiumCleveland ClinicClevelandOH
- AnesthesiaRoyal Melbourne HospitalMelbourneAustralia
| | - Alistair Royse
- SurgeryUniversity of MelbourneMelbourneAustralia
- Cardiothoracic Surgery, Royal Melbourne HospitalMelbourneAustralia
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3
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Kim HH, Yoo KJ, Youn YN. Bilateral versus Single Internal Thoracic Artery Grafting Strategies Supplemented by Radial Artery Grafting. Yonsei Med J 2023; 64:473-480. [PMID: 37488698 PMCID: PMC10375247 DOI: 10.3349/ymj.2022.0586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 05/14/2023] [Accepted: 06/13/2023] [Indexed: 07/26/2023] Open
Abstract
PURPOSE It is unclear if a second or third arterial graft can improve clinical outcomes in coronary artery bypass graft surgery. We compared the outcomes of bilateral internal thoracic artery (BITA) plus radial artery (RA) grafting versus left internal thoracic artery (LITA) plus RA grafting after off-pump coronary artery bypass grafting. MATERIALS AND METHODS Between January 2009 and December 2020, a total of 3007 patients with three-vessel coronary artery disease who underwent off-pump coronary artery bypass were analyzed. Among them, 971 patients received total arterial grafting using LITA. We divided the patients into two groups [group A, BITA+RA grafting (n=227) and group B, LITA+RA grafting (n=744)], and compared the survival and major adverse cardiac and cerebrovascular event (MACCE) rates between the two groups at 10 years. RESULTS After risk adjustment with inverse probability treatment weighting methods, the freedom from all-cause mortality was 93.1% and 88.3% in groups A and B, respectively (p=0.140). The freedom from MACCE rates were 68.3% and 89.0%, respectively (p<0.0001). LITA plus RA grafting [hazard ratio (HR): 1.3, 95% confidence interval (CI): 1.05-2.37, p=0.025] and incomplete revascularization (HR 1.2, 95% CI: 0.70-2.15, p=0.046) were significant risk factors for MACCEs in multivariable Cox regression analysis. CONCLUSION The rates of MACCEs were lower with LITA plus RA grafting than with BITA plus RA grafting in total arterial revascularization. Furthermore, complete revascularization improved long-term outcomes following total arterial grafting.
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Affiliation(s)
- Hyo-Hyun Kim
- Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
- Department of Cardiothoracic Surgery, Ilsan Hospital, National Health Insurance Service, Goyang, Korea
| | - Kyung-Jong Yoo
- Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Young-Nam Youn
- Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea.
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Chaudhuri K, Pletzer A, Smith NP. A predictive patient-specific computational model of coronary artery bypass grafts for potential use by cardiac surgeons to guide selection of graft configurations. Front Cardiovasc Med 2022; 9:953109. [PMID: 36237904 PMCID: PMC9552835 DOI: 10.3389/fcvm.2022.953109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 09/01/2022] [Indexed: 01/09/2023] Open
Abstract
Cardiac surgeons face a significant degree of uncertainty when deciding upon coronary artery bypass graft configurations for patients with coronary artery disease. This leads to significant variation in preferred configuration between different surgeons for a particular patient. Additionally, for the majority of cases, there is no consensus regarding the optimal grafting strategy. This situation results in the tendency for individual surgeons to opt for a “one size fits all” approach and use the same grafting configuration for the majority of their patients neglecting the patient-specific nature of the diseased coronary circulation. Quantitative metrics to assess the adequacy of coronary bypass graft flows have recently been advocated for routine intraoperative use by cardiac surgeons. In this work, a novel patient-specific 1D-0D computational model called “COMCAB” is developed to provide the predictive haemodynamic parameters of functional graft performance that can aid surgeons to avoid configurations with grafts that have poor flow and thus poor patency. This model has significant potential for future expanded applications.
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Affiliation(s)
- Krish Chaudhuri
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
- Green Lane Cardiothoracic Surgical Unit, Auckland City Hospital, Auckland, New Zealand
- *Correspondence: Krish Chaudhuri,
| | | | - Nicolas P. Smith
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
- School of Mechanical, Medical and Process Engineering, Queensland University of Technology, Brisbane, QLD, Australia
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5
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Hayatsu Y, Ruel M, Bader Eddeen A, Sun L. Single Versus Multiple Arterial Revascularization in Patients With Reduced Renal Function: Long-term Outcome Comparisons in 23,406 CABG Patients From Ontario, Canada. Ann Surg 2022; 275:602-608. [PMID: 32590546 DOI: 10.1097/sla.0000000000003908] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare the long-term outcomes of MAR versus SAR in patients with renal insufficiency. SUMMARY OF BACKGROUND DATA Previous studies have been insufficiently powered to address whether MAR confers long-term benefit over SAR in patients with renal dysfunction who require CABG. METHODS We conducted retrospective cohort study in Ontario, Canada of patients who underwent isolated CABG (n = 23,406). The primary outcome was MACE, defined as the composite of stroke, myocardial infarction, and repeat revascularization. We compared patients by matching them on the propensity to have received SAR versus MAR, within groups with preoperative glomerular filtration rate (GFR) ≥60 mL/min/1.73 m2; GFR between 30 and 60; and GFR <30. RESULTS In patients with GFR ≥60, the use of MAR versus SAR was associated with a lower rate of MACE [hazard ratio (HR) 0.87 (0.80-0.94)], and a lower rate of long-term mortality [HR 0.87 (0.79-0.97)]. In those with GFR between 30 and 60, MAR was not associated with a difference in MACE [HR 1.04 (0.87-1.26)], and a lower rate of long-term mortality [HR 0.75 (0.65-0.87)] was observed. In those with GFR <30, MAR was not associated with a difference in outcomes. CONCLUSIONS MAR versus SAR does not correlate with a difference in MACE amongst patients with GFR between 30 and 60 and better survival raises the possibility of indication bias. Furthermore, MAR did not confer a benefit in those with severely reduced renal function. These data suggest that the potential long-term benefits of using MAR in CABG patients with renal insufficiency may be offset by competing health risks.
