Single Artery Grafts Research Articles

Is It Safe to Use Arterial Grafts in Patients with Acute Myocardial Infarction? Short-Mid-Term Propensity Analysis.

The use of multiple arterial grafts (MAGs) has an impact on patient survival; however, preference for its use in the acute phase of myocardial infarction (AMI) has not yet been established. This study aimed to compare the short-mid-term clinical results of AMI patients undergoing coronary artery bypass grafting (CABG) with a single arterial graft (SAG) vs. MAGs. This is a cross-sectional cohort study of 4,053 patients from the Registro Paulista de Cirurgia Cardiovascular II (REPLICCAR II). CABG in the AMI was considered when performed between one and seven days after diagnosis (n=238). Thirty-five patients underwent surgery with ≥ 2 arterial grafts (MAG group), population adjustment in SAG group was performed using the propensity score matching (PSM). Clinical follow-up was performed by telephone to assess need for readmission, new AMI, reoperation, and death. After PSM, 70 patients were evaluated. During hospitalization, a significant statistical difference was observed in the surgery duration: the MAG group had a median of 4.78 hours while the SAG group had 4.11 hours (P=0.040). Within the MAG group, there was a predominance use of bilateral internal thoracic artery (62.86%), followed by radial graft associated with the use of left internal thoracic artery (28.57%) and the combination of the three grafts (8.57%). There were no significant differences between the groups in terms of outcomes up to 30 days after CABG or up to five years after CABG. In REPLICCAR II, usage of MAGs in the AMI was not associated with clinical worsening of patients until the mid-term follow-up.

Multiarterial Grafting in Redo CABG: Type of Arterial Conduit and Patient Sex Determine Benefit

To evaluate whether multiarterial grafting provides incremental benefit above single arterial grafting in isolated redo CABG. From 1/1980 to 7/2020, 6559 adults underwent 6693 isolated CABG reoperations. Patients undergoing multiarterial grafting were propensity-score matched with those undergoing single arterial grafting, with or without additional vein grafts, yielding 2005 well-matched pairs. Endpoints were in-hospital postoperative complications, hospital mortality, and long-term mortality. Median follow-up was 10 years with 25% followed >17 years. Multivariable multiphase hazard modeling and nonparametric random survival forests for survival were used to identify patients for whom multiarterial grafting was most beneficial. Among propensity-matched patients, postoperative complications for multiarterial versus single arterial grafting were any reoperation, 50 (2.5%) versus 65 (3.2%); renal failure, 73 (3.6%) versus 55 (2.7%); stroke, 44 (2.2%) versus 38 (1.9%); and deep sternal infection, 36 (1.8%) versus 25 (1.2%). Hospital mortality was 1.7% (n=35) versus 2.8% (n=56) (P=.03). Comparing multiarterial to single arterial grafting, survival at 1 and 3 years was 95% versus 94% and 92% versus 88%, and at 5, 15, and 20 years, survival was 87%, 49%, and 31% versus 82%, 42%, and 25%. Better survival after multiarterial grafting was confined to males with 2 patent internal thoracic artery grafts (P<.0001). Redo CABG with multiarterial grafting can be performed with lower in-hospital mortality and similar major morbidity to single arterial grafting. It is associated with better long-term survival, particularly in males when 2 internal thoracic artery grafts are used.

Impact of Multi versus Single Arterial Coronary Bypass Graft Surgery on Postoperative Atrial Fibrillation

