How decisive is the number of distal arterial anastomoses in coronary bypass surgery?

Abstract

Background The benefit of arterial revascularization in coronary surgery remains controversial. The incremental value of additional grafts to the left internal thoracic artery (ITA) has been mainly assessed according to the number of arterial grafts, possibly limiting the detection of its actual impact. We analyzed the influence of the number of distal arterial anastomoses (DAA) performed on late mortality in patients having received from one to three arterial grafts. Methods Retrospective review of 3685 primary isolated coronary artery bypass grafting (CABG) performed from 1989 to 2014 was conducted with a 13-year mean follow-up. One arterial graft (SITA) was used in 969 patients, two arterial grafts, ITA or gastroepiploic artery (GEA), in 1883 patients (BITA: 1644; SITA+GEA: 239), and three arterial grafts in 833 patients (BITA+GEA). Totally, 795 patients (22%) received one DAA, 1142 patients (31%) two, 1337 patients (36%) three, and 411 patients (11%) four or more. A sub-group analysis was done in the 2104 patients with 3-vessel disease who received at least 2 arterial grafts. Results In this series the early mortality was 1.6% and it was not influenced by the surgical technique. Late mortality was significantly influenced by age, gender, heart failure, LV ejection fraction, diabetes status, complete revascularization, number of arterial grafts, number of DAA, both ITA, sequential ITA graft, GEA graft. In multivariable analysis with Cox regression model, the number of DAA was the only technical significant independent prognosis factor of late survival (p < 0.0001), predominant over both ITA, complete revascularization and number of arterial grafts. The impact of the number of DAA on survival was found discriminant from 1 to 3; after 3 there was no more additional effect. In 3-vessel disease patients who received at least 2 arterial grafts, the number of DAA remained a significant independent prognosis factor of late survival (p < 0.0001). Conclusions The number of distal arterial anastomoses is an independent predictor of long-term survival, predominant over the number of arterial grafts and the completeness of the revascularization; higher the number, better the late survival. It is a strong support of the extensive use of arterial grafting in CABG.

Impact of Bilateral versus Single Internal Thoracic Artery Grafting on the Long-Term Survival in Adults: A Systematic Review

“…Moreover, the great emphasis on comparing SITA and MAG was beneficial in the sense that it helped to integrate the diversity of grafts configuration and the different technicalities that go into it. 20 , 21 …”

“…Moreover, the great emphasis on comparing SITA and MAG was beneficial in the sense that it helped to integrate the diversity of grafts configuration and the different technicalities that go into it. 20,21 A new randomized study "The ROMA trial" (Randomized Comparison of the Clinical Outcome of Single Versus Multiple Arterial Grafts), comparing single and multiple arterial grafts is in process, started in January 2018 with primary completion end of 2021 and estimated completion date January 2030. 22 The findings of this study are estimated to resolve this conflict and provide the clarity needed.…”

The Canadian Women’s Heart Health Alliance Atlas on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women — Chapter 6: Sex- and Gender-Specific Diagnosis and Treatment

“…The survival benefits of using bilateral internal thoracic (mammary) artery (ITA) grafts is well established in predominantly male populations. 75 Attia et al. reported that single ITA grafting was associated with better survival in both women and men.…”

What does complete revascularization mean in 2021? – Definitions, implications, and biases

“…Considering that some studies have reported the separation between preserved LV function and late outcomes after CABG, it can be hypothesized that the prevention of spontaneous MI may be more beneficial than the restoration of LV function attributable to distal graft placement by CABG, which enables myocardial protection against proximal vessel occlusion [22,23 ▪ ]. Interestingly, an observational study recently reported that the number of distal arterial anastomoses was an independent predictor of late mortality after CABG, which was predominant over the completeness of myocardial revascularization [24 ▪ ]. Based on this rationale, milder lesions are occasionally bypassed under the expectation that bypass grafts have a protective role [25].…”