Multiple Arterial Grafts Research Articles

To promote wide use of multiple arterial grafting in coronary bypass surgery in China

多支动脉桥已成为国际上当今冠状动脉旁路移植术的重要发展方向，但我国应用很少，比例低，本文集中介绍国内几个中心的多支动脉桥应用经验，并就多支动脉桥临床应用的一些热点问题进行阐述，以推进多支动脉桥的应用，使更多的患者受益。.

Hotspot issue of clinical practice of multiple arterial grafting in coronary artery bypass surgery in China

冠状动脉旁路移植术动脉桥的临床效果优于大隐静脉，而多支动脉桥具有围手术期安全、心脏再血管化低、远期生存率好等优点，已成为冠状动脉旁路移植术的主要趋势，但我国使用率低。本文对一些亟需解决的临床热点问题进行探讨，以期促进多支动脉桥推广应用。.

Long-term outcomes of multiple and single arterial off-pump coronary artery bypass grafting.

To compare the clinical outcomes between multiple arterial (MA) and single arterial (SA) off-pump coronary artery bypass grafting (OPCAB) when applied to left main coronary disease or three-vessel disease. A total of 537 patients with left main coronary disease or three-vessel disease underwent MA OPCAB (n=114) or SA OPCAB (n=423) in our center from January 2006 to December 2008. The propensity score matching (PSM) was used to obtain the risk-adjusted outcome. Both the perioperative and long-term results were analyzed. The median follow-up time was 117 months (interquartile range, 110 to 128 months). There was no statistical difference in postoperative mortality and the volume of drainage. The intensive care unit (ICU) length of stay (LOS) of the MA group was shorter than that of the SA group {1 [1-2] vs. 2 [1-3], P=0.001). In the long term, the mortality (5.7% vs. 17.5%, P=0.006), cardiac mortality (1.0% vs. 8.8%, P=0.008), fatal myocardial infarction (MI) rate (0.0% vs. 6.1%, P=0.015) and incidence of readmission for heart failure (19.8% vs. 37.7%, P=0.003) were lower in the MA group than in the SA group. The distributions of NYHA class (P<0.001) and CCS class (P<0.001) were better in the MA group than in the SA group. There was no significant difference in other outcomes. These results were consistent with the K-M curves of freedom from the adverse events. MA OPCAB was as safe as SA OPCAB, providing better perioperative recovery and better long-term clinical outcomes in the treatment of left main coronary disease or three-vessel disease.

TRENDS AND FACTORS ASSOCIATED WITH USE OF MULTIPLE ARTERIAL GRAFTS FOR MULTIVESSEL CORONARY ARTERY BYPASS GRAFT SURGERY: A STATE-WIDE ANALYSIS OF 68,357 PROCEDURES

Current evidence suggests that CABG surgery performed using multiple arterial grafts (MAG) may be associated with improved outcomes compared with CABG using a single arterial graft (SAG) or no arterial grafts (NAG). However, the uptake and factors associated with use of MAG-CABG in real-world

Bilateral versus Single Internal-Thoracic-Artery Grafts at 10 Years

BackgroundMultiple arterial grafts may result in longer survival than single arterial grafts after coronary-artery bypass grafting (CABG) surgery. We evaluated the use of bilateral internal-thoracic-artery grafts for CABG.MethodsWe randomly assigned patients scheduled for CABG to undergo bilateral or single internal-thoracic-artery grafting. Additional arterial or vein grafts were used as indicated. The primary outcome was death from any cause at 10 years. The composite of death from any cause, myocardial infarction, or stroke was a secondary outcome.ResultsA total of 1548 patients were randomly assigned to undergo bilateral internal-thoracic-artery grafting (the bilateral-graft group) and 1554 to undergo single internal-thoracic-artery grafting (the single-graft group). In the bilateral-graft group, 13.9% of the patients received only a single internal-thoracic-artery graft, and in the single-graft group, 21.8% of the patients also received a radial-artery graft. Vital status was not known for 2.3% of the patients at 10 years. In the intention-to-treat analysis at 10 years, there were 315 deaths (20.3% of the patients) in the bilateral-graft group and 329 deaths (21.2%) in the single-graft group (hazard ratio, 0.96; 95% confidence interval [CI], 0.82 to 1.12; P=0.62). Regarding the composite outcome of death, myocardial infarction, or stroke, there were 385 patients (24.9%) with an event in the bilateral-graft group and 425 patients (27.3%) with an event in the single-graft group (hazard ratio, 0.90; 95% CI, 0.79 to 1.03).ConclusionsAmong patients who were scheduled for CABG and had been randomly assigned to undergo bilateral or single internal-thoracic-artery grafting, there was no significant between-group difference in the rate of death from any cause at 10 years in the intention-to-treat analysis. Further studies are needed to determine whether multiple arterial grafts provide better outcomes than a single internal-thoracic-artery graft. (Funded by the British Heath Foundation and others; Current Controlled Trials number, ISRCTN46552265.)

