Multiple Arterial Grafts Research Articles

Coronary artery bypass with single versus multiple arterial grafts in women: A meta-analysis.

The study objective was to investigate the impact of multiple arterial grafting on long-term all-cause mortality in women undergoing isolated coronary artery bypass grafting. A comprehensive search was performed to identify observational studies reporting outcomes after coronary artery bypass grafting reported by sex and stratified into multiple arterial grafting versus single arterial grafting strategies. Articles were considered for inclusion if they were written in English and were propensity-matched observational studies. Included studies were then pooled in a meta-analysis performed using the generic inverse variance method. The primary outcome was long-term all-cause mortality. Secondary outcomes were operative mortality and spontaneous myocardial infarction. Meta-regression was used to explore the effects of preoperative and intraoperative variables on the primary outcome. A total of 6 studies with 32,793 women (25,714 single arterial grafting and 7079 multiple arterial grafting) were included. Women who received multiple arterial grafting had lower long-term mortality (incidence rate ratio, 0.86; 95% confidence interval, 0.76-0.96; P=.007) and spontaneous myocardial infarction (incidence rate ratio, 0.80; 95% confidence interval, 0.68-0.93; P=.003) compared with women who received single arterial grafting, but the difference in mortality disappeared when including only the 3 largest studies. There was no difference between groups in operative mortality (odds ratio, 0.99; 95% confidence interval, 0.84-1.17; P=.91). Meta-regression did not identify any associations with the incidence rate ratio for long-term mortality. The use of multiple arterial grafting in women undergoing coronary artery bypass grafting is associated with lower long-term mortality, although the difference is mostly driven by small series. Further studies, including randomized trials, are needed to evaluate the efficacy of multiple arterial grafting in women undergoing coronary artery bypass grafting.

Discussion

Presenter: Doaa Alsaleh Dr Rashmi Yadav (London, United Kingdom). I'm happy to speak from here. Thank you very much. Thank you for your invitation, and thank you for your excellent presentation. If I understood your slides correctly, they do show that there was the same level of myocardial infarction and repeat revascularization in the two groups. And if that is the case, then do you think that it is the old chestnut of retrospective observational studies where we are not able to identify hidden confounder? And often, as surgeons, we have an end-of-the-bed test. We see a patient who looks better and better, and they got a multiarterial graft. Do you think that these might be noncardiac reasons why those patients have a better survival over a seven-year period? Dr Doaa Alsaleh (New York, USA). Thank you so much for your question. If I can just ask about the very first you said, about the myocardial infarction? Dr Yadav. And repeat revascularization. Was it similar in the two groups, or different? Dr Alsaleh. No. So it was not significant for the MI, but it was significant for the repeat revascularization. Dr Yadav. Okay. Thank you. So, there is some evidence that it is helping them in the longer term. My other observation, and perhaps this is simply an observation, is that as a total proportion of the group, there were approximately 30% women patients, and only 20% of women received multiple arterial grafts. And this is a trend that we're starting to see now and something that we need to address that will then get less guideline-directed revascularization compared to men. Do you have any comments about that? Dr Alsaleh. Yeah. That's an excellent observation. There are, in fact, a few papers that looked at multiple arterial vs single arterial by gender, and we're also doing that as an additional analysis and will include it in the manuscript. We're going to look at multiple arterial vs single arterial by gender and look at all the patient characteristics for women and why they're being offered less multiarterial vs in men. Dr Yadav. Thank you. Dr Alsaleh. Thank you so much. Dr Yadav. Thank you. And my final question is, do you know what is the reason for this disturbing trend of less arterial grafts over the time period that you've studied? Would you like to hazard any reasons why this is happening? Dr Alsaleh. Why is there a decline in the trend? Yeah. So, because the guidelines generally, both the US and the European guidelines, there is no clearcut guideline for the use of multiarterial vs single arterial to use in patients in general. And then each of the patients could carry higher risk of other outcomes. For example, an important risk could be seen as well with the type of the graft used. That's sternal infection. And that is also an important outcome that we're looking to explore. So maybe there is a hesitancy based on the outcomes that could be more troublesome, or also, training in arterial grafting procedures as well. Dr Yadav. Okay. Thank you very much. Well done. Dr Alsaleh. Thank you. Unidentified Speaker 1. Thank you. There's an awful lot of data there to chew over. My question relates to prior percutaneous coronary intervention (PCI). In New York State, it was shown conclusively that if you have PCI first and then coronary artery baypass graft, the results are less good. So I'm asking you, are you able to reflect on this in your database, and may that be the explanation for the poorer outcomes? Dr Alsaleh. Thank you for your question. If you can just repeat. If I could reflect on the PCI being–? Unidentified Speaker 1. Before CABG. So that it appears to many of us who do surgery that if a patient has had their coronary arteries instrumented before, particularly on multiple occasions, the target vessels are damaged in a way that produces poorer outcomes from surgical revascularization. Dr Alsaleh. Yeah. We actually included prior PCI and we adjusted for it as part of our data, and it was 1 of the variables that we actually also did propensity match. So it was adjusted for in our data. Unidentified Speaker 1. Thank you.

