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Gaudino MFL, Sandner S, Bonalumi G, Lawton JS, Fremes SE. How to build a multi-arterial coronary artery bypass programme: a stepwise approach. Eur J Cardiothorac Surg 2021; 58:1111-1117. [PMID: 33247735 DOI: 10.1093/ejcts/ezaa377] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 09/03/2020] [Accepted: 09/11/2020] [Indexed: 02/07/2023] Open
Abstract
Observational evidence shows that the use of multiple arterial grafts (MAG) is associated with longer postoperative survival and improved clinical outcomes. The current European Society of Cardiology/European Association for Cardio-Thoracic Surgery Guidelines on myocardial revascularization recommend the use of MAG in appropriate patients. However, a significant volume-to-outcome relationship exists for MAG, and lack of sufficient experience is associated with increased operative risk. A stepwise approach to building experience with MAG allows successful implementation of this technique into routine coronary surgery practice.
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Affiliation(s)
- Mario F L Gaudino
- Department of Cardiothoracic Surgery, Weill-Cornell Medical College, New York - Presbyterian Hospital, New York, NY, USA
| | - Sigrid Sandner
- Division of Cardiac Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Giorgia Bonalumi
- Department of Cardiovascular Surgery, Centro Cardiologico Monzino-IRCCS, Milan, Italy
| | - Jennifer S Lawton
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Stephen E Fremes
- Division of Cardiac Surgery, Department of Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
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2
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Gaudino M, Hameed I, Robinson NB, Ruan Y, Rahouma M, Naik A, Weidenmann V, Demetres M, Y Tam D, Hare DL, Girardi LN, Biondi-Zoccai G, E Fremes S. Angiographic Patency of Coronary Artery Bypass Conduits: A Network Meta-Analysis of Randomized Trials. J Am Heart Assoc 2021; 10:e019206. [PMID: 33686866 PMCID: PMC8174193 DOI: 10.1161/jaha.120.019206] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background Several randomized trials have compared the patency of coronary artery bypass conduits. All of the published studies, however, have performed pairwise comparisons and a comprehensive evaluation of the patency rates of all conduits has yet to be published. We set out to investigate the angiographic patency rates of all conduits used in coronary bypass surgery by performing a network meta-analysis of the current available randomized evidence. Methods and Results A systematic literature search was conducted for randomized controlled trials comparing the angiographic patency rate of the conventionally harvested saphenous vein, the no-touch saphenous vein, the radial artery (RA), the right internal thoracic artery, or the gastroepiploic artery. The primary outcome was graft occlusion. A total of 4160 studies were retrieved of which 14 were included with 3651 grafts analyzed. The weighted mean angiographic follow-up was 5.1 years. Compared with the conventionally harvested saphenous vein, both the RA (incidence rate ratio [IRR] 0.54; 95% CI, 0.35-0.82) and the no-touch saphenous vein (IRR 0.55; 95% CI, 0.39-0.78) were associated with lower graft occlusion. The RA ranked as the best conduit (rank score for RA 0.87 versus 0.85 for no-touch saphenous vein, 0.23 for right internal thoracic artery, 0.29 for gastroepiploic artery, and 0.25 for the conventionally harvested saphenous vein). Conclusions Compared with the conventionally harvested saphenous vein, only the RA and no-touch saphenous vein grafts are associated with significantly lower graft occlusion rates. The RA ranks as the best conduit. Registration URL: https://www.crd.york.ac.uk/prospero; Unique identifier: CRD42020164492.