The effect of multi-arterial (MA) versus single arterial (SA) coronary bypass graft surgery on postoperative atrial fibrillation (POAF) was not investigated. From May 2017 to May 2024, the patients with CYP2C19*2 or *3 allele receiving coronary artery grafting and post-operational aspirin 100 mg/day and clopidogrel 75mg/day were retrospectively reviewed and assigned into MA or SA group. The primary endpoint was the incidence rate of POAF in first week. The secondary endpoints were POAF burden, platelet aggregation, systemic immune-inflammation (SII) index and heart rate variability (HRV). The study included 58 cases in MA group and 174 cases in SA group. The incidence of POAF was 17% in MA group contrasting with 42% in SA group (hazard ratio: 0.353; 95% confidence interval: 0.218 to 0.569, P=0.0012). A lower POAF burden was observed in MA group than that in SA group (2 h [1, 5] versus 10 h [6, 20], P=0.02). Platelet aggregation (arachidonic acid, 46%±10% vs. 56%±8%, P<0.01; adenosine diphosphate, 58%±17% vs. 75%±13%, P<0.01) and inflammation response index (neutrophil-lymphocyte ratio, 26±4 vs. 28±5, P=0.006; SII index, 5019±771 vs. 5382±1204, P=0.032) was notably lower in MA group than those in SA group at one day after CABG. Holter electrocardiogram showed a higher HRV value in standard deviation of normal-to-normal RR intervals, and decreased low-frequency/high-frequency ratio in MA group. In conclusion, MA was associated with a lower incidence rate of POAF, and paralleled with a lower AF burden, platelet aggregation, inflammation reaction and a higher parasympathetic nerve tone compared with SA regimen.

Secondary Conduits in Coronary Artery Bypass Grafting Surgery

BackgroundRecent evidence has suggested use of the right internal mammary artery (RIMA) is associated with worse clinical outcomes in patients undergoing coronary artery bypass grafting (CABG) surgery. Therefore, we compared the clinical consequences of secondary conduit selection (RIMA vs radial artery vs saphenous vein) after CABG. MethodsA post-hoc analysis of the CABG Off or On Pump Revascularization Study, involving 3913 patients from 79 centers in 19 countries who underwent CABG surgery and received arterial grafting with at least 2 grafts. Outcomes of interest were all-cause mortality, myocardial infarction, stroke, and revascularization. ResultsA total of 3913 patients received veins (3210; 68%), radial arteries (549; 12%), or RIMAs (154; 3%) to supplement left internal mammary artery to left anterior descending artery grafts. The risk of all-cause mortality was reduced in patients who received secondary radial arteries compared with veins (weighted hazard ratio [HR], 0.79; 95% CI, 0.64-0.98) and increased in patients who received RIMA compared with veins (weighted HR, 1.37; 95% CI, 1.13-1.68) after 4.8 years of follow-up. Multiple and single arterial grafting had a similar mortality risk (weighted HR, 0.87; 95% CI, 0.73-1.03). ConclusionsSupplementing left internal mammary artery to left anterior descending artery grafting using radial arteries led to better clinical outcomes than veins, and too few RIMA were available to draw definitive conclusions. A randomized trial is needed to clarify the role of the RIMA in multiple arterial grafting CABG surgery.

Two Decades of CABG in the UK: A Propensity Matched Analysis of Outcomes by Conduit Choice.

Background/Objectives: Grafting of LIMA to LAD has long been considered the gold-standard conduit choice for patients undergoing CABG. Despite this, the LSV remains the most used conduit by volume and some patients may not receive even a single arterial conduit. However, the outcomes in this group are not frequently explored. This study, therefore, compares in-hospital outcomes of patients who underwent CABG without any arterial conduits to those who received at least one arterial conduit. Methods: Retrospective propensity-matched database analysis of consecutive patients undergoing CABG in the UK between 1996 and 2019 using data from the National Adult Cardiac Surgery Audit. Results: 335,144 patients underwent CABG, with 6% receiving venous conduits only; matched outcomes are reported for 39,812 patients. In both unmatched and matched groups, we found a significant increase in mortality with the use of veins only (matched mortality 5.3% vs. 3.8%, p < 0.001) with estimated treatment effect for mortality OR 1.43, p < 0.001 (95% CI: 1.31-1.57). We also identified greater rates of post-operative dialysis, IABP insertion, and length of hospital stay in this group. Conclusions: We identified a significant increase in in-hospital mortality with the use of veins only compared to using at least one arterial graft to the LAD. While a single arterial graft should be prioritised wherever possible, venous revascularisation retains a critical role for specific patients. We must, therefore, continue to conduct research addressing the mechanisms underlying and propagating vein graft disease in order better to optimise outcomes for this niche patient group after CABG.

A Comparative Analysis of Single Versus Multiple Arterial Grafts in Coronary Arterial Bypass Grafting: Initial Experience in Iraq.