Outcomes following coronary artery bypass grafting with multiple arterial grafting by pump status in men and women

BackgroundMultiple arterial grafting (MAG) and off-pump surgery are strategies proposed to improve outcomes with coronary artery bypass grafting (CABG). This study was conducted to determine the impact of off-pump surgery on outcomes after CABG with MAG in men and women. MethodsThis cohort study used population-based data to identify all Ontarians undergoing isolated CABG with MAG between October 2008 and September 2019. The primary outcome was all-cause mortality. Secondary outcomes included major adverse cardiac and cerebrovascular events (MACCE; hospitalization for stroke, myocardial infarction hospitalization or heart failure, or repeat revascularization). Analysis used propensity-score overlap-weighted cause-specific Cox proportional hazard regression. ResultsA total of 2989 women (1188 off-pump, 1801 on-pump) and 16,209 men (6065 off-pump, 10,144 on-pump) underwent MAG with a median follow-up of 5.0 years (interquartile range, 2.7-8.0) years. Compared to the on-pump approach, all-cause mortality was not changed with off-pump status (hazard ratio [HR] in women: 1.25 [95% CI, 0.83-1.88]; in men: 1.08 [95% CI, 0.85-1.37]). In women, the risk of MACCE was significantly higher off-pump (HR, 1.45; 95% CI, 1.04-2.03), with nonsignificantly increased risk observed for all component outcomes. ConclusionsIn patients undergoing CABG with MAG, this population-based analysis found no association between pump status and survival in either men or women. However, it did suggest that off-pump MAG in women may be associated with an increased risk of MACCE.

Multiple arterial versus single arterial grafting in patients with diabetes undergoing coronary artery bypass surgery

BackgroundData on long-term outcomes in patients with diabetes receiving multiarterial grafting (MAG) versus single-artery grafting (SAG) are limited. ObjectivesThe objective of this study is to compare long-term outcomes between MAG and SAG for coronary artery bypass graft (CABG) surgery in patients with diabetes. MethodsPatients with diabetes who underwent isolated CABG surgeries between 2000 to 2016 were identified using the New Jersey mandatory state clinical registry linked with death records and hospital discharge data (last follow-up December 31, 2019). Patients who underwent CABG for single-vessel disease, with only venous conduits, patients with previous heart surgeries, or hemodynamically unstable were excluded. Patients undergoing MAG and SAG were matched by propensity score. Cox proportional hazard models were used to investigate long-term survival and competing risk analysis was used for secondary outcomes. ResultsOf 24,944 patients, 2955 underwent MAG, and 21,989 underwent SAG CABG. Patients receiving MAG were younger, predominantly men, with a lower prevalence of hypertension, peripheral vascular disease, congestive heart failure, chronic lung disease, and renal failure. MAG was associated with lower long-term mortality compared with SAG in 2882 propensity score-matched pairs (hazard ratio [HR], 0.75; 95% CI, 0.68-0.83); lower risks of repeat revascularization (subdistribution HR, 0.86; 95% CI, 0.76-0.97); and composite outcome defined as death from any cause, stroke, postoperative myocardial infarction, and/or repeat revascularization (HR, 0.76; 95% CI, 0.71-0.82). These results were confirmed in subgroup analyses of women, men, age <70 years, and age ≥70 years patients with diabetes. MAG was also associated with lower mortality compared with SAG in patients with diabetes taking insulin in the entire cohort (Video Abstract). ConclusionsPatients with diabetes benefit from receiving MAG over SAG and demonstrated improved long-term survival, and lower hazards of secondary and composite outcomes. Coordinated efforts are needed to offer MAG to patients with diabetes.

