Radial artery vs. internal thoracic artery or saphenous vein grafts: 15-year results of the RAPCO trials

Ultrasound Guidance for Transradial Access in the Cardiac Catheterisation Laboratory: A Systematic Review of the Literature and Meta-Analysis

BACKGROUND

Although ultrasound (US) guidance for vascular access has been widely adopted, its use for transradial access (TRA) in the cardiac catheterisation laboratory is rare. There is a perception that US guidance does not offer a clinically relevant benefit over traditional palpation-guided TRA, amplified by inconsistent findings of individual studies.

METHOD

A systematic review of MEDLINE, EMBASE and the Cochrane Library identified studies comparing US to palpation-guided TRA for cardiac catheterisation. Studies evaluating radial artery (RA) cannulation for any other reason were excluded. Event rates and risk ratios (RRs) were pooled for meta-analysis. Access failure was the primary outcome. A random-effects model was used for analysis.

RESULTS

Of the 977 records screened, four studies with a total of 1,718 patients (861 US-guided and 864 palpation-guided procedures) were included in the meta-analysis. Most procedures were elective. The pooled analysis showed US guidance significantly lowered the risk of access failure (RR 0.45; 95% confidence interval [CI] 0.21-0.97; p=0.04). Heterogeneity was moderate (I2=51.2%; p=0.105). There was a strong trend to improved first-pass success with US (RR 1.29; 95% CI 1.00-1.66; p=0.05; I2=83.8%), although no differences were found in rates of difficult access (RR 0.29; 95% CI 0.07-1.18; p=0.09; I2=88.3%). Salvage US guidance was successful in 30/41 (73.2%) patients following failed palpation-guided TRA. No differences were found in already low complication rates including RA spasm (RR 1.18; 95% CI 0.70-1.99; p=0.53; I2=0.0%) and bleeding (RR 1.32; 95% CI 0.46-3.80; p=0.60; I2=0.0%).

CONCLUSIONS

US guidance was found to improve TRA success in the cardiac catheterisation laboratory. Further investigation is necessary to determine whether routine, selective, or salvage use of US confers the most RA protection, patient satisfaction, and overall clinical benefit. (PROSPERO registration: CRD42022332238).

Late results of chord transfer and other techniques for anterior leaflet repair without neochords

OBJECTIVE

Anterior and bileaflet degenerative mitral regurgitation repairs are challenging. We examined our early and late outcomes for repair using 4 techniques, without neochord repair.

METHODS

Between February 1, 2006, and June 30, 2021, a total of 2368 patients received mitral valve ± other surgery by 1 surgeon, including 1160 with degenerative mitral regurgitation. Clinical follow-up was conducted annually (mean 6.8 ± 4.4 years).

RESULTS

Repair was performed in 1137 patients (98%) (mean age, 60.5 ± 11.9 years). Repair rate varied between groups: 99% for isolated posterior leaflet (794/799), 91% for isolated anterior leaflet (83/91), and 96% for bileaflet prolapse (260/270; P < .001). Thirty-day mortality was 0.2%. On a scale of 0 to 4+ mitral regurgitation, mean mitral regurgitation grade decreased from 3.8 ± 0.6 preoperatively to 0.07 ± 0.3 at discharge, including moderate (2+) in 0.6% (7/1137) overall and 0.9% (3/343) with anterior prolapse. None were more than 2+ at discharge. Among the 3 groups of leaflet prolapse, there was no significant difference in long-term survival (P = .26), freedom from mitral valve reintervention (P = .12; 99.4% overall), and freedom from more than moderate (2+) mitral regurgitation (P = .16; 98.3% overall). The 4 most common anterior leaflet repair techniques (chord transfer 17%; commissuroplasty 10%; Alfieri [edge-to-edge] 6%); ring with posterior resection (4.3%) had similar freedom from 10-year reintervention (99.4%, 94%, 100%, and 100%, respectively; P = .29).

CONCLUSIONS

Complex anterior leaflet prolapse repairs are successful using a variety of techniques without neochord implantation. Although neochords are popular, there are other ways to repair complex valves that do not require as much judgment and experience.