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Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery Weill Cornell Medicine New York NY
| | - Irbaz Hameed
- Department of Cardiothoracic Surgery Weill Cornell Medicine New York NY
| | - N Bryce Robinson
- Department of Cardiothoracic Surgery Weill Cornell Medicine New York NY
| | - Yongle Ruan
- Department of Cardiothoracic Surgery Weill Cornell Medicine New York NY
| | - Mohamed Rahouma
- Department of Cardiothoracic Surgery Weill Cornell Medicine New York NY
| | - Ajita Naik
- Department of Cardiothoracic Surgery Weill Cornell Medicine New York NY
| | - Viola Weidenmann
- Department of Cardiothoracic Surgery Weill Cornell Medicine New York NY
| | - Michelle Demetres
- Samuel J. Wood Library and C.V. Starr Biomedical Information Centre, Weill Cornell Medicine New York NY
| | - Derrick Y Tam
- Schulich Heart Centre Sunnybrook Health Science University of Toronto Toronto Ontario Canada
| | - David L Hare
- Department of Cardiology Austin Health Melbourne Australia
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery Weill Cornell Medicine New York NY
| | - Giuseppe Biondi-Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies Sapienza University Rome Italy.,Mediterranea Cardiocentro Naples Italy
| | - Stephen E Fremes
- Schulich Heart Centre Sunnybrook Health Science University of Toronto Toronto Ontario Canada
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Gaudino M, Benedetto U, Fremes S, Ballman K, Biondi-Zoccai G, Sedrakyan A, Nasso G, Raman J, Buxton B, Hayward PA, Moat N, Collins P, Webb C, Peric M, Petrovic I, Yoo KJ, Hameed I, Di Franco A, Moscarelli M, Speziale G, Puskas JD, Girardi LN, Hare DL, Taggart DP. Association of Radial Artery Graft vs Saphenous Vein Graft With Long-term Cardiovascular Outcomes Among Patients Undergoing Coronary Artery Bypass Grafting: A Systematic Review and Meta-analysis. JAMA 2020; 324:179-187. [PMID: 32662861 PMCID: PMC7361649 DOI: 10.1001/jama.2020.8228] [Citation(s) in RCA: 107] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
IMPORTANCE Observational studies have suggested that the use of radial artery grafts for coronary artery bypass grafting may improve clinical outcomes compared with the use of saphenous vein grafts, but this has not been confirmed in randomized trials. OBJECTIVE To compare clinical outcomes between patients receiving radial artery vs saphenous vein grafts for coronary artery bypass grafting after long-term follow-up. DESIGN, SETTING, AND PARTICIPANTS Patient-level pooled analysis comparing radial artery vs saphenous vein graft in adult patients undergoing isolated coronary artery bypass grafting from 5 countries (Australia, Italy, Serbia, South Korea, and the United Kingdom), with enrollment from 1997 to 2009 and follow-up completed in 2019. INTERVENTIONS Patients were randomized to undergo either radial artery (n = 534) or saphenous vein (n = 502) grafts for coronary artery bypass grafting. MAIN OUTCOMES AND MEASURES The primary outcome was a composite of death, myocardial infarction, or repeat revascularization and the secondary outcome was a composite of death or myocardial infarction. RESULTS A total of 1036 patients were randomized (mean age, 66.6 years in the radial artery group vs 67.1 years in the saphenous vein group; 376 [70.4%] men in the radial artery group vs 351 [69.9%] in the saphenous vein group); 942 (90.9%) of the originally randomized patients completed 10 years of follow-up (510 in the radial artery group). At a median (interquartile range) follow-up of 10 (10-11) years, the use of the radial artery, compared with the saphenous vein, in coronary artery bypass grafting was associated with a statistically significant reduction in the incidence of the composite outcome of death, myocardial infarction, or repeat revascularization (220 vs 237 total events; 41 vs 47 events per 1000 patient-years; hazard ratio, 0.73 [95% CI, 0.61-0.88]; P < .001) and of the composite of death or myocardial infarction (188 vs 193 total events; 35 vs 38 events per 1000 patient-years; hazard ratio, 0.77 [95% CI, 0.63-0.94]; P = .01). CONCLUSIONS AND RELEVANCE In this individual participant data meta-analysis with a median follow-up of 10 years, among patients undergoing coronary artery bypass grafting, the use of the radial artery compared with the saphenous vein was associated with a lower risk of a composite of cardiovascular outcomes.