Multiple Arterial Graft Use in Coronary Artery Bypass Surgery: Surgeon Perspective vs Practice

BackgroundDespite supportive evidence and guidelines, the use of multiple arterial grafts (MAGs) in coronary artery bypass grafting remains low. We sought to determine surgeon perception of personal MAG use and compare this with actual MAG use. MethodsWe conducted a statewide surgeon survey of MAG use, presence of a hospital MAG protocol, and barriers for MAG use, with a response rate of 78% (n = 25). Surgeon survey responses were compared with actual Society of Thoracic Surgeons patient data from January 1, 2017, to December 31, 2020 using χ2 or Fisher’s exact tests. ResultsOf 5299 patients who had first-time, nonemergent, isolated coronary artery bypass grafting (≥2 grafts) by responding surgeons, 16% received MAG (n = 825). MAG use in patients whose surgeons self-designated as “routine” MAG users was 21% vs 7% for “nonroutine” users. Surgeons with a hospital protocol for MAG use utilized MAG more often (18% vs 14%, P = .001). Surgeons who were unconvinced by the data on the benefits of MAGs used MAGs in 11% vs 22% in surgeons who were convinced. MAG use increased over time, particularly from before to after the survey (13.1% vs 30.5%, P < .001). ConclusionsAlthough MAG use increased over time, barriers to routine use remain. In surgeons who reported routine use, only 21% of their patients received MAGs. Hospital protocols, education, and increased awareness may reduce barriers to use and encourage evidence-based clinical practice.

Vein Patch Angioplasty with Internal Mammary Artery Grafting of the Left Anterior Descending Coronary Artery

Objective. To describe the treatment outcomes of patients who underwent coronary artery bypass grafting (CABG) with vein patch angioplasty with internal mammary artery (IMA) grafting of the diffusely diseased left anterior descending (LAD) coronary artery. Methods. This is a retrospective observational study of 26 patients who have undergone vein patch angioplasty of the LAD coronary artery with IMA grafting in three centers by a single surgeon from January 2012 to August 2017. The demographic profile, intraoperative data, and postoperative outcome (including in-hospital mortality and morbidity, perioperative myocardial infarction, and NYHA functional classification) were recorded. Continuous variables were expressed as means with standard deviation and categorical variables summarized as frequencies and percentages. Student’s t-test was used to compare the preoperative versus postoperative mean NYHA functional class.Results. There were 22 (85%) males and 4 (15%) females with a mean age of 62 years (range: 34 to 82). Twentyfive patients (96%) had a three-vessel disease, and one (4%) had a two-vessel disease. Nine patients (35%) had a preoperative myocardial infarction. The mean cardiopulmonary bypass and aortic-cross clamp times were 156 and 118 minutes, respectively. The mean number of vessels grafted was 4.12. Multiple arterial grafting was used in seven patients (27%). There were two in-hospital mortalities (7.7%) and three morbidities (11.5%), including reoperation for bleeding, acute kidney injury, and leg wound infection. Six patients (23%) developed postoperative atrial fibrillation. No patient developed perioperative myocardial infarction. The mean ICU stay was three days, and the mean hospital stay was 10.27 days. The mean NYHA functional class improved from 2.85 preoperatively to 1.5 postoperatively (p&lt;0.00001). Among patients with improvement, postoperative NYHA improved by two functional classes in 38% and by one functional class in 62%.Conclusion. Vein patch angioplasty is a valuable technique for diffuse coronary stenosis of the LAD artery withacceptable early results.&nbsp; &nbsp

