Why Don’t We Kill 2 Birds with 1 Stone?
2018; Lippincott Williams & Wilkins; Volume: 137; Issue: 16 Linguagem: Inglês
10.1161/circulationaha.117.032885
ISSN1524-4539
AutoresFaisal G. Bakaeen, Lars G. Svensson,
Tópico(s)Mechanical Circulatory Support Devices
ResumoHomeCirculationVol. 137, No. 16Why Don't We Kill 2 Birds with 1 Stone? Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBWhy Don't We Kill 2 Birds with 1 Stone?Less Adverse Cardiac Events and Improved Survival With Multiarterial Coronary Artery Bypass Grafting Faisal G. Bakaeen, MD and Lars G. Svensson, MD, PhD Faisal G. BakaeenFaisal G. Bakaeen Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, OH. and Lars G. SvenssonLars G. Svensson Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, OH. Originally published17 Apr 2018https://doi.org/10.1161/CIRCULATIONAHA.117.032885Circulation. 2018;137:1708–1711Article, see p 1698In 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).Table. Barriers to Multiarterial Grafting, Proposed Solutions, and Responsible PartiesBarriersSolutionsResponsible PartiesLack of evidence from randomized trials. Data limited to short-term results only.Education that absence of proof from randomized trials does not negate the well-documented benefits reported by population-based and large, well-designed observational studies and metaanalyses.Professional associations, guideline committees, and cardiovascular thought leadersTechnical difficultyCenters of excellence for CABG, dedicated CABG teams with experienced arterial harvesters and grafters, training coursesSurgeons, training programs, medical centers, and professional associationsPerceived increased perioperative risk, including sternal wound complications with BITA grafting and conduit spasm and string sign with RA graftingTraining and education, improved harvesting (skeletonized ITA) and graft handling techniques, proper target selection, and better patient selectionSurgeons, professional associations, and specialty boardsTime and resource intensiveFinancial incentivesGovernment agencies and payersNot a quality metricMultiarterial grafting as a quality differentiatorProfessional associations, guideline committees, quality trackers, government agencies and payersLack of patient selection criteriaBetter defined criteria for patients who stand to benefit the mostClinical investigators, research funding agencies, and professional associationsBITA, bilateral internal thoracic artery; CABG, coronary artery bypass grafting; ITA, internal thoracic artery; and RA, radial artery.Starting with the scientific evidence, the California study is the largest study to date and an important addition to other large observational studies demonstrating the real-world benefits of multiarterial grafting.3–5 Clinical practice guidelines encourage multiarterial grafting,2 but the lingering argument for not embracing multiarterial grafting is lack of evidence derived from randomized trials. Ironically, though, the 1986 landmark study from Cleveland Clinic6 that set the standard of using at least 1 internal thoracic artery in CABG was an observational study that was never corroborated by multicenter randomized trials.The incremental survival benefit of multiarterial grafting over single internal thoracic artery (SITA) grafting may not be as large as the benefit of left internal thoracic artery to left anterior descending coronary artery grafting when compared with a vein-graft-only strategy,6 and the added benefit of incorporating additional arterial grafts depends on the importance of the bypassed non-left anterior descending coronary artery vessels. Regardless, the absence of evidence from large randomized trials, mostly because they lack long-term follow-up, does not negate the benefits associated with multiarterial grafting reported by large, well-designed observational studies and meta-analyses.1,3–5,7Consistent with other studies demonstrating a time lag in the realization of a survival benefit associated with multiarterial grafting,3,5 Goldstone and colleagues reported that the survival curves diverged significantly at 4 years, and the separation appears to increase with time in favor of multiarterial grafting.3,5 In the Cleveland Clinic experience, the incremental survival benefit for bilateral internal thoracic artery (BITA) versus SITA grafting at 20 years postoperatively was 10% or greater for most patients.5 Yet prevailing CABG quality metrics only incorporate SITA grafting and track mortality up to 30 days or at the conclusion of the index