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Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Umberto Benedetto
- Department of Cardiac Surgery, Bristol Heart Institute, Bristol, United Kingdom
| | - Stephen Fremes
- Department of Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Karla Ballman
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York
| | - Giuseppe Biondi-Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University, Rome, Italy
- Mediterranea Cardiocentro, Naples, Italy
| | - Art Sedrakyan
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York
| | - Giuseppe Nasso
- Cardiothoracic and Vascular Department, Maria Cecilia Hospital, GVM Care & Research, Cotignola (RA), Italy
| | - Jai Raman
- Austin Hospital, Melbourne, Victoria, Australia
- Department of Surgery, University of Melbourne, Melbourne, Victoria, Australia
| | - Brian Buxton
- Department of Surgery, University of Melbourne, Melbourne, Victoria, Australia
| | - Philip A. Hayward
- Department of Surgery, University of Melbourne, Melbourne, Victoria, Australia
| | - Neil Moat
- NHLI, Imperial College London, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | - Peter Collins
- NHLI, Imperial College London, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | - Carolyn Webb
- NHLI, Imperial College London, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | - Miodrag Peric
- Dedinje Cardiovascular Institute and Belgrade University School of Medicine, Belgrade, Serbia
| | - Ivana Petrovic
- Dedinje Cardiovascular Institute and Belgrade University School of Medicine, Belgrade, Serbia
| | - Kyung J. Yoo
- Yonsei University College of Medicine, Seoul, South Korea
| | - Irbaz Hameed
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Antonino Di Franco
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Marco Moscarelli
- Cardiothoracic and Vascular Department, Maria Cecilia Hospital, GVM Care & Research, Cotignola (RA), Italy
| | - Giuseppe Speziale
- Cardiothoracic and Vascular Department, Maria Cecilia Hospital, GVM Care & Research, Cotignola (RA), Italy
| | - John D. Puskas
- Department of Cardiovascular Surgery, Mount Sinai St. Luke's, New York, New York
| | - Leonard N. Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - David L. Hare
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
| | - David P. Taggart
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
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Bahar R, Dahl-Eriksen Ø, Busund R, Dahl PE, Hermansen SE, Iqbal A, Mannsverk JT, Myrmel T, Steigen TK, Trovik TS, Sørlie DG, Bartnes K. Direct angiography demonstrates equal 8-12 years patency rates of radial artery and saphenous vein grafts. SCAND CARDIOVASC J 2020; 54:330-335. [PMID: 32603197 DOI: 10.1080/14017431.2020.1784454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Objectives: The benefits of coronary artery bypass surgery depend on lasting graft patency. To aid rational graft selection, the relative long-term merits of radial artery and saphenous vein grafts need to be determined by a gold standard method and with minimal clinically driven selection bias. Methods: The patency rates of various conduits were determined by direct angiography in 76 patients from a cohort of 119 undergoing coronary artery bypass grafting 7.6-12.1 (mean 8.9) years before. Results: 14 out of 76 radial artery and 10 out of 61 saphenous vein grafts were occluded (rates 0.18 and 0.16, respectively). Conclusion: The high long-term patency rate of saphenous vein grafts does not support a preferential use of the radial artery as a coronary artery bypass conduit. Clinical registration number: ISRCTN23118170.
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Affiliation(s)
- Ramez Bahar
- Department of Cardiothoracic and Vascular Surgery, University Hospital North Norway, Tromsø, Norway
| | | | - Rolf Busund
- Department of Cardiothoracic and Vascular Surgery, University Hospital North Norway, Tromsø, Norway.,Institute of Clinical Medicine, University of Tromsø The Arctic University of Norway, Tromsø, Norway
| | - Per E Dahl
- Department of Cardiothoracic and Vascular Surgery, University Hospital North Norway, Tromsø, Norway
| | - Stig E Hermansen
- Department of Cardiothoracic and Vascular Surgery, University Hospital North Norway, Tromsø, Norway
| | - Amjid Iqbal
- Department of Cardiology, University Hospital North Norway, Tromsø, Norway
| | - Jan T Mannsverk
- Department of Cardiology, University Hospital North Norway, Tromsø, Norway
| | - Truls Myrmel
- Department of Cardiothoracic and Vascular Surgery, University Hospital North Norway, Tromsø, Norway.,Institute of Clinical Medicine, University of Tromsø The Arctic University of Norway, Tromsø, Norway
| | - Terje K Steigen
- Department of Cardiology, University Hospital North Norway, Tromsø, Norway.,Institute of Clinical Medicine, University of Tromsø The Arctic University of Norway, Tromsø, Norway
| | - Thor S Trovik
- Department of Cardiology, University Hospital North Norway, Tromsø, Norway
| | - Dag G Sørlie
- Department of Cardiothoracic and Vascular Surgery, University Hospital North Norway, Tromsø, Norway.,Institute of Clinical Medicine, University of Tromsø The Arctic University of Norway, Tromsø, Norway
| | - Kristian Bartnes
- Department of Cardiothoracic and Vascular Surgery, University Hospital North Norway, Tromsø, Norway.,Institute of Clinical Medicine, University of Tromsø The Arctic University of Norway, Tromsø, Norway
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