Voltar
Artigo Acesso aberto Revisado por pares
BIBTEX RIS

Transatlantic editorial: The use of multiple arterial grafts for coronary revascularization in Europe and North America

2020; Elsevier BV; Volume: 159; Issue: 6 Linguagem: Inglês

10.1016/j.jtcvs.2020.02.048

ISSN

1097-685X

Autores

Mario Gaudino, Joanna Chikwe, Volkmar Falk, Jennifer S. Lawton, John D. Puskas, David P. Taggart,

Tópico(s)

Cardiac Valve Diseases and Treatments

Resumo

The use of multiple arterial grafts (MAGs) for coronary artery bypass grafting (CABG) is encouraged by all existing guidelines and recommendations from professional societies (Table 1).1Hillis L.D. Smith P.K. Anderson J.L. et al.2011 ACCF/AHA guideline for coronary artery bypass graft surgery. A report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons.J Am Coll Cardiol. 2011; 58: e123-e210Crossref PubMed Scopus (555) Google Scholar, 2Aldea G.S. Bakaeen F.G. Pal J. et al.The Society of Thoracic Surgeons clinical practice guidelines on arterial conduits for coronary artery bypass grafting.Ann Thorac Surg. 2016; 101: 801-809Abstract Full Text Full Text PDF PubMed Scopus (216) Google Scholar, 3Sousa-Uva M. Neumann F.-J. Ahlsson A. et al.2018 ESC/EACTS guidelines on myocardial revascularization.Eur J Cardiothorac Surg. 2019; 55: 4-90Crossref PubMed Scopus (255) Google Scholar However, it should be noted that the evidence basis in support of the use of MAGs is not definitive.Table 1Summary of current guidelines on the use of multiple arterial grafts for coronary artery bypass graftingGuidelineSummaryACC/AHA,1Hillis L.D. Smith P.K. Anderson J.L. et al.2011 ACCF/AHA guideline for coronary artery bypass graft surgery. A report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons.J Am Coll Cardiol. 2011; 58: e123-e210Crossref PubMed Scopus (555) Google Scholar 2011When anatomically and clinically suitable, use of a second IMA to graft the left circumflex or right coronary artery (when critically stenosed and perfusing LV myocardium) is reasonable to improve the likelihood of survival and to decrease reintervention (Class IIa, LOE B).STS,2Aldea G.S. Bakaeen F.G. Pal J. et al.The Society of Thoracic Surgeons clinical practice guidelines on arterial conduits for coronary artery bypass grafting.Ann Thorac Surg. 2016; 101: 801-809Abstract Full Text Full Text PDF PubMed Scopus (216) Google Scholar 2016As an adjunct to LITA, a second arterial graft (RITA or RA) should be considered in appropriate patients (COR IIa, LOE B).Use of BITAs should be considered in patients who do not have an excessive risk of sternal complications (COR IIa, LOE B).As an adjunct to LITA to LAD (or in patients with inadequate LITA grafts), use of a RA graft is reasonable when grafting coronary targets with severe stenoses (COR IIa, LOE B).The RGEA may be considered in patients with poor conduit options or as an adjunct to more complete arterial revascularization (COR IIb, LOE B).Use of arterial grafts (specific targets, number, and type) should be a part of the discussion of the heart team in determining the optimal approach for each patient (COR I, LOE C).ESC/EACTS,3Sousa-Uva M. Neumann F.-J. Ahlsson A. et al.2018 ESC/EACTS guidelines on myocardial revascularization.Eur J Cardiothorac Surg. 2019; 55: 4-90Crossref PubMed Scopus (255) Google Scholar 2018Additional arterial graft should be considered in appropriate patients (Class IIa, Level B).The use of the radial artery is recommended over the saphenous vein in patients with high grade coronary artery stenosis (Class I, Level B).BIMA grafting should be considered in patients who do not have a high risk of sternal wound infection (Class IIa, Level B).Multiple arterial grafting should be considered using the radial artery for high-grade stenosis and/or BIMA grafting for patients who do not have an increased risk of sternal wound infection.ACC, American College of Cardiology; AHA, American Heart Association; IMA, internal mammary artery; LV, left ventricle; LOE, level of evidence; STS, The Society of Thoracic Surgeons; LITA, left internal thoracic artery; RITA, right internal thoracic artery; RA, radial artery; COR, class of recommendation; BITA, bilateral internal thoracic artery; LAD, left anterior descending; RGEA, right gastroepiploic artery; ESC, European Society of Cardiology; EACTS, European