CABG hospitalization. This holds true for the current CABG star ranking by the Society of Thoracic Surgeons,8 quality metrics endorsed by the National Quality Forum, and institutional ranking by the US News & World Report. None of these quality platforms currently incorporates multiarterial grafting and longer-term outcomes in their measures, nor do coronary revascularization guidelines recommend multiarterial grafting as strongly as they do SITA use. In addition, no healthcare payers adequately compensate for the additional resources needed for multiarterial grafting, despite the technical challenges and prolonged operative times associated with it.Improved mid- to long-term patency of RA compared with saphenous vein grafts has been reported by randomized trials,9,10 but improved survival has been reported only by observational studies.7,11 With regard to comparative studies of RA versus RITA grafting, the RAPCO trial (Radial Artery Patency and Clinical Outcomes) reported similar angiographic and clinical outcomes associated with both procedures,9 and observational studies have reported mixed results.12,13 We recently reported similar perioperative and long-term outcomes of RA and RITA grafting in patients with diabetes and view them as superior conduits to veins.14 Notably, Goldstone et al did not look at the diabetic population as a distinct subgroup.The California data support the equivalent efficacy of RA and RITA grafts, but the authors go a step further by suggesting that radial arteries may be the preferred second conduit because RITA grafting was associated with increased sternal wound infections.1 We suggest caution in declaring a winner between RA and RITA grafting based on the study design and available data. Radial arteries are more vulnerable to competitive flow, and target selection is more restrictive than for RITAs.2 Therefore, in the absence of granular data on target coronary anatomy and lesion severity, it is hard to compare patients undergoing RA and RITA grafting and provide definitive conclusions. Regarding the sternal wound complications, they may be mitigated by meticulous techniques, including skeletonizing BITAs.Heart team discussions about coronary revascularization in multivessel disease should take into account patients' age, risk profile, and coronary disease complexity. When appropriate, the knowledge that multiarterial grafting can offer a long-term advantage over percutaneous intervention, particularly for young patients, or over CABG with SITA and vein grafts, should be shared with patients as part of the informed consent process.4,15As noted by Goldstone et al,1 notwithstanding the interim nature of the results, explanations for the negative findings of the 5-year interim-analysis results of ART (Arterial Revascularization Trial) include a significant prevalence (>20%) of RA grafting in the SITA group that likely narrowed the outcomes difference between the study arms, and higher-than-expected crossovers between treatment arms. In fact, 14% of patients who underwent surgery in the BITA arm ended up receiving SITA grafting. This underscores that multiarterial grafting is not always possible or preferable, because despite satisfying the trial's screening criteria and apparent eligibility for BITA, BITA grafting was not performed in 14% of patients based on the intraoperative judgment of the surgeons, who are arguably multiarterial enthusiasts. Therefore, in the average cardiac surgical practice, a much higher percentage of all-comers would not be suitable to receive BITA or RA grafting.With regard to the probing question of whether any subgroup of patients might not benefit from multiarterial grafting, Goldstone et al identified an age cut-off of 78 years for multiarterial benefit.1 A recent Canadian population-based study3 identified severely reduced ejection fraction and age >70 years as risk factors that could neutralize the benefits of multiarterial grafting. In addition, a multi-institutional review also reported lack of survival benefit of multiarterial grafting for patients >70 years of age.12 Lytle et al concluded that most patients derive a benefit from BITA, but not all benefit equally, and the benefit occurs at different points during follow-up for different patient subsets. Patients >70 years of age with a small body surface area were the only subset likely to have worse outcomes with BITA grafting, but younger patients have a marked benefit.5Although the study by Goldstone et al has limitations, primarily related to biases and