Outcomes of total arterial revascularization vs conventional revascularization in patients undergoing coronary artery bypass graft surgery: A narrative review of major studies.
Ontology highlight
ABSTRACT:
SUBMITTER: Dominici C
PROVIDER: S-EPMC9247795 | biostudies-literature |
REPOSITORIES: biostudies-literature
Similar Datasets
Project description:ImportanceThe optimal conduits for coronary artery bypass grafting (CABG) remain controversial in multivessel coronary artery disease.ObjectiveTo compare the long-term clinical outcomes of total arterial revascularization (TAR) vs non-TAR (CABG with at least 1 arterial and 1 saphenous vein graft) in a multicenter population-based study.Design, setting, and participantsThis multicenter population-based cohort study using propensity score matching took place from October 2008 to March 2017 in Ontario, Canada, with a mean and maximum follow-up of 4.6 and 9.0 years, respectively. Individuals with primary isolated CABG were identified, with at least 1 arterial graft. Exclusion criteria were individuals from out of province and younger than 18 years. Patients undergoing a cardiac reoperation or those in cardiogenic shock were also excluded because these conditions would potentially bias the surgeon toward not performing TAR. Analysis began April 2019.ExposuresTotal arterial revascularization.Main outcomes and measuresPrimary outcome was time to first event of a composite of death, myocardial infarction, stroke, or repeated revascularization (major adverse cardiac and cerebrovascular events). Secondary outcomes included the individual components of the primary outcome.ResultsOf 49 404 individuals with primary isolated CABG, 2433 (4.9%) received TAR, with the total number of bypasses being 2, 3, and 4 or more vessels in 1521 (62.5%), 865 (35.6%), and 47 individuals (1.9%), respectively. The mean (SD) age was 61.2 (10.4) years and 1983 (81.5%) were men. After propensity score matching, 2132 patient pairs were formed, with equal total number of bypasses (mean [SD], 2.4 [0.5]) but with more arterial grafts in the TAR group (mean [SD], 2.4 [0.5] vs 1.2 [0.4]; P < .01). In-hospital death (15 [0.7%] vs 21 [1.0%]; P = .32) did not differ between TAR vs non-TAR groups after propensity score matching. Throughout 8 years, TAR was associated with improved freedom from major adverse cardiac and cerebrovascular events (hazard ratio, 0.78; 95% CI, 0.68-0.89), death (hazard ratio, 0.80; 95% CI, 0.66-0.97), and myocardial infarction (hazard ratio, 0.69; 95% CI, 0.51-0.92). There was no difference in stroke and repeated revascularization.Conclusions and relevanceTotal arterial revascularization was associated with improved long-term freedom from major adverse cardiac and cerebrovascular events, death, and myocardial infarction and may be the procedure of choice for patients with reasonable life expectancy requiring CABG.
| S-EPMC7042852 | biostudies-literature
Project description:BackgroundBypass grafting for chronic total occlusions (CTOs) remains surgically challenging and controversial. Therefore, we evaluated the incidence and clinical outcomes of revascularization on CTOs undergoing coronary artery bypass grafting (CABG).MethodsAmong 828 patients who underwent isolated CABG from January 2010 to December 2018, 245 patients (29.6%) diagnosed with at least one CTO were included and retrospectively reviewed. Primary endpoints were 30-day and overall mortality. Secondary endpoint was the composite outcome of major adverse cardiac and cerebrovascular events (MACCE).ResultsWith a mean follow-up of 56.6±6.5 months in 245 patients with CTOs, 51 patients (20.8%) received incomplete revascularization (ICR) for CTO lesions. Risk factor analysis showed that ICR was associated with increased 30-day [odds ratio 8.62; 95% confidence interval (CI): 1.64-50; P=0.011] and overall mortality (hazard ratio (HR) 2.13; 95% CI: 1.07-4.21; P=0.03). ICR also increased the risk of MACCE (HR 1.98; 95% CI: 1.12-3.54; P=0.01). Freedom from overall mortality was 92.8%, 90.4%, and 86.8% in the complete revascularization group, and 86.3%, 80.0%, and 72.7% in the ICR group, at 1, 3, and 5 years, respectively (P=0.004).ConclusionsIn patients with CTOs undergoing CABG, the rate of ICR was 20.8%, and it significantly increased the risk of mortality and MACCE. Further studies in a large cohort are needed.