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Affiliation(s)
- Yukihiro Hayatsu
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Marc Ruel
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | | | - Louise Sun
- ICES, Ottawa, ON, Canada
- Division of Cardiac Anesthesiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
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6
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Nakamura M, Yaku H, Ako J, Arai H, Asai T, Chikamori T, Daida H, Doi K, Fukui T, Ito T, Kadota K, Kobayashi J, Komiya T, Kozuma K, Nakagawa Y, Nakao K, Niinami H, Ohno T, Ozaki Y, Sata M, Takanashi S, Takemura H, Ueno T, Yasuda S, Yokoyama H, Fujita T, Kasai T, Kohsaka S, Kubo T, Manabe S, Matsumoto N, Miyagawa S, Mizuno T, Motomura N, Numata S, Nakajima H, Oda H, Otake H, Otsuka F, Sasaki KI, Shimada K, Shimokawa T, Shinke T, Suzuki T, Takahashi M, Tanaka N, Tsuneyoshi H, Tojo T, Une D, Wakasa S, Yamaguchi K, Akasaka T, Hirayama A, Kimura K, Kimura T, Matsui Y, Miyazaki S, Okamura Y, Ono M, Shiomi H, Tanemoto K. JCS 2018 Guideline on Revascularization of Stable Coronary Artery Disease. Circ J 2022; 86:477-588. [DOI: 10.1253/circj.cj-20-1282] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Masato Nakamura
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center
| | - Hitoshi Yaku
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University Graduate School of Medical Sciences
| | - Hirokuni Arai
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University
| | - Tohru Asai
- Department of Cardiovascular Surgery, Juntendo University Graduate School of Medicine
| | | | - Hiroyuki Daida
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine
| | - Kiyoshi Doi
- General and Cardiothoracic Surgery, Gifu University Graduate School of Medicine
| | - Toshihiro Fukui
- Department of Cardiovascular Surgery, Graduate School of Medical Sciences, Kumamoto University
| | - Toshiaki Ito
- Department of Cardiovascular Surgery, Japanese Red Cross Nagoya Daiichi Hospital
| | | | - Junjiro Kobayashi
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Tatsuhiko Komiya
- Department of Cardiovascular Surgery, Kurashiki Central Hospital
| | - Ken Kozuma
- Department of Internal Medicine, Teikyo University Faculty of Medicine
| | - Yoshihisa Nakagawa
- Department of Cardiovascular Medicine, Shiga University of Medical Science
| | - Koichi Nakao
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center
| | - Hiroshi Niinami
- Department of Cardiovascular Surgery, Tokyo Women’s Medical University
| | - Takayuki Ohno
- Department of Cardiovascular Surgery, Mitsui Memorial Hospital
| | - Yukio Ozaki
- Department of Cardiology, Fujita Health University Hospital
| | - Masataka Sata
- Department of Cardiovascular Medicine, Tokushima University Graduate School of Biomedical Sciences
| | | | - Hirofumi Takemura
- Department of Cardiovascular Surgery, Graduate School of Medical Sciences, Kanazawa University
| | | | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Hitoshi Yokoyama
- Department of Cardiovascular Surgery, Fukushima Medical University
| | - Tomoyuki Fujita
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Tokuo Kasai
- Department of Cardiology, Uonuma Institute of Community Medicine, Niigata University Uonuma Kikan Hospital
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
| | - Takashi Kubo
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Susumu Manabe
- Department of Cardiovascular Surgery, Tsuchiura Kyodo General Hospital
| | | | - Shigeru Miyagawa
- Frontier of Regenerative Medicine, Graduate School of Medicine, Osaka University
| | - Tomohiro Mizuno
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University
| | - Noboru Motomura
- Department of Cardiovascular Surgery, Graduate School of Medicine, Toho University
| | - Satoshi Numata
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine
| | - Hiroyuki Nakajima
- Department of Cardiovascular Surgery, Saitama Medical University International Medical Center
| | - Hirotaka Oda
- Department of Cardiology, Niigata City General Hospital
| | - Hiromasa Otake
- Department of Cardiovascular Medicine, Kobe University Graduate School of Medicine
| | - Fumiyuki Otsuka
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Ken-ichiro Sasaki
- Division of Cardiovascular Medicine, Kurume University School of Medicine
| | - Kazunori Shimada
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine
| | - Tomoki Shimokawa
- Department of Cardiovascular Surgery, Sakakibara Heart Institute
| | - Toshiro Shinke
- Division of Cardiology, Department of Medicine, Showa University School of Medicine
| | - Tomoaki Suzuki
- Department of Cardiovascular Surgery, Shiga University of Medical Science
| | - Masao Takahashi
- Department of Cardiovascular Surgery, Hiratsuka Kyosai Hospital
| | - Nobuhiro Tanaka
- Department of Cardiology, Tokyo Medical University Hachioji Medical Center
| | | | - Taiki Tojo
- Department of Cardiovascular Medicine, Kitasato University Graduate School of Medical Sciences
| | - Dai Une
- Department of Cardiovascular Surgery, Okayama Medical Center
| | - Satoru Wakasa
- Department of Cardiovascular and Thoracic Surgery, Hokkaido University Graduate School of Medicine
| | - Koji Yamaguchi
- Department of Cardiovascular Medicine, Tokushima University Graduate School of Biomedical Sciences
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University
| | | | - Kazuo Kimura
- Cardiovascular Center, Yokohama City University Medical Center
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Yoshiro Matsui
- Department of Cardiovascular and Thoracic Surgery, Graduate School of Medicine, Hokkaido University
| | - Shunichi Miyazaki
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Kindai University
| | | | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Kazuo Tanemoto
- Department of Cardiovascular Surgery, Kawasaki Medical School
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Kemp U, Davies RA. OUP accepted manuscript. Interact Cardiovasc Thorac Surg 2022; 34:735-738. [PMID: 35149863 PMCID: PMC9070453 DOI: 10.1093/icvts/ivac021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 12/18/2021] [Accepted: 01/02/2022] [Indexed: 11/18/2022] Open
Abstract
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was ‘What is the best choice for third conduit when using bilateral internal mammary arteries for coronary artery bypass grafting—radial artery or saphenous vein graft?’. Altogether >525 papers were found using the reported search, of which 7 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Overall, there was no survival benefit demonstrated with the use of a radial artery over the use of a saphenous vein graft as a choice of third conduit following bilateral internal mammary artery grafts for coronary artery bypass grafting. The main limitation of the current evidence available is the restricted follow-up periods and the high attrition rates with small sample sizes affecting the strength of conclusions that can be drawn beyond 10 years of follow-up. We conclude that despite previous evidence supporting improved long-term patency of radial arterial grafts, there is no strong evidence that the use of a radial artery, over a saphenous vein graft, has any survival benefit when used as the third conduit following bilateral internal mammary artery grafts.
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Affiliation(s)
- Ursula Kemp
- Cardiothoracic Department, St George Hospital, Sydney, Australia
- Corresponding author. Cardiothoracic Department, St George Hospital, Gray St, Kogarah, NSW 2217, Australia. Tel: +61-408905831; e-mail: (U. Kemp)
| | - Reece A Davies
- Cardiothoracic Department, St George Hospital, Sydney, Australia
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8
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Formica F, Maestri F, D'Alessandro S, Di Mauro M, Singh G, Gallingani A, Nicolini F. Survival effect of radial artery usage in addition to bilateral internal thoracic arterial grafting: A meta-analysis. J Thorac Cardiovasc Surg 2021; 165:2076-2085.e9. [PMID: 34462132 DOI: 10.1016/j.jtcvs.2021.06.062] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 06/08/2021] [Accepted: 06/30/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Little evidence shows whether the radial artery (RA) as third arterial graft provides superior outcomes compared with the use of the bilateral internal thoracic artery (BITA) and saphenous vein (SV) graft in patients undergoing coronary artery bypass grafting. A meta-analysis of propensity score-matched observational studies that compared the long-term outcomes of coronary artery bypass grafting with the use of BITA and the RA (BITA + RA) versus BITA and SV (BITA + SV) was performed. METHODS Electronic databases from January 2000 to November 2020 were screened. Studies that reported long-term mortality were analyzed. The primary outcome was long-term overall mortality. A secondary end point was in-hospital/30-day mortality. Pooled hazard ratio with 95% confidence interval (CI) were calculated for survival and time-to-event analysis according to a random effect model. Differences were expressed as odds ratio with 95% CI for in-hospital/30-day mortality. RESULTS Six propensity score-matched studies that reported on 2500 matched patients (BITA + RA: 1250; BITA + SV: 1250) were identified for comparison. The use of BITA + RA was not statistically associated with early mortality (odds ratio, 0.90; 95% CI, 0.36-2.28; P = .83). The mean follow-up time ranged from 7.5 to 12 years. The pooled analysis of long-term survival revealed a significant difference between the 2 groups favoring BITA + RA treatment (hazard ratio, 0.71; 95% CI, 0.50-0.91; P = .031). The survival rate for BITA + RA versus BITA + SV at 5, 10, and 15 years were: 96.2% versus 94.8%, 88.9% versus 87.4%, and 83% versus 77.9%, respectively (log rank test, P = .02). CONCLUSIONS In patients with coronary artery bypass grafting, BITA + RA usage is not associated with higher rates of operative risk and is associated with superior long-term overall survival.
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9
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Gaudino M, Bakaeen FG, Benedetto U, Di Franco A, Fremes S, Glineur D, Girardi LN, Grau J, Puskas JD, Ruel M, Tam DY, Taggart DP, Antoniades C, Patrono C, Schwann TA, Tatoulis J, Tranbaugh RF. Arterial Grafts for Coronary Bypass. Circulation 2019; 140:1273-1284. [DOI: 10.1161/circulationaha.119.041096] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Observational and randomized evidence shows that arterial grafts have better patency rates than saphenous vein grafts (SVGs) in coronary artery bypass grafting. Observational studies suggest that the use of multiple arterial grafts is associated with longer postoperative survival, but this must be interpreted in the context of treatment allocation bias and hidden confounders intrinsic to the study designs. Recently, a pooled analysis of 6 randomized trials comparing the radial artery with the SVG as the second conduit and the largest randomized trial comparing the use of single and bilateral internal thoracic arteries have provided apparently divergent results about a clinical benefit with the use of >1 arterial conduit. However, both analyses have methodological limitations that may have influenced their results. At present, it is unclear whether the well-documented increased patency rate of arterial grafts translates into clinical benefits in the majority of patients undergoing coronary artery bypass grafting. A large randomized trial testing the arterial grafts hypothesis (ROMA [Randomized Comparison of the Clinical Outcome of Single Versus Multiple Arterial Grafts]) is underway and will report the results in a few years.
