Total arterial revascularization strategies: A meta-analysis of propensity score-matched observational studies

Trends in utilization and clinical outcomes with and without the use of distal filter wire embolic protection devices

BACKGROUND

Embolic protection devices were developed to reduce the risk of common complications encountered during percutaneous coronary intervention (PCI) of saphenous vein grafts, however, in the setting of contemporary multi-modality medical management, their overall efficacy has been called into question. This study aimed to assess the evolving utilization and clinical outcomes associated with distal filter wire embolic protection devices in saphenous vein PCI.

METHODS

Consecutive patients undergoing PCI to a saphenous vein graft in a registry were included. Peri-procedural and long-term outcomes including 12-month mortality and 30-day MACCE rates were compared between PCI using a distal filter wire embolic protection device and unprotected PCI.

RESULTS

From 2005 to 2020, a total of 753 patients underwent PCI to a saphenous vein graft with 256 using a distal filter wire embolic protection device. At one year, the use of a distal filter wire embolic protection devices was not associated with a decrease in mortality (4.7 % vs 5.4 %, p = 0.19) and there was no difference in 30-day MACCE rates between protected and unprotected saphenous vein PCI (3.1 % vs 5.8 %, p = 0.10).

CONCLUSION

In this 12-month analysis of saphenous vein graft PCI, there was no evidence that distal filter wire embolic protection devices improved short term post procedural or long-term mortality outcomes.

Left ventricular recovery after total arterial coronary artery bypass grafting versus conventional coronary artery bypass grafting in patients with multivessel coronary artery disease and reduced left ventricular ejection fraction

BACKGROUND

We compared total arterial revascularization (TAR) versus conventional revascularization (CR) in terms of left ventricular function recovery in patients with multivessel coronary artery disease (CAD) and reduced left ventricular ejection fraction (LVEF).

METHODS

We conducted a retrospective cohort study of 162 consecutive patients with multivessel CAD and reduced LVEF who underwent isolated coronary artery bypass grafting at our institution between January 2013 and July 2022. We assessed left ventricular function by transthoracic echocardiography at admission, before discharge, and at follow-up of 3, 6, and 12 months, using LVEF, global longitudinal peak strain, end-diastolic volume index, and end-systolic volume index. We also evaluated mitral valve regurgitation and graft patency rate at 1 year.

RESULTS

The TAR group had a significantly higher increase in LVEF and global longitudinal peak strain, and a significantly lower decrease in end-diastolic volume index and end-systolic volume index than the CR group at 6 and 12 months after surgery. The TAR group also had a significantly lower degree of mitral valve regurgitation than the CR group at all-time points within 12 months after surgery. The TAR group had a significantly higher graft patency rate than the CR group at 12 months. There was no significant difference in hospital mortality or repeat revascularization between the groups.

CONCLUSIONS

TAR was associated with better recovery of left ventricular function than CR in patients with multivessel CAD and reduced LVEF. Further studies are needed to confirm these findings in this high-risk population.

A Single-Surgeon Experience Transitioning to Total Arterial Revascularization

Background: Coronary artery bypass grafting remains the standard of care for advanced and multifocal coronary artery disease; however, for patients that are surgical candidates, total arterial revascularization (TAR) remains underutilized due to concerns such as sternal wound infections and the learning curve. We present the results of a large cohort of mid-career surgeons transitioning to TAR, focusing on short-term outcomes and the learning curve. Methods: The surgeons transitioned to using TAR as the preferred revascularization technique in August of 2017. The Society of Thoracic Surgeons database was reviewed to identify all patients who underwent isolated non-emergent CABG performed by a single surgeon from January 2014 through January 2022. Patients were divided into two groups-those who had TAR and those who had traditional CABG using one internal mammary artery and vein grafts (IMA-SVG). Results: Eight hundred ninety-eight patients meet inclusion criteria (458 IMA-SVG and 440 TAR). The TAR group had slightly longer cardiopulmonary bypass time, cross clamp times, and operative times (all p < 0.05); however, ICU stay was shorter and 30-day readmission rate was lower for TAR compared to IMA-SVG (all p < 0.05). The TAR group also required fewer postoperative transfusions (p = 0.005). There was no difference in prolonged intubation, stroke, length of stay, mortality, or sternal wound complications between groups (all p > 0.05). The average TAR was 30 min longer; however, learning curves, stratified by number of grafts placed, showed no significant learning curve associated with TAR. Conclusions: An experienced surgeon transitioning from IMA-SVG to TAR slightly increases operative time, but decreases ICU stay, readmissions, and postoperative transfusions with no significant difference in rates of immediate post-operative complications or 30-day mortality, with a minimal learning curve.

Application of the radial artery after angiography in patients undergoing total arterial coronary revascularization

OBJECTIVE

There is growing evidence supporting the utilization of the radial artery as a secondary arterial graft in coronary artery bypass grafting (CABG) surgery. However, debates continue over the recovery period of the radial artery following angiography. This study aims to evaluate the clinical outcomes and experiences related to the use of the radial artery post-angiography in total arterial coronary revascularization.

