Abstract
BackgroundWhile it is believed that total arterial grafting (TAG) for coronary artery bypass grafting (CABG) confers improved long-term outcomes when compared to conventional grafting with left internal mammary artery and saphenous vein grafts (LIMA+SVG), to date, this has not become the standard of care. In this study, we assessed the impact of TAG on medium-term outcomes after CABG.MethodsPeri-operative data was prospectively collected on consecutive first-time, isolated CABG patients between 1995 and 2005. Patients were divided into two groups based on grafting strategy: TAG (all arterial grafts no saphenous veins) or LIMA+SVG. Patients who had an emergent status or underwent fewer than two distal bypasses were excluded. Medium term univariate and risk-adjusted comparisons between TAG and LIMA+SVG cases were performed.ResultsA total of 4696 CABG patients were included with 1019 patients undergoing TAG (22%). Unadjusted in-hospital mortality was 1.5% for TAG patients compared to 2.0% for LIMA+SVG (p = 0.31). The mean follow-up was 4.8 ± 2.0 years for TAG patients compared to 6.1 ± 3.0 years for LIMA+SVG patients (p < 0.0001). At follow-up total mortality (8% vs 19%; p < 0.0001), and the incidence of readmission to hospital for cardiac reasons (29% vs 38%; p < 0.0001) were significantly lower in TAG compared to LIMA+SVG patients. However, after adjusting for clinical covariates, TAG did not emerge as a significant independent predictor of long-term mortality (HR 0.92; CI 0.71–1.18), readmission to hospital (HR 1.02; CI 0.89–1.18) or the composite outcome of mortality and readmission (HR 1.00; CI 0.88–1.15). Risk adjusted survival was better than 88% in both TAG and LIMA-SVG patients at 5 years follow-up.ConclusionPatients undergoing TAG appear to experience lower rates of medium-term all-cause mortality and readmission to hospital for any cardiac cause when compared to patients undergoing LIMA+SVG. However, after adjusting for clinical variables, this difference no longer persists suggesting that at median follow-up there are no mortality or morbidity benefit based on the choice of conduit.
Highlights
Since its introduction nearly four decades ago, coronary artery bypass grafting (CABG) has established itself as an important therapeutic intervention for patients with symptomatic coronary artery disease
The conduits used for total arterial grafting (TAG) patients were: the left internal mammary artery (LIMA; 100%), right internal mammary artery (RIMA; 39%), and radial artery (62%)
Overall there were fewer distal anatomoses performed in TAG patients (3.1 ± 0.9 grafts) compared to LIMA+saphenous vein grafts (SVG) patients (3.2 ± 0.8 grafts; p < 0.001) (Table 1)
Summary
Since its introduction nearly four decades ago, coronary artery bypass grafting (CABG) has established itself as an important therapeutic intervention for patients with symptomatic coronary artery disease. During the early to mid 1980's, reports emerged in the literature describing the considerably diminished long-term patency rates of saphenous vein grafts (SVG), eventually leading to SVG occlusion which would result in the inevitable recurrence of symptoms, the need for readmission to hospitalization and coronary re-intervention and possibly even death [3,4]. Around the same time, publications exalting the superior long-term patency rates of the left internal mammary artery (LIMA) graft and the improved long-term survival associated with grafting of the LIMA to the left anterior descending (LAD) artery surfaced, re-establishing confidence in the long-term benefits of CABG [3,4,5]. While it is believed that total arterial grafting (TAG) for coronary artery bypass grafting (CABG) confers improved long-term outcomes when compared to conventional grafting with left internal mammary artery and saphenous vein grafts (LIMA+SVG), to date, this has not become the standard of care. We assessed the impact of TAG on medium-term outcomes after CABG
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