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Affiliation(s)
- Mario Gaudino
- Department of Cardio-Thoracic Surgery, Weill Cornell Medicine, New York (M.G., A.D.F., L.N.G.)
| | - Faisal G. Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, OH (F.G.B.)
| | - Umberto Benedetto
- Bristol Heart Institute, University of Bristol, School of Clinical Sciences, UK (U.B.)
| | - Antonino Di Franco
- Department of Cardio-Thoracic Surgery, Weill Cornell Medicine, New York (M.G., A.D.F., L.N.G.)
| | - Stephen Fremes
- Schulich Heart Centre, Sunnybrook Health Science, University of Toronto, ON, Canada (S.F., D.Y.T.)
| | - David Glineur
- Division of Cardiac Surgery, University of Ottawa Heart Institute, ON, Canada (D.G., J.G., M.R.)
| | - Leonard N. Girardi
- Department of Cardio-Thoracic Surgery, Weill Cornell Medicine, New York (M.G., A.D.F., L.N.G.)
| | - Juan Grau
- Division of Cardiac Surgery, University of Ottawa Heart Institute, ON, Canada (D.G., J.G., M.R.)
| | - John D. Puskas
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York (J.D.P.)
| | - Marc Ruel
- Division of Cardiac Surgery, University of Ottawa Heart Institute, ON, Canada (D.G., J.G., M.R.)
| | - Derrick Y. Tam
- Schulich Heart Centre, Sunnybrook Health Science, University of Toronto, ON, Canada (S.F., D.Y.T.)
| | - David P. Taggart
- Department of Cardiovascular Surgery, University of Oxford, UK (D.P.T.)
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10
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Rocha RV, Tam DY, Karkhanis R, Nedadur R, Fang J, Tu JV, Gaudino M, Royse A, Fremes SE. Multiple Arterial Grafting Is Associated With Better Outcomes for Coronary Artery Bypass Grafting Patients. Circulation 2019; 138:2081-2090. [PMID: 30474420 DOI: 10.1161/circulationaha.118.034464] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Observational studies have shown better survival in patients undergoing coronary artery bypass grafting (CABG) with 2 arterial grafts compared with 1. However, whether a third arterial graft is associated with incremental benefit remains uncertain. We sought to analyze the outcomes of 3 versus 2 arterial grafts during CABG. As a secondary objective, we compared CABG with 2 or 3 arterial grafts (multiple arterial grafts [MAG]) with CABG using a single arterial graft (SAG). METHODS Retrospective cohort analyses of all patients undergoing primary isolated CABG in Ontario, Canada, from October 2008 to March 2016. Propensity score matching was performed between patients with 3 arterial grafts (3Art group) versus 2 (2Art group). The primary outcome was time to first event of a composite of death, myocardial infarction, stroke, and repeat revascularization (major adverse cardiac and cerebrovascular events). Additional analyses were performed to evaluate the association between MAG versus SAG and long-term outcomes using propensity score matching. RESULTS Fifty thousand, two hundred thirty patients underwent isolated CABG during our study period; 3044 (6.1%) and 8253 (16.4%) patients had 3 and 2 arterial grafts, respectively, resulting in 2789 propensity score matching pairs for the primary analyses. Mean and maximum follow-up was 4.2 and 8.5 years, respectively. Radial artery grafting was more common in the 3Art versus 2Art group (79.3% versus 65.6%, P<0.01). In-hospital outcomes were not significantly different, including death (3Art 0.8% versus 2Art 0.5%, P=0.26). Up to 8 years, there were no differences in major adverse cardiac and cerebrovascular events (3Art 27%, 95% confidence interval [CI], 24% to 30% versus 2Art 25%, 95% CI, 22% to 28%; hazard ratio [HR], 1.08, 95% CI, 0.94-1.25), death (HR, 1.08; 95% CI, 0.90-1.29), myocardial infarction (HR, 1.15; 95% CI, 0.87-1.51), stroke (HR, 1.39; 95% CI, 0.95-2.06), or repeat revascularization (HR, 1.04; 95% CI, 0.82-1.32). When evaluating MAG versus SAG, 8629 patient pairs were formed using propensity score matching. At 8 years, cumulative incidences of major adverse cardiac and cerebrovascular events (HR, 0.82, 95% CI, 0.77-0.88), survival (HR, 0.80; 95% CI, 0.73-0.88), repeat revascularization (HR, 0.79; 95% CI, 0.69-0.90), and myocardial infarction (HR, 0.83; 95% CI, 0.72-0.97) were superior in the MAG group. CONCLUSIONS CABG with 3 arterial grafts was not associated with increased in-hospital death nor with better clinical outcomes at 8-year follow-up, compared with CABG with 2 arterial grafts. MAG was associated with superior outcomes compared with SAG.
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Affiliation(s)
- Rodolfo V Rocha
- Division of Cardiac Surgery (R.V.R., D.Y.T., R.K., R.N., S.E.F.), University of Toronto, Ontario, Canada
| | - Derrick Y Tam
- Division of Cardiac Surgery (R.V.R., D.Y.T., R.K., R.N., S.E.F.), University of Toronto, Ontario, Canada.,Schulich Heart Centre, Department of Surgery, Sunnybrook Health Sciences Centre, and Institute of Health Policy, Management, and Evaluation (D.Y.T., R.K., S.E.F.), University of Toronto, Ontario, Canada
| | - Reena Karkhanis
- Division of Cardiac Surgery (R.V.R., D.Y.T., R.K., R.N., S.E.F.), University of Toronto, Ontario, Canada.,Schulich Heart Centre, Department of Surgery, Sunnybrook Health Sciences Centre, and Institute of Health Policy, Management, and Evaluation (D.Y.T., R.K., S.E.F.), University of Toronto, Ontario, Canada
| | - Rashmi Nedadur
- Division of Cardiac Surgery (R.V.R., D.Y.T., R.K., R.N., S.E.F.), University of Toronto, Ontario, Canada
| | - Jiming Fang
- Cardiovascular Program, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (J.F., J.V.T.)
| | - Jack V Tu
- Division of Cardiology (J.V.T.), University of Toronto, Ontario, Canada.,Cardiovascular Program, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (J.F., J.V.T.)
| | - Mario Gaudino
- Department of Cardio-Thoracic Surgery, Weill Cornell Medicine, New York (M.G.)
| | - Alistair Royse
- Division of Cardiac Surgery, Royal Melbourne Hospital, Parkville, Victoria, Australia (A.R.)
| | - Stephen E Fremes
- Division of Cardiac Surgery (R.V.R., D.Y.T., R.K., R.N., S.E.F.), University of Toronto, Ontario, Canada.,Schulich Heart Centre, Department of Surgery, Sunnybrook Health Sciences Centre, and Institute of Health Policy, Management, and Evaluation (D.Y.T., R.K., S.E.F.), University of Toronto, Ontario, Canada
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11
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Urso S, Sadaba R, González JM, Nogales E, Pettinari M, Tena MÁ, Paredes F, Portela F. Total arterial revascularization strategies: A meta-analysis of propensity score-matched observational studies. J Card Surg 2019; 34:837-845. [PMID: 31376215 DOI: 10.1111/jocs.14169] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 06/11/2019] [Accepted: 06/16/2019] [Indexed: 01/30/2023]
Abstract
BACKGROUND AND AIM OF THE STUDY We explored the current evidence available on total arterial revascularization (TAR) carrying out a meta-analysis of propensity score-matched studies comparing TAR versus non-TAR strategy. METHODS PubMed, EMBASE, and Google Scholar were searched for propensity score-matched studies comparing TAR vs non-TAR. The generic inverse variance method was used to compute the combined hazard ratio (HR) of long-term mortality. The Der-Simonian and Laird method were used to compute the combined risk ratio (RR) of 30-day mortality, deep sternal wound infection, and reoperation for bleeding. RESULTS Eighteen TAR vs non-TAR matched populations were included. Meta-analysis showed a significant benefit in terms of long-term survival of the TAR group over the non-TAR group (HR: 0.73; 95% confidence interval [CI]: 0.68-0.78). Better long-term survival over non-TAR strategy was confirmed by both subgroups: TAR with the bilateral internal mammary artery (BIMA) and TAR without BIMA. Meta-regression suggests that TAR may offer a higher protective survival effect in diabetic patients (coefficient: -0.0063; 95% CI: -0.01 to 0.0006), when carried out with BIMA (coefficient: -0.15; 95% CI: -0.27 to -0.03) or using three arterial conduits (coefficient: -0.12; 95% CI: -0.25 to 0.007). A TAR strategy carried out using BIMA, differently from TAR without BIMA, increases the risk of deep sternal infection (RR: 1.44; 95% CI: 1.17-1.77). CONCLUSIONS TAR provides a long-term survival benefit compared with the non-TAR strategy. Also, compared with TAR without BIMA, TAR with BIMA may offer a higher protective long-term survival effect at the expense of a higher risk of sternal deep wound infection.