The global recognition of multiple arterial grafting (MAG) and total arterial grafting (TAG) in coronary artery bypass grafting (CABG) is increasing. However, many centers have not yet adopted these procedures. Our study aims to examine the intraoperative, early postoperative, and two-year follow-up outcomes associated with MAG and TAG in candidates for CABG. The goal is to provide valuable insights into the role of these procedures. A prospective comparative study was conducted at Sulaimani Cardiac Hospital to analyze a cohort of 300 patients who underwent CABG surgery between January 2021 and April 2022. Convenience sampling was used to select participants. Prior to surgery, patients underwent comprehensive pre-operative evaluations, with certain CABG types being excluded. The patients were then categorized into three groups based on their surgical approach: single arterial conduit (SA), two arterial conduits (MA), and total arterial revascularization (TA). The standard bypass procedure was performed for all patients, and they were monitored for 30 days, six months, and two years after the surgery. A range of variables, including bypass and cross-clamp times, as well as postoperative complications such as bleeding and stroke, were recorded and analyzed. Statistical Product and Service Solutions (SPSS, version 25; IBM Corp.,Armonk, NY) was used for this analysis, with a predetermined significance threshold of p ≤ 0.05. The study included 300 participants who underwent CABG. The participants had an average age of 61.19 ± 4.67 years (95% CI: 36-81) and an average BMI of 27.40 ± 8.4 kg/m² (95% CI: 18-45). Diabetes was present in 40.3% of the patients, and the majority of the participants were male (77.7%). The number of vessels involved in the bypass varied, with two vessels in 21% of cases, three vessels in 65%, and four vessels in 14%. The left internal thoracic artery (LITA) was primarily used for arterial revascularization, and additional arterial conduits were used in 30.3% of cases. Statistical analysis showed significant differences in the number of grafts among patient groups (P = 0.042). However, there were no significant differences in bypass duration, cross-clamp duration, stroke incidence, or in-hospital mortality rates among the groups (P > 0.05). The rates of myocardial infarction (MI) approached significance (P = 0.05), and the mortality rates were comparable over a two-year period after CABG (4.7%) and at shorter intervals. These findings highlight the importance of age and the number of grafts in determining outcomes in CABG patients. In a developing nation, the lack of a specialized center for MAG does not hinder the implementation of MAG or TAG. The overall occurrence of complications after CABG is similar across all groups, except for MI. Patients who undergo MAG have higher rates of overall survival compared to those who receive SA and TAG.

Impact of Multiarterial Revascularization on Long-term Major Adverse Cardiovascular Events After Coronary Bypass in 23,798 Patients

BackgroundThis study evaluated the association between bypass grafting with multiarterial grafts (MAG) and single arterial grafts (SAG) and all-cause mortality and major adverse cardiovascular and cerebrovascular events (MACCE), overall and across different patient subgroups from a Middle Eastern nation. MethodsThis single-center retrospective cohort study included 23,798 patients. MAG and SAG groups were balanced using inverse probability weighting (IPW). Associations between MAG and outcomes were assessed using Cox regression. A series of covariate-adjusted Cox models were conducted to evaluate the effect of MAG on outcomes at different levels of independent variables, including age, sex, and cardiovascular risk factors. ResultsIn the study population (73.9% were men, 65.11 ± 9.94 years), 986 patients (4.1%) underwent MAG. Compared with the SAG group, MAG had lower crude mortality (14.1% vs 21.6%) and MACCE (28.8% vs 34.7%) rates during a median follow-up of 9.23 years (quartile 1-quartile 3, 9.13-9.33 years). Although MAG was significantly associated with reduced risk of study outcomes at the univariate level, these associations disappeared after matching (all-cause mortality (IPW hazard ratio, 0.90; 95% CI, 0.67-1.22) and MACCEs (IPW hazard ratio, 0.94; 95% CI, 0.76-1.15). However, covariate-adjusted models indicated that MAG was associated with a significantly reduced risk of adverse events, particularly MACCEs, in men, younger patients, and those without risk factors. ConclusionsMAG was not associated with improved postsurgery outcomes among the total coronary artery bypass graft population. Our findings, however, should be interpreted in the context of a relatively low total institutional MAG burden. Choosing a second arterial conduit over saphenous vein grafts in specific patient subgroups might be reasonable. This hypothesis-generating finding should be investigated in future clinical trials in these patients.