SINGLE VERSUS MULTIPLE ARTERIAL GRAFTS: COMPARISON OF IN HOSPITAL MORTALITY

Even though not all findings have been equally positive, many retrospective studies seem to have shown an incremental survival improvement by increasing the number of arterial grafts. Multiple arterial (MultArt) grafting is only currently used in a small number of coronary arteries bypass grafting (CABG) surgeries, despite the convincing and comprehensive information in the published literature. The goal of the study is to compare the incidence of in-hospital mortality in patients following CABG with single versus multiple arterial grafts and to evaluate the frequency of single and multiple CABG arterial grafts in patients undergoing CABG for coronary arteries diseases (CAD). Following institutional review board permission, this descriptive case series was carried out at Jinnah Hospital's heart surgery department in Lahore. 250 patients receiving CABG under general anaesthesia were a part of this study. The quantity of arteries grafted was recorded during CABG. It was observed whether there were one or several arterial grafts. A single surgical team carried out every procedure, under general anaesthesia. Patients were moved to post-surgical wards after surgery. Following surgery, patients were monitored there for 7 days. In-hospital mortality is defined as when a patient dies while receiving treatment in the hospital. In this study, inpatient mortality affected 7 (or 5.9%) of patients treated with single grafts and just 1 (or 0.8%) of patients treated with multiple grafts (p=0.022). Patients who received single graft CABG had a considerably greater incidence of in-hospital mortality. The superiority of multiple arterial graft CABG in terms of lower hospital mortality rate was demonstrated by the study's findings.

Early Results of Total Coronary Revascularization via Left Anterior Thoracotomy.

Avoidance of sternotomy while preserving complete revascularization remains challenging in multivessel coronary disease. Technical issues and in-hospital outcomes of total coronary revascularization via a small left anterior thoracotomy (TCRAT) in nonselected patients with multivessel disease are reported. From November 2019 to September 2021, coronary artery bypass grafting via left anterior minithoracotomy on cardiopulmonary bypass and cardioplegic cardiac arrest was performed in 102 patients (92 males; 67 ± 10 [42-87] years). Slings were placed around ascending aorta, left pulmonary veins, and inferior vena cava for exposure of lateral and inferior ventricular wall. All patients had multivessel coronary disease (three-vessel disease: n = 72; two-vessel disease: n = 30; left main stenosis: n = 44). We included patients at old age (> 80 years, 14.7%), with severe left ventricular dysfunction (ejection fraction < 30%, 6.9%), massive obesity (body mass index > 35, 11.6%), and at increased risk (EuroSCORE II > 4, 15.7%). Left internal thoracic artery (n = 101), radial artery (n = 83), and saphenous vein (n = 39) grafts were used for total (61.8%) or multiple (19.6%) arterial grafting. A total of 323 distal anastomoses (3.2 ± 0.7 [2-5] per patient) were performed to revascularize left anterior descending (100%), circumflex (91.2%), and right coronary artery (67.7%). Complete revascularization was achieved in 95.1%. In-hospital mortality was 2.9%, stroke rate was 1.0%, myocardial infarction rate was 2.9%, and repeat revascularization rate was 2.0%. This novel surgical technique allows complete coronary revascularization in the broad majority of multivessel disease patients without sternotomy. TCRAT can be introduced into clinical routine safely. Long-term results remain to be investigated.

Abstract 14694: Effect of Saphenous Vein Graft on Multiple Arterial Grafting Survival

Introduction: Saphenous vein graft (SVG) is associated with increased mortality and adverse cardiac events compared to arterial conduits, but uncertainty exists whether its presence would influence the outcome in multiple arterial revascularization (MAG). Hypothesis: That use of SVG adversely affects survival even in the setting of MAG. Methods: All patients undergoing primary isolated CABG between June 2001 to Jan 2020 were identified through a national registry. Exclusion criteria were reoperations, concomitant or previous cardiac surgery, and the absence of arterial grafting. The primary outcome was long-term mortality reported as time-to-event from the date of the operation. We performed a complete case retrospective comparison between MAG and single arterial grafting (SAG). Additional analysis was performed in MAG patients with or without SVG.Propensity score matching (PSM) and Cox proportional hazard model were used with significance defined as two-tailed P&lt;0.05. Results: A total of 72,444 eligible patients had 58,629 (80.9%) males with 32,966 SAG (45.5%) and 39,478 MAG (54.5%). Two PSM was used to generate 29,354 matched pairs for SAG vs. MAG and 12,314 matched pairs for MAG with or without SVG. At a mean follow-up duration of 6.7 years, long-term mortality was significantly lower for MAG than SAG (HR, 0.89; 95% CI, 0.85-0.93). The cumulative Kaplan-Meier survival was 60.6% for SAG and 63.3% for MAG at 15 years postoperative, (P=0.002). In the comparison of MAG with or without SVG, the group without SVG (total arterial revascularization) had a lower risk of late mortality (HR, 0.91; 95% CI, 0.85-0.96). The interaction term analysis confirmed a significant effect for the presence of vein graft on the observed mortality when using MAG, (P=0.02). Sensitivity analyses produced consistent outcomes as the primary investigation. Conclusions: Multiple arterial grafting is associated with significantly improved long-term survival compared to single arterial grafting, and when total arterial revascularization was achieved, there was an incremental survival benefit.