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Affiliation(s)
- Stefano Urso
- Cardiac Surgery Department, Hospital Universitario Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | - Rafael Sadaba
- Cardiac Surgery Department, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Jesús María González
- Research Unit, Hospital Universitario Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | - Eliú Nogales
- Cardiology Department, Hospital Universitario Insular, Las Palmas de Gran Canaria, Spain
| | - Matteo Pettinari
- Cardiac Surgery Department, Ziekenhuis Oost Limburg, Genk, Belgium
| | - María Ángeles Tena
- Cardiac Surgery Department, Hospital Universitario Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | - Federico Paredes
- Cardiac Surgery Department, Hospital Universitario Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | - Francisco Portela
- Cardiac Surgery Department, Hospital Universitario Dr. Negrín, Las Palmas de Gran Canaria, Spain
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12
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Gaudino MFL, Spadaccio C, Taggart DP. State-of-the-Art Coronary Artery Bypass Grafting: Patient Selection, Graft Selection, and Optimizing Outcomes. Interv Cardiol Clin 2019; 8:173-198. [PMID: 30832941 DOI: 10.1016/j.iccl.2018.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Despite the progressive expansion of clinical indications for percutaneous coronary intervention and the increasingly high risk profile of referred patients, coronary artery bypass grafting (CABG) remains the mainstay in multivessel disease, providing good long-term outcomes with low complication rates. Multiple arterial grafting, especially if associated with anaortic techniques, might provide the best longer-term outcomes. A surgical approach individualized to the patients' clinical and anatomic characteristics, and surgeon and team experience, are key to excellent outcomes. Current evidence regarding patient selection, indications, graft selection, and potential strategies to optimize outcomes in patients treated with CABG is summarized.
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Affiliation(s)
- Mario F L Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, NewYork-Presbyterian Hospital, 525 East 68th Street, New York, NY 10021, USA.
| | - Cristiano Spadaccio
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, Glasgow G81 4DY, UK; University of Glasgow, Institute of Cardiovascular and Medical Sciences, 126 University Place, Glasgow G128TA, UK
| | - David P Taggart
- Department of Cardiovascular Surgery, University of Oxford, Headley Way, Oxford, Oxforshire OX39DU, UK; Department Cardiac Surgery, John Radcliffe Hospital, Headley Way, Headington, Oxford, Oxfordshire OX3 9DU, UK
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13
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Lazar HL. Commentary: Total arterial revascularization: Is it for everyone? J Thorac Cardiovasc Surg 2019; 157:2237-2239. [PMID: 30709675 DOI: 10.1016/j.jtcvs.2018.12.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 12/17/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Harold L Lazar
- Division of Cardiac Surgery, Boston University School of Medicine, Boston, Mass.
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14
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Formica F, D'Alessandro S, Singh G, Ciobanu AM, Messina LA, Scianna S, Moscatiello M. The impact of the radial artery or the saphenous vein in addition to the bilateral internal mammary arteries on late survival: A propensity score analysis. J Thorac Cardiovasc Surg 2019; 158:141-151. [PMID: 30745048 DOI: 10.1016/j.jtcvs.2018.12.078] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 12/16/2018] [Accepted: 12/26/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Long-term survival benefits of full arterial revascularization with radial artery (RA) used in addition to bilateral internal mammary arteries (BIMA) compared with saphenous vein (SV) used in addition to BIMA has not been clearly defined. METHODS We retrospectively analyzed 660 3-vessel coronary artery disease subjects who received BIMA in addition to either RA (n = 206) or SV (n = 454) grafting in a period between June 1999 and November 2017. After propensity score matching, we obtained 190 matched pairs for analysis. RESULTS In the matched population, in-hospital mortality occurred in 4 patients (1%), with 2 deaths (1.1%) in the BIMA + RA group and 2 deaths (1.1%) in BIMA + SV group (P > .99). The median follow-up time was 9.2 years (interquartile range, 5.6-13 years) with a maximum follow-up time of 18.5 years. There was not a significant difference in long-term survival between the 2 groups over the follow-up period. Survival at 5, 10, and 15 years were 94.8 ± 1.7%, 83.7 ± 3.1%, and 78.6 ± 3.9% in the BIMA + RA group and 96.2 ± 1.4%, 85.1 ± 2.9%, and 80.4 ± 3.6% in the BIMA + SV group (stratified log-rank P = .78). Cox proportional hazard regression model was used to estimate that the use of RA in addition to BIMA did not affect the late mortality (propensity score adjusted hazard ratio, 1.05; 95% confidence interval, 0.62-1.79; P = .83). CONCLUSIONS In a relatively small population of triple-vessel coronary artery disease, the use of RA as a third arterial conduit with BIMA did not confer a long-term survival benefit.
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Affiliation(s)
- Francesco Formica
- Cardiac Surgery Unit, ASST San Gerardo Hospital, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.
| | - Stefano D'Alessandro
- Cardiac Surgery Unit, ASST San Gerardo Hospital, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Gurmeet Singh
- Division of Cardiac Surgery, Department of Critical Care Medicine, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | | | | | - Salvatore Scianna
- Cardiac Surgery Unit, ASST San Gerardo Hospital, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Mario Moscatiello
- Cardiac Surgery Unit, ASST San Gerardo Hospital, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
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15
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Tatoulis J. The radial artery in coronary surgery, 2018. Indian J Thorac Cardiovasc Surg 2018; 34:234-244. [PMID: 33060944 DOI: 10.1007/s12055-018-0694-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 07/12/2018] [Indexed: 11/30/2022] Open
Abstract
It is now 25 years since the radial artery (RA) was reintroduced in coronary surgery. It has evolved into being a significant coronary artery bypass conduit and ranks third in usage after the internal thoracic artery (ITA) and saphenous vein grafts (SVG). Its advantages are that it can be readily and efficiently harvested, is of good length and appropriate size for coronary artery bypass graft (CABG) surgery, is robust and easy to handle, and remains free of atheroma, and there is minimal wound morbidity. The RA must be used judiciously with attention to spasm prophylaxis because of its muscular wall, and by avoiding competitive flow. Its patency is equivalent to the ITAs when placed to similar coronary territories and under similar conditions (stenosis, size, quality) and RA patencies are always superior to those of SVG in both observational and randomized studies-88-90% versus 50-60% at 10 years, and 80-87% versus 25-40% at 20 years. Its use and excellent patencies result in survival results equivalent to bilateral internal thoracic artery (BITA) grafting and always superior to left internal thoracic artery (LITA) +SVG. Typical radial artery multiarterial bypass grafting (RA-MABG) 10-year survivals are 80-90% versus 70-80% for LITA-SVG. In general, for every 100 patients undergoing CABG, 10 more patients will be alive at 10 years post-operatively. The RA also is important in achieving total arterial revascularization, and several reports indicate a further survival advantage for patients having three arterial grafts over two. The RAs are especially useful in diabetic, morbidly obese patients, those with conduit shortage, and leg pathology, and in coronary reoperations. Although the RA has equivalent patencies to the right internal thoracic artery (RITA), it is much more versatile. RAs that have been instrumented by angiography or percutaneous coronary intervention should be avoided. The radial artery has proved to be an excellent arterial conduit, is equivalent to but more versatile than the RITA, and is always superior to SVG. Its use should be part of every coronary surgeon's skill set.