Multiple arterial vs. single arterial coronary artery bypass grafting: sex-related differences in outcomes.

Uncertainty exists over whether multiple arterial grafting has a sex-related association with survival after coronary artery bypass grafting. This study aims to compare the long-term survival of using multiple arterial grafting vs. single arterial grafting in women and men undergoing coronary artery bypass grafting. The retrospective study used the Australian and New Zealand Society of Cardiothoracic Surgical Database with linkage to the National Death Index. Patients from 2001 to 2020 were identified. Sex-stratified, inverse probability weighted Cox proportional hazard model was used to facilitate survival comparisons. The primary outcome was all-cause mortality. A total number of 54 275 adult patients receiving at least two grafts in primary isolated bypass operations were analysed. The entire study cohort consisted of 10 693 (19.7%) female patients and 29 711 (54.7%) multiple arterial grafting procedures. At a median (interquartile range) postoperative follow-up of 4.9 (2.3-8.4) years, mortality was significantly lower in male patients undergoing multiarterial than single arterial procedures (adjusted hazard ratio 0.82; 95% confidence interval 0.77-0.87; P < .001). The survival benefit was also significant for females (adjusted hazard ratio 0.83; 95% confidence interval 0.76-0.91; P < .001) at a median (interquartile range) follow-up of 5.2 (2.4-8.7) years. The interaction model from Cox regression suggested insignificant subgroup effect from sex (P = .08) on the observed survival advantage. The survival benefits associated with multiple arterial grafting were consistent across all sex-stratified subgroups except for female patients with left main coronary disease. Compared to single arterial grafting, multiple arterial revascularization is associated with improved long-term survival for women as well as men.

Selecting conduits for coronary artery bypass grafting: caution regarding the right internal mammary artery

This narrative review summarizes the angiographic and clinical outcome results of the most common coronary artery bypass grafting (CABG) conduits. The left internal mammary artery is the preferred first conduit to bypass the left anterior descending artery due to superior long-term survival and graft patency. Recent studies suggest the radial artery may be the preferred second conduit for the circumflex or right coronary artery territories, challenging the belief that the right internal mammary artery is the best choice. Despite their historical high failure rates, saphenous vein grafts continue to be widely used as secondary conduits. Several recent studies report suboptimal rates of right internal mammary artery graft failure, with clinical outcomes comparable to or worse than saphenous veins. The suboptimal rates of RIMA graft failure may be attributed to several factors such as improvements in vein graft failure rates, the use of in situ and non-left anterior descending artery grafting configurations, and skeletonized harvesting techniques. While observational studies favor multiple over single arterial grafting, randomized studies are needed for confirmation. The ongoing Randomized comparison of the clinical Outcome of single vs. Multiple Arterial grafts (ROMA) trial aims to determine if multiple arterial grafting reduces major adverse cardiovascular events and mortality and how secondary conduit selection influences these outcomes. Greater adoption of arterial grafting strategies is likely to come from high-quality evidence of benefit and safety from ongoing and future large pragmatic trials.

Single versus multiple arterial coronary artery bypass grafting in men and women: results from Polish National Registry of Cardiac Surgery Procedures.

The objective of this multicenter study aimed to investigate the impact of sex on long-term survival among patients with multivessel coronary artery disease undergoing coronary artery bypass grafting (CABG) using multiple arterial grafting (MAG) or a single artery with saphenous vein grafts. Data were obtained from the Polish National Registry of Cardiac Surgery Procedures database. This study included 81136 patients who underwent CABG for multivessel disease between January 2012 and December 2020 (22.9 were women and 77.1% were men). MAG was performed in 8.3 and 11.7% of female and male patients, respectively. A 1:1 propensity score (PS)-matching was performed. Long-term mortality was compared between matched groups of men and women. Subgroup analyses of patients aged <70 and ≥70 years, with an ejection fraction (EF) >40% and ≤40%, and with and without diabetes, obesity, peripheral artery disease (PAD), or chronic lung disease (CLD) were performed separately in women and men. MAG was associated with lower long-term mortality than saphenous vein grafts in 1528 PS-matched female pairs [hazard ratio (HR): 0.74; 95% CI: 0.59-0.92; P =0.007) and 7283 PS-matched male pairs (HR: 0.80; 95% CI: 0.72-0.88; P <0.001). Subgroup analyses confirmed the results among female patients aged <70 years, with diabetes and EF >40%, and without PAD or CLD, and of male patients aged <70 and ≥70 years; with EF >40%; with or without diabetes, obesity, or PAD; and without CLD. In patients undergoing CABG, MAG was associated with significantly improved survival in both sexes. The long-term benefits of MAG observed across subgroups of men and women support the consideration of a multiarterial revascularization strategy for a broader spectrum of patients.