Hybrid Coronary Revascularization: Early Outcomes and Midterm Follow-Up in Patients Undergoing Single or Multivessel Robotic TECAB and PCI.

Hybrid coronary revascularization (HCR) is the integration of sternal-sparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in patients with multivessel coronary artery disease (CAD). It is traditionally performed with single-vessel bypass (left internal mammary artery [LIMA] to left anterior descending artery [LAD]) and PCI but can also be accomplished with multiple arterial grafts using bilateral IMA conduits. We sought to review our HCR experience over an 8-year period with robotic totally endoscopic coronary artery bypass (TECAB) and PCI. Of 694 patients undergoing beating-heart TECAB from August 2013 to June 2022, 306 patients were designated as intention-to-treat HCR candidates. Patients underwent PCI prior to, the same day as, or following TECAB, performed using single or bilateral IMA grafts. We retrospectively reviewed early and midterm outcomes up to 8 years in this cohort of patients. The mean Society of Thoracic Surgeons predicted risk of mortality was 1.5% ± 2.5%. There were 44 patients (14%) who had ≥70% left main disease and 218 patients (71%) who had triple-vessel disease. A total of 193 patients (63%) underwent multivessel grafting (advanced HCR), with 83% bilateral IMA use. Mean operative time was 263 ± 80 min, and mean length of stay was 2.6 days. The mean number of vessels bypassed per patient was 1.7 ± 0.6. The mean number of vessels stented was 1.2 ± 0.5. Of the patients, 84% underwent TECAB first, 14% PCI first, and 2% same-day TECAB/PCI. Mortality was 0.6% (observed to expected ratio: 0.42). Early graft patency was 97% (328 of 339 grafts); LIMA-LAD patency was 98%. At 8-year follow-up (mean 37 ± 26 months), all-cause and cardiac-related mortality were 13% and 2.6%, respectively. Freedom from major adverse cardiac and cerebrovascular events was 92%. In patients with multivessel CAD, integrating robotic single and multivessel TECAB with PCI resulted in excellent early and midterm outcomes. In experienced hands, the robotic endoscopic approach allows the routine use of multiple arterial grafting during HCR.

Trend and factors associated with multiple arterial revascularization in coronary artery bypass grafting in the UK

Benefits of using multiple arterial grafting (MAG), over single arterial grafting in major adverse cardiac event rates and the need for repeat revascularization, have been widely reported. Several guidelines have recommended the use of MAG in selected patients. We report the trend of MAG in patients undergoing isolated coronary artery bypass grafting (CABG) in the UK. This is a retrospective analysis of a prospectively collected UK national database in patients undergoing non-emergency, isolated CABG from 1996 to 2018. Patients were divided into single arterial grafting and MAG, and trends in perioperative characteristics were analysed. A total of 336321 patients were included, of whom 284003 (84.44%) received single arterial grafting and 52318 (15.56%) received MAG. The use of MAG after an initial increase from 1996 to 2001, steadily decreased thereafter, particularly in the use of radial artery. MAG was likely to be performed in younger patients [66.72 (standard deviation: 9.22) vs 62.30 (standard deviation: 10.06), P < 0.001] and males (85% vs 81%, P < 0.001). After propensity score matching, the single arterial grafting group was more likely to undergo on-pump CABG (90% vs 69%, P < 0.001), experienced a lower in-hospital mortality (1.1% vs 1.3%, P < 0.001) and incidence of return to theatre for bleeding (2.5% vs 3.0%, P < 0.001). Our data show that the use of MAG in CABG in the UK after an initial increase from 1996 to 2001 steadily decreased thereafter until 2018. This is likely to be multifactorial and a better understanding of the main causes may contribute to establishing the best indication for MAG in everyday clinical practice.