| S-EPMC8662467 | biostudies-literature
Project description:PurposeReimplanting the radial artery in the left internal thoracic artery as a composite graft allows total arterial revascularization (TAR) without aortic manipulation. The limitation of this strategy is the length of the radial artery required to reach distal right coronary artery (RCA) branches. Our analysis focuses on the feasibility of this strategy.MethodsA total of 169 patients underwent TAR using the radial artery in a composite grafting configuration. Length of the radial artery, number of sequential anastomoses, heart size, target location, length of the arm, patient height, body surface area, and flow in the composite graft were prospectively collected.ResultsThe mean length of the radial artery was 18.02 cm. Patients with a mean length of the radial artery of 15.9 cm needed an extension of the radial artery with another conduit to reach the RCA distal branches. When T-configuration is used, the length of the radial artery should be 0.53 cm per sequential anastomosis to reach the RCA distal branches.ConclusionsOur study shows that an average length of 18.02 cm of radial artery is needed to reach targets on the RCA distal branches in composite grafting. In T-configuration, we need 0.53 cm more length per anastomosis to achieve TAR.
| S-EPMC10902649 | biostudies-literature
Project description:BackgroundThere is still uncertainty about the safety of aprotinin for coronary artery bypass graft surgery. The ART (Arterial Revascularization Trial) was designed to compare survival after bilateral versus single internal thoracic artery grafting. Many of the ART patients (?30%) received perioperative aprotinin. We investigated the association between perioperative aprotinin administration and short-term (in-hospital) and long-term outcomes by performing a post hoc analysis of the ART.Methods and resultsAmong patients enrolled in the ART (n=3102) from 2004 to 2007, we excluded those who did not undergo surgery (n=18) and those with no information about use of perioperative aprotinin (n=9). Finally, 836 of 3076 patients (27%) received aprotinin. Propensity matching was used to select 536 pairs for final comparison. Aprotinin was also associated with an increased risk of hospital mortality (9 [1.7%] versus 1 [0.2%]; odds ratio, 9.12; 95% confidence interval [CI], 1.15-72.2; P=0.03), intra-aortic balloon pump insertion (37 [6.9%] versus 17 [3.2%]; odds ratio, 2.26; 95% CI, 1.26-4.07; P=0.006), and acute kidney injury (102 [19.0%] versus 76 [14.2%]; odds ratio, 1.42; 95% CI, 1.03-1.97; P=0.03). Aprotinin was not associated with a lower incidence of transfusion (37 [6.9%] versus 28 [5.2%]; odds ratio, 1.34; 95% CI, 0.81-2.23; P=0.25) and reexploration (26 [4.9%] versus 19 [3.5%]; hazard ratio, 1.39; 95% CI, 0.76-2.53; P=0.28). At 5 years, all-cause mortality was significantly increased in the aprotinin group (56 [10.6%] versus 38 [7.3%]; hazard ratio, 1.51; 95% CI, 1.0-2.28; P=0.045).ConclusionsIn the present post hoc ART analysis, aprotinin was associated with a significantly increased risk of early and late mortality.Clinical trial registrationURL: http://www.isrctn.com. Unique identifier: ISRCTN46552265.
| S-EPMC5866323 | biostudies-literature
Project description:ObjectivesThe objective of this investigation was to determine the preoperative prognostic factors of long-term (10-year) mortality in patients treated with isolated coronary artery bypass graft surgery in the arterial revascularization trial (ART).MethodsA post hoc analysis of the ART was conducted. Cumulative 10-year mortality was estimated using the Kaplan-Meier method. Prospectively collected preoperative data were used to determine the prognostic factors of 10-year all-cause mortality in patients who participated in the ART (Cox proportional hazards model).ResultsA total of 3102 patients who participated in the ART were included in the analysis. Ten-year follow-up was completed in 3040 patients (98%). A total of 644 patients (20.8%) had died by 10 years. Preoperative factors that were identified as statistically significant predictors of 10-year mortality in the multivariable analysis (all P ≤ 0.01) were: left ventricular ejection fraction, atrial fibrillation, age, diabetes, prior cerebrovascular event (stroke or transient ischaemic attack), serum creatinine and smoking status. The following variables were significantly associated in univariable models but did not retain significance in the multivariable model for mortality: non-Caucasian ethnicity, hypertension, peripheral vascular disease, chronic obstructive pulmonary disease and prior myocardial infarction.ConclusionsIndependent predictors of 10-year mortality in the ART were multifactorial. Several key independent predictors of 10-year mortality in the ART were identified including: heart function, renal function, cerebrovascular disease, age, atrial fibrillation, smoking status and diabetes. Understanding which preoperative variables influence long-term outcome after coronary artery bypass grafting may help to target treatments to those at higher risk to reduce mortality.