Multiarterial vs Single-Arterial Coronary Surgery: 10-Year Follow-up of 1 Million Patients

BackgroundAlthough many options exist for multivessel coronary revascularization, controversy persists over whether multiarterial grafting (MAG) confers a survival advantage over single-arterial grafting (SAG) with saphenous vein in coronary artery bypass grafting (CABG). This study sought to compare longitudinal survival between patients undergoing MAG and those undergoing SAG. MethodsAll patients undergoing isolated CABG with ≥2 bypass grafts in The Society of Thoracic Surgeons Adult Cardiac Surgery Database (2008-2019) were linked to the National Death Index. Risk adjustment was performed using inverse probability weighting and multivariable modeling. The primary end point was longitudinal survival. Subpopulation analyses were performed and volume thresholds were analyzed to determine optimal benefit. ResultsA total of 1,021,632 patients underwent isolated CABG at 1108 programs (100,419 MAG [9.83%]; 920,943 SAG [90.17%]). Median follow-up was 5.30 years (range, 0-12 years). After risk adjustment, all characteristics were well balanced. At 10 years, MAG was associated with improved unadjusted (hazard ratio, 0.59; 95% CI 0.58-0.61) and adjusted (hazard ratio, 0.86; 95% CI, 0.85-0.88) 10-year survival. Center volume of ≥10 MAG cases/year was associated with benefit. MAG was associated with an overall survival advantage over SAG in all subgroups, including stable coronary disease, acute coronary syndrome, and acute infarction. Survival was equivalent to that with SAG for patients age ≥80 years and those with severe heart failure, renal failure, peripheral vascular disease, or obesity. Only patients with a body mass index ≥40 kg/m2 had superior survival with SAG. ConclusionsMultiarterial CABG is associated with superior long-term survival and should be the surgical multivessel revascularization strategy of choice for patients with a body mass index of less than 40 kg/m2.

Early Post-operative Outcomes of Single versus Multiple Arterial Grafts in Coronary Artery Bypass Grafting; A Comparative Analysis

Objective: To compare early post-operative outcomes of Single versus Multiple Arterial grafts in Coronary Artery Bypass Grafting (CABG) surgery. Study Design: Analytical Cross-sectional study. Place and Duration of Study: Adult Cardiac Surgery, Armed Forces Institute of Cardiology/National Institute of Heart Diseases Rawalpindi Pakistan, from Jul 2022 to May 2023. Methodology: One hundred and forty nine patients planned for elective isolated CABG (with two or more grafts) were enrolled in study using consecutive sampling. They were allocated into two groups, group A (Multiple Arterial CABG group) and group B (Conventional CABG group). Data was collected on early post-op outcomes i.e. ICU stay, ventilation time, inotropic duration, chest drainage, rhythm complications including Supraventricular Tachycardia (SVT) and mortality using a structured proforma. Chi-square and t-test were applied to make comparison between both groups. p&lt;0.05 was considered statistically significant. Results: Out of one hundred and forty nine patients, who underwent elective CABG, majority were males 124(83.2%). Mean age of the patients was 59.18±9.28 years. Seventy four (49.7%) patients underwent Multiple Arterial CABG while 75(50.3%) had conventional CABG. Mean ICU stay duration was 56.74±48.30 hours in group A while it was 67.25±73.42 hours in group B; p=0.30. Mean Chest Drainage was 622.05±505.69 ml in group A while it was 846.13±799.67 ml in group B; p=0.04. Mean ventilation time was 10.28 ± 19.88 hours.................. Conclusion: The use of the Radial Artery (RA) in CABG surgery was associated with better early ...............