METHODS

A retrospective analysis was performed on data from patients who underwent total arterial CABG surgery at the University of Hong Kong Shenzhen Hospital from July 1, 2020, to September 30, 2022. Preoperative assessments included ultrasound evaluations of radial artery blood flow, diameter, intimal integrity, and the Allen test. Additionally, pathological examinations of the distal radial artery and coronary artery CT angiography were conducted, along with postoperative follow-up to assess the safety and efficacy of using the radial artery in patients undergoing total arterial CABG.

RESULTS

A total of 117 patients, compromising 102 males and 15 females with an average age of 60.0 ± 10.0 years, underwent total arterial CABG. The internal mammary artery was used in situ in 108 cases, while in 4 cases, it was grafted to the ascending aorta due to length limitations. Bilateral radial arteries were utilized in 88 patients, and bilateral internal mammary arteries in 4 patients. Anastomoses of the proximal radial arteries to the proximal ascending aorta included 42 cases using distal T-anastomosis and 4 using sequential grafts. The interval between bypass surgery and coronary angiography ranged from 7 to 14 days. Pathological examination revealed intact intima and continuous elastic membranes with no significant inflammatory infiltration or hyperplastic lumen stenosis in the radial arteries. There were no hospital deaths, 3 cases of perioperative cerebral infarction, 1 secondary thoracotomy for hemorrhage control, 21 instances of intra-aortic balloon pump (IABP) assistance, and 2 cases of poor wound healing that improved following debridement. CT angiography performed 2 weeks post-surgery showed no internal mammary artery occlusions, but 4 radial artery occlusions were noted.

CONCLUSION

Ultrasound may be used within 2 weeks post-angiography to assess the recovery of the radial artery in some patients. Radial arteries with intact intima may be considered in conjunction with the internal mammary artery for total arterial coronary CABG. However, long-term outcomes of these grafts require further validation through larger prospective studies.

Bilateral internal thoracic artery versus single internal thoracic artery plus radial artery: A double meta-analytic approach

OBJECTIVES

We explored the current evidence on the best second conduit in coronary surgery carrying out a double meta-analysis of propensity score matched or adjusted studies comparing bilateral internal thoracic artery (BITA) versus single internal thoracic artery plus radial artery.

METHODS

PubMed, Embase, and Google Scholar were searched for propensity score matched or adjusted studies comparing BITA versus single internal thoracic artery plus radial artery. The end point was long-term mortality. Two statistical approaches were used: the generic inverse variance method and the pooled meta-analysis of Kaplan-Meier-derived individual patient data.

RESULTS

Twelve matched populations comparing 6450 patients with BITA versus 9428 patients with single internal thoracic artery plus radial artery were included in our meta-analysis. The generic inverse variance method showed a statistically significant survival benefit of the BITA group (hazard ratio, 0.84; 95% CI, 0.74-0.95; P = .04). The Kaplan-Meier estimates of survival at 1, 5, 10, and 15 years of the BITA group were 97.0%, 91.3%, 80.0%, and 68.0%, respectively. The Kaplan-Meier estimates of survival at 1, 5, 10, and 15 years of the single internal thoracic artery plus radial artery group were 97.3%, 91.5%, 79.9%, and 63.9%, respectively. The Kaplan-Meier-derived individual patient data meta-analysis applied to very long follow-up time data, showed that BITA provided a survival benefit after 10 years from surgery (hazard ratio, 0.77; 95% CI, 0.63-0.94; P = .01). No differences in terms of survival between the 2 groups were detected when the analysis was focused on the first 10 years of follow-up (hazard ratio, 0.99; 95% CI, 0.91-1.09; P = .93).

CONCLUSIONS

The present meta-analysis suggests that double internal thoracic artery may provide, compared with single internal thoracic artery plus radial artery, a statistically significant survival advantage after 10 years of follow-up, but not before. VIDEO ABSTRACT.

Late Clinical Outcomes of Total Arterial Revascularization or Multiple Arterial Grafting Compared to Conventional Single Arterial with Saphenous Vein Grafting for Coronary Surgery

Coronary surgery provides better long-term outcomes than percutaneous coronary intervention. Conventional practice is to use a single arterial conduit supplemented by saphenous vein grafts. The use of multiple arterial revascularization (MAG), or exclusive arterial revascularization (TAR), however, is reported as having improved late survival. Survival is a surrogate for graft failure that may lead to premature death, and improved survival reflects fewer graft failures in the non-conventional strategy groups. The reasons for not using MAG or TAR may be due to perceived technical difficulties, a lack of definitive large-scale randomized evidence, a lack of confidence in arterial conduits, or resources or time constraints. Most people consider radial artery (RA) grafting to be new, with use representing approximately 2-5% worldwide, despite select centers reporting routine use in most patients for decades with improved results. In conclusion, the current body of evidence supports more extensive use of total and multiple arterial revascularization procedures in the absence of contraindications.