unmeasured covariates common to all observational studies, it confirms that at a population level, 2 arteries are better than 1 in multivessel CABG and supports use of an RA as an attractive alternative to RITA grafting. It also highlights a disappointing trend in the decline of multiarterial grafting.In summary, the body of evidence based on large and well-designed observational studies such as this one cannot be ignored. The magnitude of benefit associated with multiarterial grafting is variable and depends on a patient's risk profile and coronary anatomy. Multiarterial CABG is probably best performed by surgeons experienced in this technique to ensure superior outcomes and minimize possible complications. Efforts focused on research, education and training, and expanding the quality sphere to incorporate long-term cost effectiveness can drive improved and durable coronary care in California and beyond (Table).In conclusion, while some may argue that the advantage of multiarterial grafting awaits validation by randomized trials before adoption, we believe that surgeons comfortable with RA and RITA grafting should offer these options to patients who may benefit from the increased longevity it can provide.Sources of FundingSheikh Hamdan bin Rashid Al Maktoum Distinguished Chair in Thoracic and Cardiovascular Surgery held by Dr Bakaeen, and the Marty and Michelle Weinberg and Family Fund.DisclosuresNone.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.http://circ.ahajournals.orgFaisal G. Bakaeen, MD, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Avenue/Desk J4-1, Cleveland, OH 44195. E-mail [email protected]References1. Goldstone AB, Chiu P, Baiocchi M, Wang H, Lingala B, Boyd JH, Woo YJ. Second arterial versus venous conduits for multivessel coronary artery bypass surgery in California.Circulation. 2018; 137:1698–1707. doi: 10.1161/CIRCULATIONAHA.117.030959.LinkGoogle Scholar2. Aldea GS, Bakaeen FG, Pal J, Fremes S, Head SJ, Sabik J, Rosengart T, Kappetein AP, Thourani VH, Firestone S, Mitchell JD; Society of Thoracic Surgeons. The Society of Thoracic Surgeons Clinical Practice Guidelines on Arterial Conduits for Coronary Artery Bypass Grafting.Ann Thorac Surg. 2016; 101:801–809. doi: 10.1016/j.athoracsur.2015.09.100.CrossrefMedlineGoogle Scholar3. Pu A, Ding L, Shin J, Price J, Skarsgard P, Wong DR, Bozinovski J, Fradet G, Abel JG. 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Akhrass R and Bakaeen F (2021) The 10 Commandments for Multiarterial Grafting, Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery, 10.1177/15569845211003094, 16:3, (209-213), Online publication date: 1-May-2021. Bakaeen F, Johnston D and Svensson L (2021) Commentary: Coronary artery bypass grafting as a subspecialty: Hype or reality, The Journal of Thoracic and Cardiovascular Surgery, 10.1016/j.jtcvs.2020.04.013, 161:6, (2136-2137), Online publication date: 1-Jun-2021. Qureshi S, Boulemden A, Darwin O, Shanmuganathan S, Szafranek A and Naik S (2021) Multiarterial coronary grafting using the radial artery as a second arterial graft: how far does the survival benefit extend?, European Journal of Cardio-Thoracic Surgery, 10.1093/ejcts/ezab308, 61:1, (216-224), Online publication date: 27-Dec-2022. Bakaeen F (2021) Commentary: Total-arterial, anaortic revascularization, and the boutique practice of coronary surgery, JTCVS Techniques, 10.1016/j.xjtc.2021.10.013, 10, (151-152), Online publication date: 1-Dec-2021. Bakaeen F, Ravichandren K, Blackstone E, Houghtaling P, Soltesz E, Johnston D, Mick S, Navia J, Tong M, McCurry K, Akhrass R, Abdallah M, Pettersson G, Smedira N, Roselli E, Gillinov A and Svensson L (2020) Coronary Artery Target Selection and Survival After Bilateral Internal Thoracic Artery Grafting, Journal of the American College of Cardiology, 10.1016/j.jacc.2019.11.026, 75:3, (258-268), Online publication date: 1-Jan-2020. Locker C (2019) Commentary: Is the era of bilateral internal thoracic artery coming for diabetic patients? Yes, 取决于你问谁 [depends who you ask], The Journal of Thoracic and Cardiovascular Surgery, 10.1016/j.jtcvs.2019.02.124, 158:6, (1573-1575), Online publication date: 1-Dec-2019. April 17, 2018Vol 137, Issue 16 Advertisement Article InformationMetrics © 2018 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.117.032885PMID: 29661950 Originally publishedApril 17, 2018 Keywordscoronary artery bypassinternal thoracic arteryEditorialsradial arterymulti-arterial graftingPDF download Advertisement
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