Survival Benefit of Multiple Arterial Revascularization With and Without Supplementary Saphenous Vein Graft.

It is unknown if the presence of saphenous vein grafting (SVG) adversely affects late survival following coronary surgery with multiple arterial grafting (MAG) versus single arterial grafting. A retrospective, observational, multicenter cohort study from 2001 to 2020 was conducted using the Australian and New Zealand Society of Cardiac and Thoracic Surgeons Database linked to the National Death Index. Patients undergoing primary isolated coronary artery bypass grafting with ≥2 grafts were included, and exclusions were patients aged <18 years, reoperations, concomitant or previous cardiac surgery, and the absence of arterial grafting. Demographics, comorbidities, medication, and operative configurations were propensity score matched between cohorts. The primary outcome was all-cause late death. Of 59 689 eligible patients, 35 113 were MAG (58.8%), and 24 576 were single arterial grafting (41.2%). Of the MAG cohort, 17 055 (48.6%) patients did not receive supplementary SVG(total arterial revascularization). Matching separately generated 22 764 patient pairs for MAG versus single arterial grafting, and 11 137 patient pairs for MAG with total arterial revascularization versus MAG with ≥1 supplementary vein grafts. At a median follow-up duration of 5.0 years postoperatively, the mortality rate was significantly lower for MAG than single arterial grafting (hazard ratio [HR], 0.79 [95% CI, 0.76-0.83]; P<0.001). The stratified MAG analysis found that MAG with total arterial revascularization had a lower risk of late death (HR, 0.85 [95% CI, 0.80-0.91]; P<0.001) compared with MAG with ≥1 supplementary vein grafts. Sensitivity analyses produced consistent outcomes as the primary analysis. Following adjustment for the presence of SVG in the Cox model, the survival advantage of incremental number of arteries was lost. Multiple arterial grafting has significantly improved long-term survival compared with single arterial grafting. A further incremental survival benefit exists when no SVG is used.

Bilateral versus single internal thoracic coronary artery bypass grafting: the ART RCT

Background There is debate whether the use of more arterial grafts during coronary artery bypass graft surgery provides advantages to the standard operation using the left internal thoracic artery plus vein grafts. We review data from the Arterial Revascularisation Trial to determine whether there is support for the multiple arterial graft hypothesis. Methods Patients undergoing coronary artery bypass graft for clinical reasons and who provided written informed consent were randomised to standard coronary artery bypass graft using the single internal thoracic artery or use of bilateral internal thoracic arteries. Additional vein grafts could be used. The primary outcome was all-cause mortality at 10 years and exploratory analyses were carried out to test the multiple arterial graft hypothesis. Results A total of 3102 patients were enrolled (1548 bilateral internal thoracic artery and 1554 single internal thoracic artery). Follow-up to 10 years for vital status was 98% complete. In the bilateral group, 14% of patients received a single internal thoracic artery only and use of radial artery grafts occurred in about 20% of patients in both groups. Aspirin was used in 81% of the patients, beta-blockers in 74%, statins in 90% and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers in 73%. At 10 years, death rates were 20.3% and 21.2% in the bilateral internal thoracic artery and single internal thoracic artery groups, respectively (hazard ratio 0.96, 95% confidence intervals 0.82 to 1.12; p = 0.62) and composite of all-cause mortality, myocardial infarction or stroke 24.9% and 27.3%, respectively (hazard ratio 0.90, 95% confidence interval 0.79 to 1.03; p = 0.12). Exploratory analyses using the ‘as-treated’ approach indicate that outcomes were better in patients who received multiple arterial grafts (adding the right internal thoracic and/or radial arteries) compared with a single arterial graft. This effect appeared to be greater in patients with diabetes and those aged 70 years or less. Use of total arterial grafting without vein grafts may provide the best outcomes. Limitations The elevated cross-over rate between bilateral internal thoracic artery and single internal thoracic artery and the non-randomised use of radial artery grafts may have contributed to a loss of power to detect a difference in mortality between the two groups. Moreover, secondary analyses are prone to bias as they compare non-randomised groups. Conclusions The Arterial Revascularisation Trial is one of the largest long-term studies in cardiac surgery. The primary analysis did not show a mortality benefit for bilateral internal thoracic artery at 10 years, perhaps due to high crossover rates in the bilateral internal thoracic artery group and concomitant use of the radial artery. Secondary analyses suggest a mortality benefit for patients receiving multiple arterial grafts compared with single arterial graft with possible greater effects in patients with diabetes and separately in patients aged 70 years or above. The trial will follow patients to 15 years and the continuing Randomized Comparison of the Clinical Outcome of Single versus Multiple Arterial Grafts trial will further test the multiple arterial graft hypothesis. Trial registration This trial is registered as ISRCTN46552265. Funding This project was funded by the British Heart Foundation, the UK. Medical Research Council and the National Institute for Health and Care Research (NIHR) Efficacy and Mechanism Evaluation programme and will be published in full in Efficacy and Mechanism Evaluation; Vol. 10, No. 7. See the NIHR Journals Library website for further project information.