Is it safe to perform total arterial grafting in elderly patients lacking vein grafts? A single surgeon comparison

OBJECTIVES

The results of coronary artery bypass graft (CABG) surgery with total arterial revascularisation (TA-CABG) in elderly patients, who may have insufficient vein graft material for conventional CABG (CO-CABG), have not been fully established. We therefore sought to compare the short- and long-term outcomes of patients >70 years old undergoing CO-CABG and TA-CABG.

METHODS

We performed a retrospective observational study analyzing all consecutive adult patients aged >70 years undergoing first-time CABG over the 15-year period from 2004 to 2020 under a single surgeon. Primary outcomes of interest were in-hospital mortality, long-term mortality, and re-intervention rate. Secondary outcomes of interest included operative durations and the incidence of peri-operative complications.

RESULTS

There were 46 patients (age 76 ± 3 SD) in the TA-CABG group and 145 patients (age 76 ± 4 SD) in the CO-CABG group. Cardio-pulmonary bypass and cross-clamp durations were comparable between groups (p = .11 and p = .23, respectively). Stroke occurred in 1.0% undergoing CO-CABG compared to 0% in the TA-CABG group (p = .42). Hospital mortality was 3.0% with CO-CABG (EuroSCORE; mean [SD] 6.81 (5.81)) and 2.0% with TA-CABG (EuroSCORE; mean [SD] 6.38 (6.57)) (p = .93). On long-term follow-up, myocardial infarction occurred in 10.0% of CO-CABG patients compared to 4.0% of TA-CABG patients (p = .25). Re-intervention rates were 7% following CO-CABG, and 2% after TA-CABG (p = .23). There was no significant difference in long-term mortality between patients undergoing CO-CABG and TA-CABG (47% vs. 57%, p = .27). Long-term survival was comparable between grafting techniques (p = .27).

CONCLUSIONS

There were no significant differences in major adverse cardiac and cerebrovascular events, re-intervention rate, hospital or long-term mortality between CO-CABG and TA-CABG. TA-CABG represents a safe and feasible alternative to CO-CABG in elderly patients offering good long-term outcomes.

A Partially Randomized Patient Preference Trial to Assess the Quality of Life and Patency Rate After Minimally Invasive Cardiac Surgery-Coronary Artery Bypass Grafting: Design and Rationale of the MICS-CABG PRPP Trial

Background

Minimally invasive cardiac surgery-coronary artery bypass grafting (MICS-CABG) has emerged as a safe alternative to standard cardiac surgery. However, treatment preferences can decrease the generalizability of RCT results to the clinical population (i.e., reduce external validity) and influence adherence to the treatment protocol and study outcomes (i.e., reduce internal validity). However, this has not yet been properly investigated in randomized trials with consideration of treatment preferences.

Study Design

In this study, patients with a preference will be allocated to treatment strategies accordingly, whereas only those patients without a distinct preference will be randomized. The randomized trial is a 248-patient controlled, randomized, investigator-blinded trial. It is designed to compare whether treatment with MICS-CABG is beneficial in comparison to CABG. This study is aimed to establish the superiority hypothesis for the physical component summary (PCS) accompanied by the non-inferiority hypothesis for overall graft patency. Patients with no treatment preference will be randomized in a 1:1 fashion to one of the two treatment arms. The primary efficacy endpoints are the PCS score at 30 days after surgery and the overall patency rate of the grafts within 14 days after surgery. Secondary outcome measures include the PCS score and patency rate at different time points. Safety endpoints include major adverse cardiac and cerebrovascular events, complications, bleeding, wound infection, death, etc.

Conclusions

This trial will address essential questions of the efficacy and safety of MICS-CABG. The study will also address the impact of patients' preferences on external validity and internal validity.

Percutaneous Coronary Intervention with Stenting versus Coronary Artery Bypass Grafting in Stable Coronary Artery Disease

The debate over coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) with stent placement for the treatment of stable multivessel coronary artery disease (CAD) continues in spite of numerous studies investigating the issue. This paper reviews the most recent randomized control trials (RCT) and meta-analyses of pooled RCT data to help address this issue. General trends demonstrated that CABG was superior in all-cause mortality and fulfilling the need for repeat revascularization. These advantages tended to be more pronounced in multivessel CAD and diabetes, and less so in left main CAD. PCI showed a consistently lower rate of cerebrovascular events. CABG continues to offer significant advantages over PCI, even as drug-eluting stent technology continues to evolve. The ideal endpoint for comparing PCI and CABG remains to be determined. Furthermore, additional research is required to further refine patient selection criteria for each intervention.

Survival effect of radial artery usage in addition to bilateral internal thoracic arterial grafting: A meta-analysis

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.