Total arterial revascularization in patients with multi–vessel coronary artery disease: modern insight on conduit selection

Coronary artery bypass grafting (CABG) remains the most common operation performed by cardiac surgeons today. Fundamental basis of CABG is to reestablish perfusion to the myocardium, however there are different approaches in accomplishing this goal. The collection of scientific publications suggest the use of multiple arterial conduits in patients of young age, preferable without advanced comorbidity and low body surface area. Despite common use of saphenous vein grafts, lots publications demonstrate advantages of arterial conduits. Internal mammary artery (IMA) has patency rates in the region of 90–95% ten to fifteen years after CABG. Based on superior long-term results of the internal mammary artery (IMA), other arteries is being used in CABG. Radial artery (RA) nowadays it is the most popular arterial graft after the IMA in both low- and high-risk patients. Although, this conduit is underused, despite numerous observational studies, which documented excellent RA patency of 89% at 10 years. Furthermore RA and ITA grafting shows a strong protective effect against native coronary artery disease progression in symptomatic patients after CABG. The constellation of recent data and 2018 guidelines of European Society of Cardiology and European Association for Cardiothoracic Surgeons on myocardial revascularization suggest performing total arterial revascularization in patients with multi-vessel coronary artery disease.&#x0D; Purpose. Literature review on recent data in surgical revascularization using multiple arterial grafts in patients with multi-vessel coronary artery disease.&#x0D; Conclusions. Total arterial revascularization is safe and effective method in treatment of multi-vessel coronary artery disease. There is undoubted benefit of total arterial revascularization in short-, mid- and long–term results in frames of angina recurrence, major adverse cardiac events and redo surgery, associated with graft failure, compared to saphenous vein grafts. Total arterial revascularization may have protective effect on native coronary artery from disease progression, along with excellent patency rates in patients after CABG. However, clinical choice of grafts should be based on patient’s general condition, coronary artery anatomy and severity of stenosis.

ESC/EACTS guidelines on myocardial revascularization 2018 : The most important innovations

The guidelines on myocardial revascularization published in 2018 are ajoint initiative of the European Society of Cardiology and the European Association for Cardio-Thoracic Surgery. To establish indications for myocardial revascularization by percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), evidence of the functional relevance of coronary artery stenoses is needed either by non-invasive imaging function tests or intravascular hemodynamic measurements. The prognostic and symptomatic benefits of myocardial revascularization depend on whether complete revascularization can be achieved. This needs to be considered when choosing the most appropriate revascularization strategy. In addition, the individual operative risk, the technical feasibility, the presence of diabetes mellitus and the anatomical complexity of coronary artery disease, as assessed by the SYNTAX score, are key criteria when choosing the optimal method of revascularization. For PCI radial artery access and the general use of drug-eluting stents are recommended. For CABG multiple arterial grafts should be strived for including the radial artery for treatment of high-grade coronary stenosis.

New Strategies for Surgical Myocardial Revascularization.

We summarize the evidence on the new strategies for coronary artery bypass grafting (CABG). Hybrid CABG implies surgical grafting of the left anterior descending artery and percutaneous treatment of the other target vessels, with the promise of combining the durable benefits of surgery with the less invasive approach of percutaneous coronary interventions. Robotic CABG and minimally invasive CABG are performed through minimal incision or port access with dedicated equipment and instruments. Anaortic coronary artery bypass refers to off-pump CABG using only in-situ grafts. The use of multiple arterial grafts has been shown to improve patency and is potentially associated with better clinical outcomes. All these techniques require dedicated training and are more complex than conventional CABG but can significantly improve the results of surgery. Validation of the results of these new approaches in large randomized trials is a priority for the surgical community.

The ROMA trial: why it is needed.