Single or multiple arterial grafting to design a coronary bypass: a retrospective study

Aim. To compare the efficiency of single arterial grafting (SAG) and multiple arterial grafting (MAG) at coronary artery bypass graft (CABG) surgery in the long term.Material and Methods. To assess the angiographic outcomes, we evaluated the patency of 323 bypasses at 102 angiograms obtained during coronary angiography performed &gt; 10 years post-CABG surgery.Results. Out of 323 analyzed bypasses, 230 (71.2%) showed physiological functioning, whereas stenosis, occlusions, and other coronary artery alterations were found in 93 (28.8%) bypasses. The most common cause for the failure of anastomoses was competitive flow (most frequently registered in the anastomoses between left internal thoracic artery and left anterior descending artery, left internal thoracic artery and diagonal branches of left anterior descending artery, right internal thoracic artery and left anterior descending artery, and between right internal thoracic artery and right coronary artery), poor distal bed (most frequently revealed in the anastomosis between left internal thoracic artery and obtuse marginal artery, saphenous vein and diagonal branches of left anterior descending artery, saphenous vein and obtuse marginal artery, and between saphenous vein and right coronary artery), progression of atherosclerosis in combination with poor distal bed (most frequently detected in the anastomosis between right internal thoracic artery and obtuse marginal artery), and combination of poor distal bed, competitive flow, and graft degeneration (most frequently found in the anastomoses between radial artery and obtuse marginal artery and between radial artery and right coronary artery). In 5 (5.4%) cases, the cause of coronary bypass dysfunction was unclear.Conclusion. The main causes for the coronary bypass failure included competitive flow (in case with multiple arterial grafting) and poor distal bed (in case with single arterial grafting).

Long-Term Survival Associated With Multiple Arterial Grafting in Off-Pump and On-Pump Coronary Bypass Surgery

There is a paucity of evidence on whether the survival advantage of multiple arterial revascularisation (MAG) would have an association with off-pump (OPCAB) or on-pump coronary artery bypass grafting (ONCAB). Therefore, this study sought to evaluate the long-term survival of using multi aterial grafting (MAG) vs single arterial grafting (SAG) in OPCAB and ONCAB cohorts.

The effect of the multiple arterial grafts compared with single arterial graft for coronary artery bypass grafting on sternal wound complications: A meta-analysis.

A meta-analysis investigation was executed to measure the influence of multiple arterial grafts (MAGs) compared with single arterial graft (SAG) for coronary artery bypass grafting (CABG) on sternal wound complications (SWCs). A comprehensive literature inspection till February 2023 was applied and 1048 interrelated investigations were reviewed. The seven chosen investigations enclosed 11 201 individuals with CABG in the chosen investigations' starting point, 4870 of them were using MAGs, and 6331 were using SAG. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were utilised to compute the value of the effect of the MAGs compared with SAG for CABG on SWCs by the dichotomous approaches and a fixed or random model. MAGs had significantly higher SWC (OR, 1.38; 95% CI, 1.10-1.73, P = .005) compared with those with SAG in CABG. MAGs had significantly higher SWC compared with those with SAG in CABG. However, care must be exercised when dealing with its values because of the low number of selected investigations for the meta-analysis.

Long-Term Survival of Multiple Versus Single Arterial Coronary Bypass Grafting in Elderly Patients.