Changes in Controllable Coronary Artery Bypass Grafting Practice for White and Black Americans

BackgroundRacial disparities in outcomes after cardiac surgery are well reported. We sought to determine whether variation by race exists in controllable practices during coronary artery bypass graft surgery (CABG). We hypothesized that racial disparities exist in CABG quality metrics, but have improved over time. MethodsAll patients undergoing isolated CABG (2000 to 2019) in a multiple state database were stratified into three eras by race. Analysis included propensity matched White Americans and Black Americans. Primary outcomes included left internal mammary artery use, multiple arterial grafting, revascularization completeness, and guideline-directed medication prescription. ResultsOf 72 248 patients undergoing CABG, Black American patients (n = 10 270, 15%) had higher rates of diabetes mellitus, hypertension, prior stroke, and myocardial infarction. After matching, 19 806 patients (n = 9903 per group) were well balanced. Left internal mammary artery use was significantly different early (era 1, Black Americans 84.7% vs White Americans 86.6%; P = .03), but equalized over time. Importantly, multiarterial grafting differed between Black Americans and White Americans over the entire study (9.1% vs 11.5%, P < .001) and within each era. Black Americans had more incomplete revascularization during the study period (14% vs 12.8%, P = .02) driven by a large disparity in era 1 (9.5% vs 7.2%, P < .001). Despite similar rates of preoperative use, Black Americans were more often discharged on a regimen of β-blockers (91.8% vs 89.6%, P < .001). ConclusionsCoronary artery bypass graft surgery metrics of left internal mammary artery use and optimal medical therapy have improved over time and are similar despite patient race. Black Americans undergo less frequent multiarterial grafting and greater discharge β-blocker prescription. Identifying changes in controllable CABG quality practices across races supports a continued focus on standardizing such efforts.

Long-term Outcomes After On-Pump vs Off-Pump Coronary Artery Bypass Grafting for Ischemic Cardiomyopathy

BackgroundA post-hoc analysis of the Surgical Treatment for Ischemic Heart Failure (STICH) trial was performed to evaluate the perioperative and long-term outcomes after off-pump vs on-pump coronary artery bypass graft surgery in patients with ischemic cardiomyopathy (coronary artery disease with left ventricular ejection fraction 35% or less). MethodsPatients who underwent isolated coronary artery bypass graft surgery were enrolled from the STICH trial. Operative details, perioperative outcomes, and long-term outcomes were compared in a 1-to-2 propensity score matching cohort. The primary outcome was death from any cause. ResultsAmong 768 included patients operated on between July 2002 and May 2007, 152 (19.8%) received off-pump and 616 (80.2%) received on-pump coronary artery bypass graft surgery. In the 1-to-2 matched cohort (152 off pump and 304 on pump), off pump was associated with a higher prevalence of multiple arterial grafting (17.1% vs 8.6%, P = .01) and incomplete revascularization (34.2% vs 17.1%, P < .001). The overall 30-day mortality (3.3% vs 5.3%, P = .34) was comparable between the two groups. After a median follow-up of 8.7 years, off-pump surgery was associated with a similar risk of death from any cause (hazard ratio 0.82; 95% confidence interval, 0.61 to 1.09), with comparable estimated all-cause mortality at 1 year (12.5% vs 11.9%), 5 years (32% vs 32.8%), and 10 years (51.4% vs 62.3%). No significant interaction was detected in the subgroup analyses of incomplete revascularization, multiple arterial grafting, and three-vessel disease. ConclusionsIn patients with ischemic cardiomyopathy, off-pump coronary artery bypass graft surgery could be performed with comparable 30-day mortality and similar long-term survival, and appears to have a lower incidence of perioperative morbidities.

Single vs Multiple Arterial Reconstructions in Living Donor Liver Transplant

It is true that multiple arterial reconstructions are sometimes required in living donor liver transplant (LDLT). However, the best procedure is still controversial regarding arterial reconstruction in liver grafts with multiple arteries. A total of 93 patients, 55 right lobe grafts and 38 left lobe grafts, who underwent LDLT at our university from 2003 to 2017 were enrolled for this study. Regarding arterial reconstruction in grafts with multiple hepatic arteries, the dominant artery was reconstructed first. Subsequently, when both the pulsating arterial flow from the remaining artery stumps and the intra-graft arterial flow by Doppler ultrasonography were confirmed, the remaining arteries were not reconstructed. The patients were divided into the following 3 groups: (1) single artery/single reconstruction (n=81), (2) selective arterial reconstruction of multiple arterial grafts (n=7), and (3) multiple arterial reconstructions (n=5). A total of 12.9% (12/93; right lobe: 2/55; left lobe 10/38) of grafts had multiple arteries. The incidence of multiple arteries was significantly higher in the left lobe grafts (P=.0029). The arterial diameters (SD) of multiple arterial grafts were narrower (2.43 [0.84] mm) than single arterial grafts (3.70 [1.30] mm) (P=.0135). Extra-anatomic arterial reconstruction were frequently required in multiple arterial reconstructions (group 1 and 2 vs 3) (P=.0007). The strategy of selective arterial reconstruction with the above criteria did not negatively affect the rates of biliary complications or the overall patient survival (P=.52). It can be argued that selective arterial reconstructions demonstrated acceptable outcomes in LDLT, provided that the above criteria were satisfied.