We herein summarize the current evidence on the clinical outcome associated with the use of single and multiple arterial grafts for coronary bypass surgery and the role and importance of the Randomized comparison of the clinical Outcome of single versus Multiple Arterial grafts (ROMA) trial. Observational evidence suggests that the use of multiple arterial grafts is associated with better clinical outcomes compared to the use of a single arterial graft. Randomized evidence is inconclusive; the 5-year interim analysis of the largest randomized trial on the topic did not show any clinical benefit associated with the use of bilateral versus single internal thoracic arteries, whereas a pooled analysis of the trials comparing the radial artery and the saphenous vein as a second graft showed a significant reduction in follow-up cardiac events using the radial artery. Hidden confounders and treatment allocation biases as well as methodological flaws are the most likely explanation of this contradiction. ROMA was conceived based on the lessons learned from a critical analysis of the existing randomized and observational evidence with the aim to provide a definitive answer to the question of the potential clinical benefit of multiple arterial grafts for coronary bypass.

The effect of completeness of revascularization during CABG with single versus multiple arterial grafts.

Incomplete coronary revascularization is associated with suboptimal outcomes. We investigated the long-term effects of Incomplete, Complete, and Supra-complete revascularization and whether these effects differed in the setting of single-arterial and multi-arterial coronary artery bypass graft (CABG). We analyzed 15-year mortality in 7157 CABG patients (64.1 ± 10.5 years; 30% women). All patients received a left internal thoracic artery to left anterior descending coronary artery graft with additional venous grafts only (single-arterial) or with at least one additional arterial graft (multi-arterial) and were grouped based on a completeness of revascularization index (CRI = number of grafts minus the number of diseased principal coronary arteries): Incomplete (CRI ≤ -1 [N = 320;4.5%]); Complete (CRI = 0 [N = 2882;40.3%]; reference group); and two Supra-complete categories (CRI = +1[N = 3050; 42.6%]; CRI ≥ + 2 [N = 905; 12.6%]). Risk-adjusted mortality hazard ratios (AHR) were calculated using comprehensive propensity score adjustment by Cox regression. Incomplete revascularization was rare (4.5%) but associated with increased mortality in all patients (AHR [95% confidence interval] = 1.53 [1.29-1.80]), those undergoing single-arterial CABG (AHR = 1.27 [1.04-1.54]) and multi-arterial CABG (AHR = 2.18 [1.60-2.99]), as well as in patients with 3-Vessel (AHR = 1.37 [1.16-1.62]) and, to a lesser degree, with 2-Vessel (AHR = 1.67 [0.53-5.23]) coronary disease. Supra-complete revascularization was generally associated with incrementally decreased mortality in all patients (AHR [CRI = +1] = 0.94 [0.87-1.03]); AHR [CRI ≥ +2] = 0.74 [0.64-0.85]), and was driven by a significantly decreased mortality risk in single-arterial CABG (AHR [CRI = +1] = 0.90 [0.81-0.99]; AHR [CRI ≥ +2] = 0.64 [0.53-0.78]); and 3-Vessel disease patients (AHR [CRI = +1] = 0.94 [0.86-1.04]; and AHR [CRI ≥ +2] = 0.75 [0.63-0.88]) with no impact in multi-arterial CABG (AHR [CRI = +1] = 1.07 [0.91-1.26]; AHR [CRI ≥ +2] = 0.93 [0.73-1.17]). Incomplete revascularization is associated with decreased late survival, irrespective of grafting strategy. Alternatively, supra-complete revascularization is associated with improved survival in patients with 3-Vessel CAD, and in single-arterial but not multi-arterial CABG.

Meta-Analysis Comparing Outcomes of Drug Eluting Stents Versus Single and Multiarterial Coronary Artery Bypass Grafting

Relative benefits of coronary artery bypass (CABG) using single and multiple arterial grafting (SAG, MAG) and drug eluting stent (DES) in multivessel coronary disease remain uncertain. We compared SAG, MAG, and DES in a pairwise and network meta-analysis. Randomized trials and adjusted observational studies comparing CABG versus DES were included (primary end point: long-term mortality; secondary end points: operative mortality, perioperative stroke, and follow-up repeated revascularization [RR]). Studies with ≥1.7 arterial grafts and/or patient were classified as MAG. Bayesian network meta-analyses and random-model pairwise meta-analyses were performed. A total of 53,239 patients (8 randomized, 17 observational studies) were included (26,306 DES; 26,933 CABG). In pairwise comparison (mean follow-up: 5.42 years), CABG (MAG + SAG) was associated with lower long-term mortality (incident rate ratio [IRR] 0.77, 95% confidence interval [CI] 0.66 to 0.90), lower RR (IRR 0.37, 95% CI 0.27 to 0.51), increased perioperative stroke (odds ratio [OR] 3.18, 95% CI 1.70 to 5.97), and similar operative mortality (OR 1.04, 95% CI 0.64 to 1.70) compared with DES. There was a nonsignificant trend toward lower long-term mortality for studies with higher mean number of arterial grafts. In network meta-analyses, compared with DES, MAG was associated with lower long-term mortality (IRR 0.72, 95% credible interval [CrI] 0.57 to 0.92) and late RR (IRR 0.32, 95% CrI 0.21 to 0.49), SAG was associated with lower long-term mortality and RR (IRR 0.80, 95% CrI 0.66 to 0.97 and IRR 0.42, 95% CrI 0.29 to 0.61, respectively). In conclusion, CABG was associated with reduced 5-year mortality and need for RR compared with DES. MAG was ranked as the best treatment for the primary and all secondary outcomes.

