IMPORTANCEThe relative safety and patency of skeletonized vs pedicled internal mammary artery grafts in patients undergoing coronary artery bypass graft (CABG) surgery are unknown.OBJECTIVE To investigate the association of skeletonized vs pedicled harvesting with internal mammary artery graft patency and clinical outcomes 1 year after CABG surgery. DESIGN, SETTING, AND PARTICIPANTS This study was a post hoc analysis of the multicenter, randomized, double-blind, placebo-controlled Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) clinical trial, which enrolled 27 395 patients from 602 centers in 33 countries from March 2013 through May 2016. Eligibility criteria for the trial included CABG surgery for coronary artery disease with at least 2 grafts implanted and an estimated glomerular filtration rate of at least 30 mL/min. A total of 1002 of 1448 patients were randomized to the CABG arm of the COMPASS trial and underwent skeletonized (282 [28.1%]) or pedicled (720 [71.9%]) internal mammary artery harvesting. The patients had evaluable angiography results 1 year after surgery. Data were analyzed from October 11, 2019, to May 14, 2020. INTERVENTIONS Patients underwent graft harvesting with either the pedicled technique or skeletonized technique. MAIN OUTCOMES AND MEASURES The primary outcome was graft occlusion 1 year after CABG surgery, as assessed by computed tomography angiography. RESULTS A total of 1002 patients underwent skeletonized (282 [28.1%]; mean [SD] age, 65.9 [8.1] years; 229 men [81.2%]; 194 White patients [68.8%]) or pedicled (720 [71.9%]; mean [SD] age, 64.8 [7.6] years; 603 men [83.8%]; 455 White patients [63.2%]) internal mammary artery harvesting. Rates of internal mammary artery graft occlusion 1 year after CABG surgery were higher in the skeletonized group than in the pedicled group (33 of 344 [9.6%] vs 30 of 764 [3.9%]; graft-level adjusted odds ratio, 2.41; 95% CI, 1.39-4.20; P = .002), including the left internal mammary artery to left anterior descending artery (21 of 289 [7.3%] vs 25 of 725 [3.4%]; graft-level adjusted odds ratio, 2.10; 95% CI, 1.14-3.88, P = .02). After a mean follow-up of 23 months, skeletonized graft harvesting was also associated with a higher rate of major adverse cardiovascular events (20 [7.1%] vs 15 [2.1%]; adjusted hazard ratio, 3.19; 95% CI, 1.53-6.67; P = .002) and repeated revascularization (14 [5.0%] vs 10 [1.4%]; adjusted hazard ratio, 2.75; 95% CI, 1.10-6.88; P = .03). CONCLUSIONS AND RELEVANCEThis post hoc analysis of the COMPASS randomized clinical trial found that harvesting of the internal mammary artery during CABG surgery using a skeletonized technique was associated with a higher rate of graft occlusion and worse clinical outcomes than the traditional pedicled technique. Future randomized clinical trials are needed to establish the safety and patency of the skeletonized technique.

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Table ). Mean age was 70.5 and 22.3% of participants were female. Clopidogrel was the P2Y12i employed in most patients (88-100%) and 54.9% of patients were recruited in the context of ACS. Compared with TT, patients randomized to an aspirin-omitted DT consisting of solely a P2Y12i and a DOAC at full-dose did not have significantly increased rates of thrombotic events (RR¼1.01; 95%CI, 0.83-1.23; I2¼0%, Figure). Mortality similarly did not differ between the two strategies (RR¼1.06; 95%CI, 0.78-1.33; I2¼0%, Figure ). CONCLUSION: In patients requiring therapeutic anticoagulation following ACS or PCI, our meta-analysis of RCTs demonstrates that a restrictive antithrombotic strategy omitting aspirin and consisting solely of a P2Y12i and full-dose DOAC confers similar thrombotic efficacy to traditional TT strategies consisting of DAPT coupled with a VKA. Given the measure of association's proximity to the null and the low heterogeneity, this is unlikely to change with the publication of future trials. Considering the well-established decreased bleeding-risk with restrictive antithrombotic strategies, our meta-analysis confers valuable evidence reassuring clinicians that restrictive strategies may be safely and effectively employed.

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