Outcomes of total arterial revascularization vs conventional revascularization in patients undergoing coronary artery bypass graft surgery: A narrative review of major studies.

Coronary artery bypass grafting (CABG) is a widely used surgical procedure which improves clinical outcomes in appropriately selected patients. Conventionally, the greater saphenous vein is often used in CABG. However, due to their higher long-term patency rates, arterial conduits are routinely used, with the left internal thoracic artery (LITA) on left anterior descending (LAD) being the gold standard in CABG. Our aim in the present work was to investigate the outcomes of a total arterial grafting (TAG) on the whole heart, with no use of venous grafts, compared to mixed conduits in real-world data. A literature search was conducted in the bibliographic databases PubMed and Web of Science. Only studies comparing TAG with conventional CABG (at least one venous graft plus one or more arterial grafts), with at least one hundred patients in each group were included in this review. After study selection, a total of 15 relevant studies were evaluated and discussed in the present review. Results indicated that TAG is a highly efficient technique, and multiple arterial grafts can be used to reliably revascularize all coronary artery territories. TAG was more beneficial in terms of both short and long-term outcomes and its use should be encouraged. Large randomized clinical trials are needed to confirm the superiority of total arterial grafting with regard to long-term outcomes.

Twenty-Year Follow-up: Multiple Arterial Grafting Is Associated with Better Outcomes for Coronary Artery Bypass Grafting Patients

Twenty-Year Follow-up: Multiple Arterial Grafting Is Associated with Better Outcomes for Coronary Artery Bypass Grafting Patients

Multiple arterial coronary bypass grafting is associated with better survival compared with second-generation drug-eluting stents in patients with stable multivessel coronary artery disease

ObjectiveWe sought to compare the long-term outcomes of multiarterial graft (MAG) coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) with second-generation drug-eluting stents (DES) to treat stable multivessel coronary artery disease. MethodsThis study was a multicenter population-based retrospective analysis of all residents of Ontario, Canada, from January 1, 2011, to December 31, 2019. We identified 3600 cases of elective primary isolated CABG with MAG and 2187 cases of PCI with second-generation DES. ResultsAfter the application of propensity score-weighting using overlap weights, MAG was associated with better survival over 5 years compared with DES (96.8% vs 94.5%; hazard ratio [HR], 0.56; 95% CI, 0.37-0.85). MAG was also associated with better secondary outcomes including a composite of death, myocardial infarction, and stroke (94.3% vs 88.5%; HR, 0.49; 95% CI, 0.36-0.65). The rate of death, stroke, myocardial infarction, and repeat revascularization (91.2% vs 70.7%; HR, 0.24; 95% CI, 0.20-0.30), and the individual end points of myocardial infarction (1.4% vs 6.9%; HR, 0.22; 95% CI, 0.13-0.35), and repeat revascularization (4.1% vs 24.2%; HR, 0.14; 95% CI, 0.10-0.18) were lower with MAG. PCI with second-generation DES was associated with a lower rate of stroke up to 5 years (0.6% vs 1.8%; HR, 3.97; 95% CI, 1.45-10.88). ConclusionsCABG with MAG was associated with better survival and fewer major cardiac adverse events compared with second-generation DES and might be considered the treatment of choice for patients with stable multivessel coronary artery disease. Further randomized controlled trials are needed to confirm this hypothesis.