Multiple arterial grafting (MAG) utilizes more than one arterial graft with any additional grafts being saphenous vein grafts (SVG). It remains an infrequently used coronary surgical revascularization technique, especially in elderly patients. Our study aims to evaluate the age-related association with the relative outcomes of multiple versus single arterial grafting (SAG). The Australian and New Zealand national registry was used to identify adult patients undergoing primary isolated CABG with at least two grafts. Exclusion criteria included reoperations, concomitant or previous cardiac surgery, and the absence of arterial grafting. Propensity score matching was used to match patient groups. The primary outcome was all-cause late mortality and the secondary outcomes were 30-day mortality and 30-day hospital readmission. We selected 69,624 eligible patients with a mean (standard deviation) age of 65.0 (10.2) years old. Matching between MAG and SAG generated 16,882 pairs of patients < 70 years old and 10,921 pairs of patients ≥ 70 years old. At a median [interquartile range] follow-up duration of 5.9 [3.2-9.6] years, MAG was associated with significantly reduced mortality compared to SAG (hazard ratio [HR], 0.73; 95% confidence interval [CI], 0.68-0.78; p < 0.001) in the younger subgroup as well as the elderly subgroup (HR, 0.84; 95% CI, 0.79-0.88; p < 0.001). In conclusion, MAG offers a survival benefit over SAG, in both younger and elderly patients.

Survival of multiple arterial grafting in diabetic populations: a 20-year national experience.

Diabetics may have diminished survival after coronary artery bypass grafting even with multiple arterial revascularization. We compared multi-arterial versus single-arterial grafting (SAG) survival in diabetic and non-diabetic patients undergoing primary isolated bypass surgery. This is a retrospective analysis of the Australian and New Zealand Society of Cardiac-Thoracic Surgical Database from June 2001 to January 2020. Patients were classified as having either single or multiple arterial grafting irrespective of the number of venous grafts. The end points were long-term all-cause mortality and 30-day clinical outcomes, which was compared in 1:1 propensity score-matched patients. Cox regression model was used to assess interactions between diabetes and the treatment effect of multi-arterial grafting, reported as hazard ratios (HRs) and confidence intervals (CIs). Short-term outcomes were compared with McNemar's paired t-test. From 69 624 patients, matching generated 17 474 non-diabetic and 10 989 diabetic patient pairs. At a median [interquartile range] of 5.9 [3.2-9.6] years postoperative, mortality was significantly lower after multi-arterial grafting for both diabetic (HR, 0.83; 95% CI, 0.76-0.90, P < 0.001) and non-diabetic (HR, 0.88; 95% CI, 0.82-0.95; P < 0.001) cohorts than SAG. The incidence of 30-day myocardial infarction was significantly higher in single than multiple arterial grafting for both cohorts (diabetic, P = 0.029; non-diabetic, P < 0.001). The interaction analysis suggested an insignificant effect of diabetes (P = 0.55) on the observed survival advantage. Further stratification by diabetic management generated consistent results. Multi-arterial grafting was associated with improved overall survival compared to SAG for both non-diabetic and diabetic patients.

Reconstruction Technique Options for Achieving Total Arterial Revascularization and Multiple Arterial Grafting.

Ischemic heart disease is the leading cause of morbidity and mortality worldwide and may require coronary revascularization when more severe or symptomatic. Coronary artery bypass grafting (CABG) is the most common cardiac surgical procedure and can be performed with different bypass conduits and anastomotic techniques. Saphenous vein grafts (SVGs) are the most frequently used conduits for CABG, in addition to the left internal thoracic artery. Outcomes with a single internal thoracic artery and SVGs are favorable, and the long-term patency of SVGs may be improved through novel harvesting techniques, preservation methods, and optimal medical therapy. However, increasing evidence points towards the superiority of arterial grafts, especially in the form of multiple arterial grafting (MAG). Nevertheless, the uptake of MAG remains limited and variable, both as a result of technical complexity and a scarcity of conclusive randomized controlled trial evidence. Here, we present an overview of CABG techniques, harvesting methods, and anastomosis types to achieve total arterial revascularization and adopt MAG. We further narratively summarize the available evidence for MAG versus single arterial grafting to date and highlight remaining gaps and questions that require further study to elucidate the role of MAG in CABG.