Early and late results of coronary revascularization with saphenous vein and internal mammary artery grafts

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Five hundred forty-seven consecutive coronary revascularizations for anginal syndromes and 72 combined with other procedures (valve replacement, myocardial resection, closure of septal rupture) were performed during a five year period beginning in January 1972. The 619 patients received 1,794 grafts; 208 had one or two internal mammary artery grafts (IMAG) into anterior coronary arteries with or without additional saphenous vein grafts (SVG), and 411 had SVGs only. A 99.5 per cent follow-up of eighteen to seventy-eight months (mean, 50 months) allows a balanced view of the merits and shortcomings of each conduit and an evaluation of long-term surgical results. Hospital mortality of 3.3 per cent (13 of 547) in revascularization alone included 9 deaths in 402 patients (2.2 per cent) with stable angina, 4 in 134 (3.0 per cent) with unstable angina, and 5 in 11 (45.0 per cent) with cardiogenic shock. Mortality and morbidity were similar with or without IMAGs. IMAG and SVG flows measured at operation were comparable, but one year patency was 97 per cent and 86 per cent, respectively ( p < 0.05). Late occlusion (3 per cent) or “distal thread” stenosis (2 per cent) occurred only in those with small IMAGs, especially when the coronary lesion was only moderately severe. Graft occlusion and recurrence of symptoms required reoperation in five SVG and two IMAG patients. Actuarial survival was 95 per cent at one year, 93 per cent at three years, and 92 per cent at five years. Ninety-five per cent of the survivors improved one functional class (FC) or more, and 85 per cent are asymptomatic, with a higher proportion in IMAG patients. Eighty-two per cent of those less than age sixty years resumed gainful employment. Hospital mortality was higher for those with combined procedures, especially with infarctectomy and/or closure of septal rupture. Zero mortality occurred in the last two years in those with revascularization and valve replacement, perhaps related to cold cardioplegic myocardial protection. Coronary revascularization provides excellent long-term functional results. Survival in the entire group, including patients with unstable angina and those with cardiogenic shock, is significantly better than survival of patients with stable angina recently reported by the Veterans Administration Cooperative Study. A 10 per cent better long-term patency rate with an IMAG is particularly important in muscular young individuals with stable hemodynamics. Its use is not warranted in unstable patients, in patients with combined procedures, and in patients with massive left ventricular hypertrophy.