Off-pump versus on-pump coronary artery bypass grafting: a propensity score-matching analysis of safety and long-term results

Abstract Background The role and the indications for using off-pump coronary artery bypass surgery (OPCAB), instead of the traditional on-pump (ONCAB), is still to be addressed. Aim To describe our centre experience and to compare 15-years survival and early safety outcomes between OPCAB and ONCAB. Methods Single-centre retrospective cohort including 9-years of isolated first CABG (2005–2013). Multi-vessel disease with at least 2 surgical grafts patients were considered and the first 50 surgeries of each surgeon with each technique were excluded to account for the learning curve effect. Emergent surgeries and on-pump beating heart procedures were also excluded. A propensity-score matching (PSM) analysis was performed to balance groups and both survival and early outcomes comparison was done within the matched cohort using Kaplan-Meier or Cox stratified and paired tests, respectively. The median follow-up was 9 years, maximum 15 years. Results From 3012 multi-vessel patients with at least 2 surgical grafts, 2503 were included at the main analysis: 1487 ONCAB and 1016 OPCAB. ONCAB patients presented more frequently 3-vessels disease and left ventricular dysfunction, but received similar number of grafts than OPCAB, who in turn, received more frequently multiple arterial grafts. The surgical completeness of revascularization (CR) was similar, but hybrid procedures were more frequent in OPCAB raising CR rate in this group. After PSM (646 pairs), both groups were similar regarding pre and peri-operative characteristics. The long-term survival was similar (HR stratified by pair: 1.02 (0.81–1.30), but OPCAB evidenced benefits at early term results including bleeding, postoperative atrial fibrillation and stroke incidence. Conclusion At our centre, OPCAB performed by experienced surgeons provides rates of complete revascularization and long-term survival similar to ONCAB. In-hospital results favoured OPCAB. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): Universidade do Porto/FMUP; Social European Fund; FCT-Fundação para a Ciência e a Tecnologia

Long-term survival after coronary bypass surgery with multiple versus single arterial grafts.

OBJECTIVESThis study sought to evaluate the long-term differences in survival between multiple arterial grafts (MAG) and single arterial grafts (SAG) in patients who underwent coronary artery bypass grafting (CABG) in the SYNTAX study.METHODSThe present analysis included the randomized and registry-treated CABG patients (n = 1509) from the SYNTAX Extended Survival study (SYNTAXES). Patients with only venous (n = 42) or synthetic grafts (n = 1) were excluded. The primary end point was all-cause death at the longest follow-up. Multivariable Cox regression was used to adjust for differences in baseline characteristics. Sensitivity analysis using propensity matching with inverse probability for treatment weights was performed.RESULTSOf the 1466 included patients, 465 (31.7%) received MAG and 1001 (68.3%) SAG. Patients receiving MAG were younger and at lower risk. At the longest follow-up of 12.6 years, all-cause death occurred in 23.6% of MAG and 40.0% of SAG patients [adjusted hazard ratio (HR) 0.74, 95% confidence interval (CI) (0.55–0.98); P = 0.038], which was confirmed by sensitivity analysis. MAG in patients with the three-vessel disease was associated with significant lower unadjusted and adjusted all-cause death at 12.6 years [adjusted HR 0.65, 95% CI (0.44–0.97); P = 0.033]. In contrast, no significance was observed after risk adjustment in patients with the left main disease, with and without diabetes, or among SYNTAX score tertiles.CONCLUSIONSIn the present post hoc analysis of all-comers patients from the SYNTAX trial, MAG resulted in markedly lower all-cause death at 12.6-year follow-up compared to a SAG strategy. Hence, this striking long-term survival benefit of MAG over SAG encourages more extensive use of multiple arterial grafting in selected patients with reasonable life expectancy.Trial registrationSYNTAXES ClinicalTrials.gov reference: NCT03417050; SYNTAX ClinicalTrials.gov reference: NCT00114972.

Never again. Once used for cardiac catherization the radial artery cannot be used for CABG.

The use of the radial artery (RA) as a conduit in coronary artery bypass grafting (CABG) has been steadily increasing since the early 1990s and based on the most recent data may well become the standard of care for patients with multivessel coronary artery disease requiring multiple arterial grafts. The transradial access (TRA) approach for cardiac catherization has also increased steadily in use by interventional cardiologists owing to its reduction in bleeding and vascular complications when compared with the femoral approach and is now considered the preferred arterial access. However, prior use of TRA for cardiac catherization is a contraindication for the use of the RA for CABG because of high rates of structural damage to the vascular wall and potential for graft failure. In this issue of the Journal of Cardiac Surgery Clarke et al. examine the RA of two patients who had TRA for coronary angiography 8 and 12 years prior and note that both patients had chronic injury with dissection and obstruction of the lumen secondary to fibrosis suggesting that TRA causes long-term and irreversible damage rendering them unsuitable as conduits for CABG.