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Affiliation(s)
- James Tatoulis
- Royal Melbourne Hospital, Melbourne, Australia.,University of Melbourne, Melbourne, Australia
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16
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The Incremental Value of Three or More Arterial Grafts in CABG: The Effect of Native Vessel Disease. Ann Thorac Surg 2018; 106:1071-1078. [DOI: 10.1016/j.athoracsur.2018.05.088] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 04/07/2018] [Accepted: 05/21/2018] [Indexed: 11/18/2022]
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17
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Tatoulis J, Schwann TA. Long term outcomes of radial artery grafting in patients undergoing coronary artery bypass surgery. Ann Cardiothorac Surg 2018; 7:636-643. [PMID: 30505748 DOI: 10.21037/acs.2018.05.11] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Single arterial left internal thoracic artery (LITA) based coronary artery bypass surgery (LITA-SABG) has been the principal revascularization strategy for over 25 years across all patient demographics. In line with the current emphasis being placed on personalized medicine, which tailors individual, patient-specific therapy to optimize outcomes, coronary artery bypass grafting (CABG) techniques have also evolved to achieve enhanced results among specific groups of patients with coronary artery disease. Most notable has been the development of multi-arterial bypass grafting (MABG) techniques, using either the radial artery (RA) or the right internal thoracic artery (RITA) in conjunction with the LITA, as both techniques have been shown to enhance long term survival of CABG patients. This article reviews the latest data on the long-term outcomes of RA-MABG and considers its impact in various sub-cohorts of CABG that are increasingly being treated by cardiac surgeons. The primary aim of this review is to highlight the advantages of RA-MABG over LITA-SABG and thereby potentiate its adoption into clinical practice. Our secondary aim is to summarize the results of RA-MABG in specific CABG sub-cohorts, to more closely align CABG surgery with the emerging consensus that personalized medicine enhances healthcare value.
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Affiliation(s)
- James Tatoulis
- Department of Surgery, University of Melbourne, Melbourne, Australia
| | - Thomas A Schwann
- Department of Surgery, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
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18
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Abstract
PURPOSE OF REVIEW To provide a broad overview of the current state of knowledge of coronary artery bypass grafting with bilateral internal thoracic artery (BITA). RECENT FINDINGS There exists a large body of literature from mostly observational studies supporting the use of BITA in patients undergoing coronary artery bypass grafting but selection bias is a major issue with nonrandomized data. The precise method of BITA use does not appear to impact graft patency nor clinical outcomes - in other words, BITA in any configuration appears to be protective. The major downside is the increased risk of sternal complications, which can be mitigated with sternal-sparring adjuncts. The 5-year interim results of the landmark Arterial Revascularization Trial comparing BITA versus single internal thoracic artery did not show a clinical benefit for BITA but the end-of-trial results are pending. Despite wide guideline support for BITA use, uptake in the surgical community remains low and this is likely because of technical and institutional barriers. SUMMARY The published literature thus far supports surgical revascularization with BITA and we eagerly await the 10-year Arterial Revascularization Trial results. The general consensus is that a greater proportion of surgical revascularization should be performed using BITA.
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19
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Schwann TA, El Hage Sleiman AKM, Yammine MB, Tranbaugh RF, Engoren M, Bonnell MR, Habib RH. Incremental Value of Increasing Number of Arterial Grafts: The Effect of Diabetes Mellitus. Ann Thorac Surg 2018; 105:1737-1744. [DOI: 10.1016/j.athoracsur.2018.01.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 12/22/2017] [Accepted: 01/03/2018] [Indexed: 10/18/2022]
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20
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Radial artery as a graft for coronary artery bypass surgery in the era of transradial catheterization. Hellenic J Cardiol 2018; 59:150-154. [DOI: 10.1016/j.hjc.2018.01.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 01/07/2018] [Accepted: 01/12/2018] [Indexed: 01/13/2023] Open
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21
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Luthra S, Leiva-Juárez MM, Matuszewski M, Morgan IS, Billing JS. Does a third arterial conduit to the right coronary circulation improve survival? J Thorac Cardiovasc Surg 2017; 155:855-860.e2. [PMID: 29248279 DOI: 10.1016/j.jtcvs.2017.09.163] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 08/12/2017] [Accepted: 09/07/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND The long-term benefits of a third arterial conduit to the right circulation in triple-vessel disease remain debatable. This retrospective, single-center, propensity-matched study investigates the impact of a third arterial conduit to the right circulation on early and intermediate survival after coronary artery bypass grafting. METHODS Data were retrospectively collected from 2004 to 2014 for all surgical revascularizations for triple-vessel disease with at least 2 arterial conduits to the left circulation and a third arterial or venous conduit to the right circulation. A total of 167 pairs were propensity matched to arterial versus venous third conduit to right circulation. Hazard functions were obtained with Cox multivariate regression and Kaplan-Meier survival curves were compared between the matched cohorts. RESULTS Extracardiac arteriopathy, logistic euroSCORE, and left main stem disease were significant predictors of adverse survival. A third arterial conduit to the right circulation was not a significant predictor of improved survival in multivariate analysis (HR, 0.72; 95% CI, 0.34-1.55; P = .411). 30-day mortality was 0.6% in both groups. There was no significant difference in early or intermediate survival in the propensity-matched groups (venous vs arterial, 99.2% vs 99.2%; P = 1.000 at 1 year; 85.2% vs 88.8%; P = .248 at 5 years and 69.2% vs 88.8%; P = .297 at 7 years) CONCLUSIONS: The use of a third arterial versus a venous conduit to the right circulation does not improve early or intermediate survival up to 7 years in triple-vessel coronary artery disease in this study. Longer follow-up and larger cohorts may be needed for differences to emerge.
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Affiliation(s)
- Suvitesh Luthra
- Division of Cardiac Surgery, Derriford Hospital, Plymouth, Devon, United Kingdom.
| | | | - Maciej Matuszewski
- Department of Cardiothoracic Surgery, New Cross Hospital, Wolverhampton, West Midlands, United Kingdom
| | - Ian S Morgan
- Department of Cardiothoracic Surgery, New Cross Hospital, Wolverhampton, West Midlands, United Kingdom
| | - John S Billing
- Department of Cardiothoracic Surgery, New Cross Hospital, Wolverhampton, West Midlands, United Kingdom
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22
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Stouffer CW, Halkos ME. Conduit conundrum: If not two, why three? J Thorac Cardiovasc Surg 2017; 155:863-864. [PMID: 29153285 DOI: 10.1016/j.jtcvs.2017.10.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 10/13/2017] [Indexed: 11/17/2022]
Affiliation(s)
- Chadwick W Stouffer
- Division of Cardiothoracic Surgery, Joseph B. Whitehead Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Michael E Halkos
- Division of Cardiothoracic Surgery, Joseph B. Whitehead Department of Surgery, Emory University School of Medicine, Atlanta, Ga.
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23
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Glineur D, Etienne PY, Kuschner CE, Shaw RE, Ferrari G, Rioux N, Papadatos S, Brizzio M, Mindich B, Zapolanski A, Grau JB. Bilateral internal mammary artery Y construct with multiple sequential grafting improves survival compared to bilateral internal mammary artery with additional vein grafts: 10-year experience at 2 different institutions†. Eur J Cardiothorac Surg 2017; 51:368-375. [PMID: 28186272 DOI: 10.1093/ejcts/ezw282] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 06/08/2016] [Accepted: 07/04/2016] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVES Utilization of bilateral internal mammary arteries (BIMAs) has been shown to improve long-term outcomes in patients undergoing coronary artery bypass grafting. To achieve complete revascularization, BIMAs may be used as either sole conduits for revascularization through a Y-graft configuration (BIMA-Y) or deployed with additional grafts used in conjunction with BIMAs. The purpose of this study was to compare the long-term outcomes of two institutions that predominantly used either the BIMA-Y configuration or BIMA plus additional grafts to achieve optimal revascularization. METHODS From 1 January 2000 to 31 December 2010, 436 patients were revascularized using a non-sequential BIMA grafting at one institution (Group A), with veins being used for additional targets. At the second institution (Group B), 771 patients were revascularized using a BIMA-Y graft for all distal targets. Kaplan–Meier analysis was used to compare unadjusted survival between the groups. Cox proportional hazards regression modelling was used to provide an adjusted comparison of survival between the groups. RESULTS There was no statistically significant difference between the average number of anastomotic sites used in Group A and Group B (A = 4.0 ± 0.7 vs B = 4.0 ± 0.7; P = 0.24). Group A did not have a significantly greater in-hospital mortality (0.7% vs 1.0% P = 0.39), stroke (0.5% vs 0.8% P = 0.40), deep sternal wound infection (0.0% vs 0.6% P = 0.11) or reoperation for bleeding (1.6% vs 0.6% P = 0.10) than Group B. Cox proportional hazards analyses demonstrated that at 14 years, Group B had a significantly improved survival compared to Group A (Group B = 88% vs Group A = 81%) with an overall reduction in mortality (adjusted hazard ratio 0.780, 95% confidence interval 0.448–0.849; P = 0.043). CONCLUSION Utilization of the BIMA-Y configuration was associated with improved survival when compared to BIMA grafting with additional vein grafts. Further studies are necessary to evaluate the efficacy of BIMA-Y grafting against other means of providing complete arterial revascularization.