Detrimental effects of incomplete revascularization following CABG-multiple arterial grafting may not solve the problem.

Journal of Cardiac SurgeryVolume 33, Issue 10 p. 629-630 INVITED COMMENTARY Detrimental effects of incomplete revascularization following CABG—multiple arterial grafting may not solve the problem Harold L. Lazar MD, Corresponding Author Harold L. Lazar MD harold.l.lazar@gmail.com Division of Cardiac Surgery, The Boston University School of Medicine, Boston, Massachusetts Correspondence Harold L. Lazar MD, Division of Cardiac Surgery, The Boston University School of Medicine, 80 E Concord Street, Boston MA 02118. Email: harold.l.lazar@gmail.comSearch for more papers by this author Harold L. Lazar MD, Corresponding Author Harold L. Lazar MD harold.l.lazar@gmail.com Division of Cardiac Surgery, The Boston University School of Medicine, Boston, Massachusetts Correspondence Harold L. Lazar MD, Division of Cardiac Surgery, The Boston University School of Medicine, 80 E Concord Street, Boston MA 02118. Email: harold.l.lazar@gmail.comSearch for more papers by this author First published: 11 September 2018 https://doi.org/10.1111/jocs.13811Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume33, Issue10October 2018Pages 629-630 RelatedInformation

Lessons learned from Radial Artery Database International ALliance (RADIAL).

Coronary artery bypass graft (CABG) surgery was first performed in the 1960s. As the surgery has evolved, there has been a growing interest in the use of multiple arterial grafts in CABG. Since the re-introduction of the radial artery (RA) to clinical use as a bypass conduit in the 1990s, there have been several randomized controlled trials (RCTs) which have compared saphenous vein graft (SVG) conduits to RA use in CABG. While most trials have shown improved patency of the RA, none of them have been able to demonstrate a survival benefit using the arterial conduit. In this review, we examine the existing RCTs on the subject. We then look at our solution to the decades-old inquiry regarding the RA compared with the SVG. The Radial Artery Database International ALliance (RADIAL) project is an individual patient-level meta-analysis developed to adequately power a study to assess if the RA has superior clinical outcomes compared with the SVG. We describe the process by which this investigation was conducted and the collaboration necessary to achieve success.

How I deploy arterial grafts

There are currently around one million coronary artery bypass graft (CABG) procedures performed worldwide annually and despite two decades of evidence to support the use of a second arterial graft, if not total arterial grafting, the stark reality is that in contemporary practice 80% of all grafts used for CABG are saphenous vein grafts (SVG). The following description of how I deploy arterial grafts has been developed over more than two decades of clinical practice and largely self-taught by a process of "trial and error" and most importantly dictated by "ease of use" rather than personal robust angiographic data of long-term patency (although there is other such existing data in the literature for some of these techniques). The fact that there are numerous potential variants of deploying multiple arterial grafts underpins the fact that there is no single operation that is ideal in every patient-it is not a case of "one size fits all" as would be the situation for the use of a single internal thoracic artery (ITA) and supplemental vein grafts.

Bilateral internal thoracic artery use in coronary bypass surgery: is there a benefit?