| S-EPMC9154348 | biostudies-literature
Project description:ImportanceIt is uncertain whether coronary artery bypass grafting (CABG) is associated with cognitive decline in older adults compared with a nonsurgical method of coronary revascularization (percutaneous coronary intervention [PCI]).ObjectiveTo compare the change in the rate of memory decline after CABG vs PCI.Design, setting, and participantsRetrospective cohort study of community-dwelling participants in the Health and Retirement Study, who underwent CABG or PCI between 1998 and 2015 at age 65 years or older. Data were modeled for up to 5 years preceding and 10 years following revascularization or until death, drop out, or the 2016-2017 interview wave. The date of final follow-up was November 2017.ExposuresCABG (including on and off pump) or PCI, ascertained from Medicare fee-for-service billing records.Main outcomes and measuresThe primary outcome was a summary measure of cognitive test scores and proxy cognition reports that were performed biennially in the Health and Retirement Study, referred to as memory score, normalized as a z score (ie, mean of 0, SD of 1 in a reference population of adults aged ≥72 years). Memory score was analyzed using multivariable linear mixed-effects models, with a prespecified subgroup analysis of on-pump and off-pump CABG. The minimum clinically important difference was a change of 1 SD of the population-level rate of memory decline (0.048 memory units/y).ResultsOf 1680 participants (mean age at procedure, 75 years; 41% female), 665 underwent CABG (168 off pump) and 1015 underwent PCI. In the PCI group, the mean rate of memory decline was 0.064 memory units/y (95% CI, 0.052 to 0.078) before the procedure and 0.060 memory units/y (95% CI, 0.048 to 0.071) after the procedure (within-group change, 0.004 memory units/y [95% CI, -0.010 to 0.018]). In the CABG group, the mean rate of memory decline was 0.049 memory units/y (95% CI, 0.033 to 0.065) before the procedure and 0.059 memory units/y (95% CI, 0.047 to 0.072) after the procedure (within-group change, -0.011 memory units/y [95% CI, -0.029 to 0.008]). The between-group difference-in-differences estimate for memory decline for PCI vs CABG was 0.015 memory units/y (95% CI, -0.008 to 0.038; P = .21). There was statistically significant increase in the rate of memory decline after off-pump CABG compared with after PCI (difference-in-differences: mean increase in the rate of decline of 0.046 memory units/y [95% CI, 0.008 to 0.084] after off-pump CABG), but not after on-pump CABG compared with PCI (difference-in-differences: mean slowing of decline of 0.003 memory units/y [95% CI, -0.024 to 0.031] after on-pump CABG).Conclusions and relevanceAmong older adults undergoing coronary revascularization with CABG or PCI, the type of revascularization procedure was not significantly associated with differences in the change of rate of memory decline.
| S-EPMC8132142 | biostudies-literature
Project description:BackgroundThe impact of utilization of intraoperative transesophageal echocardiography (TEE) at the time of isolated coronary artery bypass grafting (CABG) on clinical decision making and associated outcomes is not well understood.ObjectivesThe purpose of this study was to determine the association of TEE with post-CABG mortality and changes to the operative plan.MethodsA retrospective cohort study of planned isolated CABG patients from the Society of Thoracic Surgeons Adult Cardiac Surgery Database between January 1, 2011, and June 30, 2019, was performed. The exposure variable of interest was use of intraoperative TEE during CABG compared with no TEE. The primary outcome was operative mortality. The association of TEE with unplanned valve surgery was also assessed.ResultsOf 1,255,860 planned isolated CABG procedures across 1218 centers, 676,803 (53.9%) had intraoperative TEE. The percentage of patients receiving intraoperative TEE increased over time from 39.9% in 2011 to 62.1% in 2019 (p trend <0.0001). CABG patients undergoing intraoperative TEE had lower odds of mortality (adjusted odds ratio: 0.95; 95% confidence interval: 0.91 to 0.99; p = 0.025), with heterogeneity across STS risk groups (p interaction = 0.015). TEE was associated with increased odds of unplanned valve procedure in lieu of planned isolated CABG (adjusted odds ratio: 4.98; 95% confidence interval: 3.98 to 6.22; p < 0.0001).ConclusionsIntraoperative TEE usage during planned isolated CABG is associated with lower operative mortality, particularly in higher-risk patients, as well as greater odds of unplanned valve procedure. These findings support usage of TEE to improve outcomes for isolated CABG for high-risk patients.