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Affiliation(s)
- David Glineur
- Department of Thoracic and Cardiovascular Surgery, Cliniques St Luc Bouge, Namur, Belgium.,Division of Cardiac Surgery, Ottawa Heart Institute, Ottawa, Canada
| | - Pierre-Yves Etienne
- Department of Thoracic and Cardiovascular Surgery, Cliniques St Luc Bouge, Namur, Belgium
| | - Cyrus E Kuschner
- Department of Cardiac Surgery, Valley Heart and Vascular Institute, Ridgewood, NJ, USA
| | - Richard E Shaw
- Department of Cardiac Surgery, Valley Heart and Vascular Institute, Ridgewood, NJ, USA
| | - Giovanni Ferrari
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Nancy Rioux
- Department of Cardiac Surgery, Valley Heart and Vascular Institute, Ridgewood, NJ, USA
| | - Spiridon Papadatos
- Department of Thoracic and Cardiovascular Surgery, Cliniques St Luc Bouge, Namur, Belgium
| | - Mariano Brizzio
- Department of Cardiac Surgery, Valley Heart and Vascular Institute, Ridgewood, NJ, USA
| | - Bruce Mindich
- Department of Cardiac Surgery, Valley Heart and Vascular Institute, Ridgewood, NJ, USA
| | - Alex Zapolanski
- Department of Cardiac Surgery, Valley Heart and Vascular Institute, Ridgewood, NJ, USA
| | - Juan B Grau
- Department of Cardiac Surgery, Valley Heart and Vascular Institute, Ridgewood, NJ, USA.,Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
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Head SJ, Milojevic M, Taggart DP, Puskas JD. Current Practice of State-of-the-Art Surgical Coronary Revascularization. Circulation 2017; 136:1331-1345. [DOI: 10.1161/circulationaha.116.022572] [Citation(s) in RCA: 111] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Stuart J. Head
- From Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands (S.J.H., M.M.); Department of Cardiovascular Surgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, UK (D.P.T.); and Department of Cardiovascular Surgery, Mount Sinai Saint Luke’s Hospital, Icahn School of Medicine at Mount Sinai, New York, NY (J.D.P.)
| | - Milan Milojevic
- From Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands (S.J.H., M.M.); Department of Cardiovascular Surgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, UK (D.P.T.); and Department of Cardiovascular Surgery, Mount Sinai Saint Luke’s Hospital, Icahn School of Medicine at Mount Sinai, New York, NY (J.D.P.)
| | - David P. Taggart
- From Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands (S.J.H., M.M.); Department of Cardiovascular Surgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, UK (D.P.T.); and Department of Cardiovascular Surgery, Mount Sinai Saint Luke’s Hospital, Icahn School of Medicine at Mount Sinai, New York, NY (J.D.P.)
| | - John D. Puskas
- From Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands (S.J.H., M.M.); Department of Cardiovascular Surgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, UK (D.P.T.); and Department of Cardiovascular Surgery, Mount Sinai Saint Luke’s Hospital, Icahn School of Medicine at Mount Sinai, New York, NY (J.D.P.)
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Bilateral internal mammary arteries—are they really enough? Indian J Thorac Cardiovasc Surg 2017. [DOI: 10.1007/s12055-017-0576-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Taggart DP, Altman DG, Flather M, Gerry S, Gray A, Lees B, Benedetto U. Associations Between Adding a Radial Artery Graft to Single and Bilateral Internal Thoracic Artery Grafts and Outcomes: Insights From the Arterial Revascularization Trial. Circulation 2017; 136:454-463. [PMID: 28566338 DOI: 10.1161/circulationaha.117.027659] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 05/18/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Whether the use of the radial artery (RA) can improve clinical outcomes in coronary artery bypass graft surgery remains unclear. The ART (Arterial Revascularization Trial) was designed to compare survival after bilateral internal thoracic artery (BITA) over single left internal thoracic artery (SITA). In the ART, a large proportion of patients (≈20%) also received an RA graft instead of a saphenous vein graft (SVG). We aimed to investigate the associations between using the RA instead of an SVG to supplement SITA or BITA grafts and outcomes by performing a post hoc analysis of the ART. METHODS Patients enrolled in the ART (n=3102) were classified on the basis of conduits actually received (as treated). The analysis included 2737 patients who received an RA graft (RA group; n=632) or SVG only (SVG group; n=2105) in addition to SITA or BITA grafts. The primary end point was the composite of myocardial infarction, cardiovascular death, and repeat revascularization at 5 years. Propensity score matching and stratified Cox regression were used to compare the 2 strategies. RESULTS Myocardial infarction, cardiovascular death, and repeat revascularization cumulative incidence was 2.3% (95% confidence interval [CI], 1.1-3.4), 3.5% (95% CI, 2.1-5.0), and 4.4% (95% CI, 2.8-6.0) in the RA group and 3.4% (95% CI, 2.0-4.8), 4.0% (95% CI, 2.5-5.6), and 7.6% (95% CI, 5.5-9.7) in the SVG group, respectively. The composite end point was significantly lower in the RA group (8.8%; 95% CI, 6.5-11.0) compared with the SVG group (13.6%; 95% CI, 10.8-16.3; P=0.005). This association was present when an RA graft was used to supplement both SITA and BITA grafts (interaction P=0.62). CONCLUSIONS This post hoc ART analysis showed that an additional RA was associated with lower risk for midterm major adverse cardiac events when used to supplement SITA or BITA grafts. CLINICAL TRIAL REGISTRATION URL: https://www.situ.ox.ac.uk/surgical-trials/art. Unique identifier: ISRCTN46552265.
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Affiliation(s)
- David P Taggart
- From Nuffield Department of Surgery, University of Oxford, John Radcliffe Hospital, United Kingdom (D.P.T., B.L.); Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (D.G.A., S.G.), and Department of Public Health, Health Economics Research Centre (A.G.), University of Oxford, United Kingdom; Norwich Medical School, University of East Anglia, and Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, United Kingdom (M.F.); and Bristol Heart Institute, School of Clinical Sciences, University of Bristol, United Kingdom (U.B.)
| | - Douglas G Altman
- From Nuffield Department of Surgery, University of Oxford, John Radcliffe Hospital, United Kingdom (D.P.T., B.L.); Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (D.G.A., S.G.), and Department of Public Health, Health Economics Research Centre (A.G.), University of Oxford, United Kingdom; Norwich Medical School, University of East Anglia, and Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, United Kingdom (M.F.); and Bristol Heart Institute, School of Clinical Sciences, University of Bristol, United Kingdom (U.B.)
| | - Marcus Flather
- From Nuffield Department of Surgery, University of Oxford, John Radcliffe Hospital, United Kingdom (D.P.T., B.L.); Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (D.G.A., S.G.), and Department of Public Health, Health Economics Research Centre (A.G.), University of Oxford, United Kingdom; Norwich Medical School, University of East Anglia, and Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, United Kingdom (M.F.); and Bristol Heart Institute, School of Clinical Sciences, University of Bristol, United Kingdom (U.B.)
| | - Stephen Gerry
- From Nuffield Department of Surgery, University of Oxford, John Radcliffe Hospital, United Kingdom (D.P.T., B.L.); Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (D.G.A., S.G.), and Department of Public Health, Health Economics Research Centre (A.G.), University of Oxford, United Kingdom; Norwich Medical School, University of East Anglia, and Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, United Kingdom (M.F.); and Bristol Heart Institute, School of Clinical Sciences, University of Bristol, United Kingdom (U.B.)
| | - Alastair Gray
- From Nuffield Department of Surgery, University of Oxford, John Radcliffe Hospital, United Kingdom (D.P.T., B.L.); Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (D.G.A., S.G.), and Department of Public Health, Health Economics Research Centre (A.G.), University of Oxford, United Kingdom; Norwich Medical School, University of East Anglia, and Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, United Kingdom (M.F.); and Bristol Heart Institute, School of Clinical Sciences, University of Bristol, United Kingdom (U.B.)
| | - Belinda Lees
- From Nuffield Department of Surgery, University of Oxford, John Radcliffe Hospital, United Kingdom (D.P.T., B.L.); Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (D.G.A., S.G.), and Department of Public Health, Health Economics Research Centre (A.G.), University of Oxford, United Kingdom; Norwich Medical School, University of East Anglia, and Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, United Kingdom (M.F.); and Bristol Heart Institute, School of Clinical Sciences, University of Bristol, United Kingdom (U.B.)
| | - Umberto Benedetto
- From Nuffield Department of Surgery, University of Oxford, John Radcliffe Hospital, United Kingdom (D.P.T., B.L.); Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (D.G.A., S.G.), and Department of Public Health, Health Economics Research Centre (A.G.), University of Oxford, United Kingdom; Norwich Medical School, University of East Anglia, and Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, United Kingdom (M.F.); and Bristol Heart Institute, School of Clinical Sciences, University of Bristol, United Kingdom (U.B.).