Over the past three decades, there have been a plethora of retrospective observational data and meta-analyses which support the hypothesis of improved clinical outcomes using bilateral internal thoracic arteries (BITA) when compared to saphenous vein grafts (SVGs). However, recently published results have brought this thinking into doubt. We discuss the existing literature on the subject and attempt to clarify the appropriate use of BITA in coronary artery bypass surgery (CABG). A review of all existing meta-analyses on BITA was conducted to better understand the utility of BITA in CABG. A review of the largest randomized controlled trials on the subject was then compared to the observational data. In all existing meta-analyses, BITA shows a significant advantage over the use of a single internal thoracic artery (SITA) with SVGs. The two largest randomized controlled trials evaluating BITA failed to show a survival advantage and brought into question the complications associated with BITA. At present, the use of multiple arterial grafts remains a reasonable choice, particularly in young patients, provided that their use does not increase the operative risk. Further evidence currently being collected may lend a definitive answer in the near future.

Why Don’t We Kill 2 Birds with 1 Stone?

Article, see p 1698 In this issue of Circulation , Goldstone and colleagues1 report the early and midterm outcomes of more than 59 000 patients who underwent primary isolated multivessel coronary artery bypass grafting (CABG) at 126 nonfederal hospitals in California from 2006 to 2011. They found that after propensity matching, receipt of a second arterial conduit was associated with significantly lower all-cause mortality, myocardial infarction, and coronary reintervention at a median follow-up of more than 5 years. It is interesting to note that compared with radial artery (RA) grafting, right internal thoracic artery (RITA) grafting did not confer a survival or cardiovascular advantage, but was associated with increased risk of sternal wound infection. During the study period, use of a second arterial conduit decreased from 10.7% to 9.1%, mirroring a national trend reported by the Society of Thoracic Surgeons Adult Cardiac Surgery Database (11.6% in 2000–2009 versus 6.7% in 2010–2013).2 Notably, 30% of cardiac surgeons in California did not use a second arterial graft for the duration of the study. So why is there a reluctance to use multiple arterial grafts in multivessel CABG despite the potential benefit? As for the 70% of California’s surgeons who use 2 arteries, why do they do so only in a small percentage of patients? The answers to those questions are complex but not elusive. Barriers to multiarterial grafting are diverse, ranging from perceptions about available scientific evidence, to surgical expertise, to health economics and more (Table). View this table: Table. Barriers to Multiarterial Grafting, Proposed Solutions, and Responsible Parties Starting with the scientific evidence, the California study is the largest study to date and an important addition to other large …

Continuing Conundrum of Multiple Arterial Conduits for Coronary Artery Bypass Grafting.

The idea of using multiple arterial grafts (AGs) for coronary artery bypass graft surgery (CABG) dates back more than 4 decades, and the potential clinical benefits of this strategy represent one of the most extensively studied aspects of coronary surgery. A recent MEDLINE search for studies comparing the results of CABG using bilateral versus single internal thoracic artery (BITA versus SITA) resulted in 3950 articles. Over the years, the BITA versus SITA comparison has been summarized in 6 meta-analyses, with the most recent pooling data from 89 399 patients (20 949 with BITA and 68 450 with SITA). All of them reported significantly longer survival associated with the use of BITA, with the hazard ratio for mortality varying from 0.78 to 0.81.1 The findings are similar when the second AG is the radial artery. Multiple observational studies have reported significantly longer survival associated with the use of the radial artery in addition to the SITA.2 This has been observed even in high-risk categories such as female sex, obesity, diabetes mellitus, and reoperations.2 It is important to emphasize, however, that the great majority of the reported evidence supporting multiple AGs is observational. To date, only 3 randomized …

Invited Commentary

Invited Commentary

IN DIABETIC PATIENTS MULTIPLE ARTERIAL GRAFTS IMPROVE LONG-TERM SURVIVAL COMPARED WITH CONVENTIONAL CORONARY ARTERY BYPASS SURGERY OR STENTS

Diabetes mellitus is a risk factor for late death in patients undergoing coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). Whether extending multiple arterial grafts (MA) to diabetic patients improves survival compared with conventional left internal mammary artery

Blaise Pascal and the evidence on the use of multiple arterial grafts for coronary artery bypass surgery after the interim analysis of the Arterial Revascularization Trial.

After the publication of the interim analysis of the ART, we review the contradiction between the large numbers of observational studies published on the course of over 25 years and the randomized trials comparing the use of single versus multiple arterial grafts for coronary bypass surgery. The Arterial Revascularization Trial (ART) found no difference in survival and event-free survival at 5 years between patients randomized to receive one or two internal thoracic arteries at the time of surgery. At the moment, there is evidence that arterial grafts have higher patency rate than venous grafts and a possible protective effect on the coronary circulation. Arterial grafts are still a reasonable choice, especially in patients with long life expectancy. Further studies and the final results of ART are needed.