Quality improvement initiative to increase radial artery usage as a second arterial conduit in coronary artery bypass grafting

OBJECTIVES

Use of radial artery as a second arterial graft, compared to a saphenous vein, in coronary artery bypass grafting (CABG) can improve late outcomes. However, the radial artery remains underutilized. We initiated a quality improvement (QI) initiative to increase the usage of radial artery grafts.

METHODS

During our 4-month lead period, we disseminated evidence for radial artery graft usage to surgeons, developed a radial artery decision-making algorithm and adopted endoscopic harvesting. Our QI initiative was conducted over a 6-month period and included a postoperative survey of decision-making for graft selection and obstacles to radial artery usage.

RESULTS

Over the 6-month study period, 247 patients received isolated CABG which included 98 (40%) with radial arteries as a second arterial graft and 144 (58%) with greater saphenous veins. Radial artery usage increased with QI initiative implementation by 67% compared to 6 months prior to the study period (60 radial arteries/252 isolated CABG, 24%) (P = 0.006). The survey response rate was 93% (231/247). Barriers to radial artery graft usage were poor quality target vessel or stenosis <80% (24%), patient age >75 years (20%), ejection fraction ≤35% (8%) and renal insufficiency/dialysis (7%). No patients experienced significant complications from radial artery harvest.

CONCLUSIONS

Our institutional QI initiative was successful in (i) increasing the usage of radial artery as a second arterial graft and (ii) understanding barriers to radial artery graft usage. Implementation of a QI program can improve radial artery usage in CABG with low risk of patient morbidity from radial artery harvest.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Coronary Artery Bypass Surgery: Evidence-Based Practice

Coronary artery bypass graft (CABG) surgery remains a pivotal cornerstone, offering established symptomatic alleviation and prognostic advantages for patients grappling with complex multivessel and left main coronary artery diseases. Despite the lucid guidance laid out by contemporary guidelines regarding the choice between CABG and percutaneous coronary intervention (PCI), a notable hesitation persists among certain patients, characterized by psychological reservations, knowledge gaps, or individual beliefs that sway their inclination toward surgical intervention. This comprehensive review critically synthesizes the prevailing guidelines, modern practices, and outcomes pertaining to CABG surgery, delving into an array of techniques and advancements poised to enhance both short-term and enduring surgical outcomes. The exploration encompasses advances in on-pump and off-pump procedures, conduit selection strategies encompassing the bilateral utilization of internal mammary artery and radial artery conduits, meticulous graft evaluation methodologies, and the panorama of minimally invasive approaches, including those assisted by robotic technology. Furthermore, the review navigates the terrain of hybrid coronary revascularization, shedding light on the pivotal roles of shared decision-making and the heart team in shaping treatment pathways. As a comprehensive compendium, this review not only navigates the intricate landscape of CABG surgery but also aligns it with contemporary practices, envisioning its trajectory within the evolving currents of healthcare dynamics.

The Feasibility and Early Results of Multivessel Minimally Invasive Coronary Artery Bypass Grafting for All Comers

OBJECTIVES

Cardiovascular surgery advancements have emerged with various minimally invasive approaches for treating multivessel coronary disease to improve outcomes and minimize the burden associated with conventional cardiac surgery. We present our clinical experience and minimally invasive coronary bypass techniques through minithoracotomy, which we apply without selection to patients who have decided to have elective surgery for multivessel isolated coronary artery disease.

METHODS

It consists of 230 consecutive patients operated by the same team with this method between July 2020 and September 2022. The patients were assigned to one of the two methods preoperatively to their accompanying comorbidities and operated on either with blood cardioplegia via 5 to 7 cm left anterior minithoracotomy, with on-pump clamped technique or without pump via left anterolateral minithoracotomy.

RESULTS

Mortality was observed in two of our patients (0.9%), but myocardial infarction was not observed in our patients in the early postoperative period. None of our patients required conversion to sternotomy (0%). Five patients' needed reoperation from the same incision due to postoperative bleeding (2.2%), and atrial fibrillation developed in 17 patients in the postoperative period (7.4%). The mean number of bypasses was found to be 3.0 ± 0.9.

CONCLUSIONS

Minimally invasive coronary artery bypass surgery via minithoracotomy can be routinely reproduced safely. More long-term results and more multicenter studies are needed for more widespread acceptance of the technique.