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Locker C, Schaff HV, Daly RC, Bell MR, Frye RL, Stulak JM, Said SM, Dearani JA, Joyce LD, Greason KL, Pochettino A, Li Z, Lennon RJ, Lerman A. Multiarterial grafts improve the rate of early major adverse cardiac and cerebrovascular events in patients undergoing coronary revascularization: analysis of 12 615 patients with multivessel disease†. Eur J Cardiothorac Surg 2017; 52:746-752. [DOI: 10.1093/ejcts/ezx171] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 04/07/2017] [Indexed: 11/14/2022] Open
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Yanagawa B, Verma S, Mazine A, Tam DY, Jüni P, Puskas JD, Murugavel S, Friedrich JO. Impact of total arterial revascularization on long term survival: A systematic review and meta-analysis of 130,305 patients. Int J Cardiol 2017; 233:29-36. [DOI: 10.1016/j.ijcard.2017.02.010] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 12/26/2016] [Accepted: 02/01/2017] [Indexed: 12/01/2022]
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The Racial Paradox in Multiarterial Conduit Utilization for Coronary Artery Bypass Grafting. Ann Thorac Surg 2017; 103:1214-1221. [DOI: 10.1016/j.athoracsur.2016.07.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 06/17/2016] [Accepted: 07/15/2016] [Indexed: 11/19/2022]
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Gaudino M, Puskas JD, Di Franco A, Ohmes LB, Iannaccone M, Barbero U, Glineur D, Grau JB, Benedetto U, D'Ascenzo F, Gaita F, Girardi LN, Taggart DP. Three Arterial Grafts Improve Late Survival: A Meta-Analysis of Propensity-Matched Studies. Circulation 2017; 135:1036-1044. [PMID: 28119382 DOI: 10.1161/circulationaha.116.025453] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 01/17/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Little evidence shows whether a third arterial graft provides superior outcomes compared with the use of 2 arterial grafts in patients undergoing coronary artery bypass grafting. A meta-analysis of all the propensity score-matched observational studies comparing the long-term outcomes of coronary artery bypass grafting with the use of 2-arterial versus 3-arterial grafts was performed. METHODS A literature search was conducted using MEDLINE, EMBASE, and Web of Science to identify relevant articles. Long-term mortality in the propensity score-matched populations was the primary end point. Secondary end points were in-hospital/30-day mortality for the propensity score-matched populations and long-term mortality for the unmatched populations. In the matched population, time-to-event outcome for long-term mortality was extracted as hazard ratios, along with their variance. Statistical pooling of survival (time-to-event) was performed according to a random effect model, computing risk estimates with 95% confidence intervals. RESULTS Eight propensity score-matched studies reporting on 10 287 matched patients (2-arterial graft: 5346; 3-arterial graft: 4941) were selected for final comparison. The mean follow-up time ranged from 37.2 to 196.8 months. The use of 3 arterial grafts was not statistically associated with early mortality (hazard ratio, 0.93; 95% confidence interval, 0.71-1.22; P=0.62). The use of 3 arterial grafts was associated with statistically significantly lower hazard for late death (hazard ratio, 0.8; 95% confidence interval, 0.75-0.87; P<0.001), irrespective of sex and diabetic mellitus status. This result was qualitatively similar in the unmatched population (hazard ratio, 0.57; 95% confidence interval, 0.33-0.98; P=0.04). CONCLUSIONS The use of a third arterial conduit in patients with coronary artery bypass grafting is not associated with higher operative risk and is associated with superior long-term survival, irrespective of sex and diabetic mellitus status.
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Affiliation(s)
- Mario Gaudino
- From Department of Cardio-Thoracic Surgery, Weill Cornell Medicine, New York, NY (M.G., A.D.F., L.B.O., L.N.G.); Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.D.P.); Città della Scienza e della Salute, Department of Cardiology, University of Turin, Italy (M.I., U.B., F.D., F.G.); Division of Cardiac Surgery, University of Ottawa Heart Institute, Ontario, Canada (D.G., J.B.G.); Bristol Heart Institute, University of Bristol, UK (U.B.); and Department of Cardiac Surgery, John Radcliffe Hospital, University of Oxford, UK (D.P.T.).
| | - John D Puskas
- From Department of Cardio-Thoracic Surgery, Weill Cornell Medicine, New York, NY (M.G., A.D.F., L.B.O., L.N.G.); Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.D.P.); Città della Scienza e della Salute, Department of Cardiology, University of Turin, Italy (M.I., U.B., F.D., F.G.); Division of Cardiac Surgery, University of Ottawa Heart Institute, Ontario, Canada (D.G., J.B.G.); Bristol Heart Institute, University of Bristol, UK (U.B.); and Department of Cardiac Surgery, John Radcliffe Hospital, University of Oxford, UK (D.P.T.)
| | - Antonino Di Franco
- From Department of Cardio-Thoracic Surgery, Weill Cornell Medicine, New York, NY (M.G., A.D.F., L.B.O., L.N.G.); Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.D.P.); Città della Scienza e della Salute, Department of Cardiology, University of Turin, Italy (M.I., U.B., F.D., F.G.); Division of Cardiac Surgery, University of Ottawa Heart Institute, Ontario, Canada (D.G., J.B.G.); Bristol Heart Institute, University of Bristol, UK (U.B.); and Department of Cardiac Surgery, John Radcliffe Hospital, University of Oxford, UK (D.P.T.)
| | - Lucas B Ohmes
- From Department of Cardio-Thoracic Surgery, Weill Cornell Medicine, New York, NY (M.G., A.D.F., L.B.O., L.N.G.); Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.D.P.); Città della Scienza e della Salute, Department of Cardiology, University of Turin, Italy (M.I., U.B., F.D., F.G.); Division of Cardiac Surgery, University of Ottawa Heart Institute, Ontario, Canada (D.G., J.B.G.); Bristol Heart Institute, University of Bristol, UK (U.B.); and Department of Cardiac Surgery, John Radcliffe Hospital, University of Oxford, UK (D.P.T.)
| | - Mario Iannaccone
- From Department of Cardio-Thoracic Surgery, Weill Cornell Medicine, New York, NY (M.G., A.D.F., L.B.O., L.N.G.); Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.D.P.); Città della Scienza e della Salute, Department of Cardiology, University of Turin, Italy (M.I., U.B., F.D., F.G.); Division of Cardiac Surgery, University of Ottawa Heart Institute, Ontario, Canada (D.G., J.B.G.); Bristol Heart Institute, University of Bristol, UK (U.B.); and Department of Cardiac Surgery, John Radcliffe Hospital, University of Oxford, UK (D.P.T.)
| | - Umberto Barbero
- From Department of Cardio-Thoracic Surgery, Weill Cornell Medicine, New York, NY (M.G., A.D.F., L.B.O., L.N.G.); Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.D.P.); Città della Scienza e della Salute, Department of Cardiology, University of Turin, Italy (M.I., U.B., F.D., F.G.); Division of Cardiac Surgery, University of Ottawa Heart Institute, Ontario, Canada (D.G., J.B.G.); Bristol Heart Institute, University of Bristol, UK (U.B.); and Department of Cardiac Surgery, John Radcliffe Hospital, University of Oxford, UK (D.P.T.)