| S-EPMC8876254 | biostudies-literature
Project description:ObjectivesCovert stroke is a complication of coronary artery bypass graft surgery that is increasingly recognized as a serious problem. In noncardiac surgery settings, covert stroke is associated with the development of delirium, long-term cognitive decline, and future clinical stroke. Therefore, we sought to determine the feasibility of conducting a large, prospective cohort study of the influence of covert stroke on neurocognitive outcomes in patients undergoing coronary artery bypass graft surgery.MethodsNeuroVISION Cardiac pilot was a prospective cohort study enrolling patients aged ≥21 years undergoing isolated coronary artery bypass graft surgery to receive diffusion-weighted magnetic resonance imaging of the brain after surgery to identify patients with covert stroke. Patients were screened for postoperative delirium in-hospital and were administered questionnaires of cognitive and global function (once before and twice after surgery). Regional cerebral oxygen saturation was recorded during surgery using near-infrared spectroscopy.ResultsBetween March 27, 2017, and February 11, 2018, 50 of 66 patients enrolled (76%) completed the brain magnetic resonance imaging (1 patient per week). Among the 49 patients included in the analysis, 19 (39%; 95% confidence interval, 26%-53%) experienced perioperative covert stroke and 3 (6%) had a clinical stroke within 30 days of surgery. Postoperative delirium occurred in 5 (26%) patients with covert stroke and in 3 (10%) patients who did not experience covert stroke.ConclusionsThe NeuroVISION Cardiac pilot study established the feasibility of conducting a large, prospective cohort study of the determinants and consequences of covert stroke in patients undergoing coronary artery bypass graft surgery.
| S-EPMC9390707 | biostudies-literature
Project description: Not available
| S-EPMC8500991 | biostudies-literature
Project description:ImportanceObservational studies have suggested that the use of radial artery grafts for coronary artery bypass grafting may improve clinical outcomes compared with the use of saphenous vein grafts, but this has not been confirmed in randomized trials.ObjectiveTo compare clinical outcomes between patients receiving radial artery vs saphenous vein grafts for coronary artery bypass grafting after long-term follow-up.Design, setting, and participantsPatient-level pooled analysis comparing radial artery vs saphenous vein graft in adult patients undergoing isolated coronary artery bypass grafting from 5 countries (Australia, Italy, Serbia, South Korea, and the United Kingdom), with enrollment from 1997 to 2009 and follow-up completed in 2019.InterventionsPatients were randomized to undergo either radial artery (n?=?534) or saphenous vein (n?=?502) grafts for coronary artery bypass grafting.Main outcomes and measuresThe primary outcome was a composite of death, myocardial infarction, or repeat revascularization and the secondary outcome was a composite of death or myocardial infarction.ResultsA total of 1036 patients were randomized (mean age, 66.6 years in the radial artery group vs 67.1 years in the saphenous vein group; 376 [70.4%] men in the radial artery group vs 351 [69.9%] in the saphenous vein group); 942 (90.9%) of the originally randomized patients completed 10 years of follow-up (510 in the radial artery group). At a median (interquartile range) follow-up of 10 (10-11) years, the use of the radial artery, compared with the saphenous vein, in coronary artery bypass grafting was associated with a statistically significant reduction in the incidence of the composite outcome of death, myocardial infarction, or repeat revascularization (220 vs 237 total events; 41 vs 47 events per 1000 patient-years; hazard ratio, 0.73 [95% CI, 0.61-0.88]; P?<?.001) and of the composite of death or myocardial infarction (188 vs 193 total events; 35 vs 38 events per 1000 patient-years; hazard ratio, 0.77 [95% CI, 0.63-0.94]; P?=?.01).Conclusions and relevanceIn this individual participant data meta-analysis with a median follow-up of 10 years, among patients undergoing coronary artery bypass grafting, the use of the radial artery compared with the saphenous vein was associated with a lower risk of a composite of cardiovascular outcomes.
| S-EPMC7361649 | biostudies-literature