| | - David Glineur
- From Department of Cardio-Thoracic Surgery, Weill Cornell Medicine, New York, NY (M.G., A.D.F., L.B.O., L.N.G.); Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.D.P.); Città della Scienza e della Salute, Department of Cardiology, University of Turin, Italy (M.I., U.B., F.D., F.G.); Division of Cardiac Surgery, University of Ottawa Heart Institute, Ontario, Canada (D.G., J.B.G.); Bristol Heart Institute, University of Bristol, UK (U.B.); and Department of Cardiac Surgery, John Radcliffe Hospital, University of Oxford, UK (D.P.T.)
| | - Juan B Grau
- From Department of Cardio-Thoracic Surgery, Weill Cornell Medicine, New York, NY (M.G., A.D.F., L.B.O., L.N.G.); Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.D.P.); Città della Scienza e della Salute, Department of Cardiology, University of Turin, Italy (M.I., U.B., F.D., F.G.); Division of Cardiac Surgery, University of Ottawa Heart Institute, Ontario, Canada (D.G., J.B.G.); Bristol Heart Institute, University of Bristol, UK (U.B.); and Department of Cardiac Surgery, John Radcliffe Hospital, University of Oxford, UK (D.P.T.)
| | - Umberto Benedetto
- From Department of Cardio-Thoracic Surgery, Weill Cornell Medicine, New York, NY (M.G., A.D.F., L.B.O., L.N.G.); Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.D.P.); Città della Scienza e della Salute, Department of Cardiology, University of Turin, Italy (M.I., U.B., F.D., F.G.); Division of Cardiac Surgery, University of Ottawa Heart Institute, Ontario, Canada (D.G., J.B.G.); Bristol Heart Institute, University of Bristol, UK (U.B.); and Department of Cardiac Surgery, John Radcliffe Hospital, University of Oxford, UK (D.P.T.)
| | - Fabrizio D'Ascenzo
- From Department of Cardio-Thoracic Surgery, Weill Cornell Medicine, New York, NY (M.G., A.D.F., L.B.O., L.N.G.); Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.D.P.); Città della Scienza e della Salute, Department of Cardiology, University of Turin, Italy (M.I., U.B., F.D., F.G.); Division of Cardiac Surgery, University of Ottawa Heart Institute, Ontario, Canada (D.G., J.B.G.); Bristol Heart Institute, University of Bristol, UK (U.B.); and Department of Cardiac Surgery, John Radcliffe Hospital, University of Oxford, UK (D.P.T.)
| | - Fiorenzo Gaita
- From Department of Cardio-Thoracic Surgery, Weill Cornell Medicine, New York, NY (M.G., A.D.F., L.B.O., L.N.G.); Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.D.P.); Città della Scienza e della Salute, Department of Cardiology, University of Turin, Italy (M.I., U.B., F.D., F.G.); Division of Cardiac Surgery, University of Ottawa Heart Institute, Ontario, Canada (D.G., J.B.G.); Bristol Heart Institute, University of Bristol, UK (U.B.); and Department of Cardiac Surgery, John Radcliffe Hospital, University of Oxford, UK (D.P.T.)
| | - Leonard N Girardi
- From Department of Cardio-Thoracic Surgery, Weill Cornell Medicine, New York, NY (M.G., A.D.F., L.B.O., L.N.G.); Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.D.P.); Città della Scienza e della Salute, Department of Cardiology, University of Turin, Italy (M.I., U.B., F.D., F.G.); Division of Cardiac Surgery, University of Ottawa Heart Institute, Ontario, Canada (D.G., J.B.G.); Bristol Heart Institute, University of Bristol, UK (U.B.); and Department of Cardiac Surgery, John Radcliffe Hospital, University of Oxford, UK (D.P.T.)
| | - David P Taggart
- From Department of Cardio-Thoracic Surgery, Weill Cornell Medicine, New York, NY (M.G., A.D.F., L.B.O., L.N.G.); Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.D.P.); Città della Scienza e della Salute, Department of Cardiology, University of Turin, Italy (M.I., U.B., F.D., F.G.); Division of Cardiac Surgery, University of Ottawa Heart Institute, Ontario, Canada (D.G., J.B.G.); Bristol Heart Institute, University of Bristol, UK (U.B.); and Department of Cardiac Surgery, John Radcliffe Hospital, University of Oxford, UK (D.P.T.)
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Benedetto U, Caputo M, Zakkar M, Bryan A, Angelini GD. Are three arteries better than two? Impact of using the radial artery in addition to bilateral internal thoracic artery grafting on long-term survival. J Thorac Cardiovasc Surg 2016; 152:862-869.e2. [DOI: 10.1016/j.jtcvs.2016.04.054] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 04/11/2016] [Accepted: 04/19/2016] [Indexed: 11/26/2022]
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Kolh P, Kurlansky P, Cremer J, Lawton J, Siepe M, Fremes S. Transatlantic Editorial: A Comparison Between European and North American Guidelines on Myocardial Revascularization. Ann Thorac Surg 2016; 101:2031-44. [PMID: 27139371 DOI: 10.1016/j.athoracsur.2016.02.062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 02/18/2016] [Accepted: 02/18/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Philippe Kolh
- Cardiovascular Surgery Department, University Hospital (CHU, ULg) of Liège, Liège, Belgium.
| | - Paul Kurlansky
- Center for Innovation and Outcomes Research, Columbia University, New York, New York
| | - Jochen Cremer
- Cardiovascular Surgery Department, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Jennifer Lawton
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Matthias Siepe
- Department of Cardiovascular Surgery, University Heart Centre Freiburg Bad Krozingen, Bad Krozingen, Germany
| | - Stephen Fremes
- Division of Cardiac Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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Kolh P, Kurlansky P, Cremer J, Lawton J, Siepe M, Fremes S. Transatlantic editorial: A comparison between European and North American guidelines on myocardial revascularization. J Thorac Cardiovasc Surg 2016; 152:304-16. [PMID: 27158134 DOI: 10.1016/j.jtcvs.2016.04.053] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- Philippe Kolh
- Cardiovascular Surgery Department, University Hospital (CHU, ULg) of Liège, Liège, Belgium.
| | - Paul Kurlansky
- Center for Innovation and Outcomes Research, Columbia University, New York, NY
| | - Jochen Cremer
- Cardiovascular Surgery Department, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Jennifer Lawton
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Mo
| | - Matthias Siepe
- Department of Cardiovascular Surgery, University Heart Centre Freiburg Bad Krozingen, Bad Krozingen, Germany
| | - Stephen Fremes
- Division of Cardiac Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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Kolh P, Kurlansky P, Cremer J, Lawton J, Siepe M, Fremes S. Transatlantic Editorial: a comparison between European and North American guidelines on myocardial revascularization. Eur J Cardiothorac Surg 2016; 49:1307-17. [DOI: 10.1093/ejcts/ezw086] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Kurlansky P. Multiple arterial grafting for coronary revascularization: "A guide for the perplexed". Trends Cardiovasc Med 2016; 26:616-23. [PMID: 27180277 DOI: 10.1016/j.tcm.2016.04.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Accepted: 04/08/2016] [Indexed: 10/21/2022]
Abstract
The surgical literature abounds with articles extolling the benefits of arterial grafting for patients with advanced coronary artery disease in need of surgical revascularization. However, examination of clinical performance demonstrates that extensive use of arterial grafting is highly selective and generally uncommon. Rather than to merely repeat multiple excellent recent literature reviews, the goal herein is to provide the reader with a guide to the evaluation of the current literature as well as to suggest fruitful areas for further research. More circumspect understanding of the strengths and weaknesses of our current knowledge base will not only help to explain the current apparent disparity between theory and practice but will hopefully inform future decision-making and patient care.
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Affiliation(s)
- Paul Kurlansky
- Department of Surgery, Columbia University, New York, NY.
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Is a third arterial conduit necessary? Comparison of the radial artery and saphenous vein in patients receiving bilateral internal thoracic arteries for triple vessel coronary disease. Eur J Cardiothorac Surg 2016; 50:53-60. [DOI: 10.1093/ejcts/ezv467] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Accepted: 12/04/2015] [Indexed: 11/14/2022] Open
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Sousa Uva M, Kolh P. The radial artery for coronary artery bypass grafting: a second revival? Eur J Cardiothorac Surg 2015; 49:210-1. [PMID: 26286443 DOI: 10.1093/ejcts/ezv283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Miguel Sousa Uva
- Department of Cardiothoracic Surgery, Hospital da Cruz Vermelha, Lisbon, Portugal
| | - Philippe Kolh
- Department of Cardiovascular Surgery, University Hospital (CHU, ULg) of Liège, CHU Sart Tilman, Liège, Belgium
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