Association for Cardio-Thoracic Surgery; BIMA, bilateral internal mammary artery. Open table in a new tab ACC, American College of Cardiology; AHA, American Heart Association; IMA, internal mammary artery; LV, left ventricle; LOE, level of evidence; STS, The Society of Thoracic Surgeons; LITA, left internal thoracic artery; RITA, right internal thoracic artery; RA, radial artery; COR, class of recommendation; BITA, bilateral internal thoracic artery; LAD, left anterior descending; RGEA, right gastroepiploic artery; ESC, European Society of Cardiology; EACTS, European Association for Cardio-Thoracic Surgery; BIMA, bilateral internal mammary artery. On one hand, a large body of observational evidence suggests that patients who receive MAGs for CABG have better postoperative outcomes and superior life expectancy.4Gaudino M. Rahouma M. Abouarab A. et al.Radial artery versus saphenous vein as the second conduit for coronary artery bypass surgery: a meta-analysis.J Thorac Cardiovasc Surg. 2019; 157: 1819-1825.e10Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar,5Buttar S.N. Yan T.D. Taggart D.P. Tian D.H. Long-term and short-term outcomes of using bilateral internal mammary artery grafting versus left internal mammary artery grafting: a meta-analysis.Heart. 2017; 103: 1419-1426Crossref PubMed Scopus (100) Google Scholar In addition, several randomized trials have reported that the midterm patency rate of arterial conduits, the radial artery (RA) in particular, is higher than that of the saphenous vein (Table 2).6Taggart D.P. Benedetto U. Gerry S. et al.Bilateral versus single internal-thoracic-artery grafts at 10 years.N Engl J Med. 2019; 380: 437-446Crossref PubMed Scopus (191) Google Scholar, 7Petrovic I. Nezic D. Peric M. et al.Radial artery vs saphenous vein graft used as the second conduit for surgical myocardial revascularization: long-term clinical follow-up.J Cardiothorac Surg. 2015; 10: 127Crossref PubMed Scopus (27) Google Scholar, 8Hayward P.A.R. Gordon I.R. Hare D.L. et al.Comparable patencies of the radial artery and right internal thoracic artery or saphenous vein beyond 5 years: results from the radial artery patency and clinical outcomes trial.J Thorac Cardiovasc Surg. 2010; 139 ([discussion: 65-7]): 60-65Abstract Full Text Full Text PDF PubMed Scopus (127) Google Scholar, 9Deb S. Cohen E.A. Singh S.K. Une D. Laupacis A. Fremes S.E. RAPS InvestigatorsRadial artery and saphenous vein patency more than 5 years after coronary artery bypass surgery: results from RAPS (Radial Artery Patency Study).J Am Coll Cardiol. 2012; 60: 28-35Crossref PubMed Scopus (173) Google Scholar, 10Nasso G. Coppola R. Bonifazi R. Piancone F. Bozzetti G. Speziale G. Arterial revascularization in primary coronary artery bypass grafting: direct comparison of 4 strategies—results of the Stand-in-Y Mammary study.J Thorac Cardiovasc Surg. 2009; 137: 1093-1100Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar, 11Song S.-W. Sul S.-Y. Lee H.-J. Yoo K.J. Comparison of the radial artery and saphenous vein as composite grafts in off-pump coronary artery bypass grafting in elderly patients: a randomized controlled trial.Korean Circ J. 2012; 42: 107-112Crossref PubMed Scopus (34) Google Scholar, 12Goldman S. Sethi G.K. Holman W. et al.Radial artery grafts vs saphenous vein grafts in coronary artery bypass surgery: a randomized trial.JAMA. 2011; 305: 167-174Crossref PubMed Scopus (172) Google Scholar, 13Kim M.-S. Hwang H.Y. Kim J.S. Oh S.J. Jang M.J. Kim K.B. Saphenous vein versus right internal thoracic artery as a Y-composite graft: five-year angiographic and clinical results of a randomized trial.J Thorac Cardiovasc Surg. 2018; 156: 1424-1433.e1Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar, 14Muneretto C. Bisleri G. Negri A. et al.Left internal thoracic artery-radial artery composite grafts as the technique of choice for myocardial revascularization in elderly patients: a prospective randomized evaluation.J Thorac Cardiovasc Surg. 2004; 127: 179-184Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar, 15Collins P. Webb C.M. Chong C.F. Moat N.E. Radial Artery Versus Saphenous Vein Patency (RSVP) Trial InvestigatorsRadial artery versus saphenous vein patency randomized trial: five-year angiographic follow-up.Circulation. 2008; 117: 2859-2864Crossref PubMed Scopus (213) Google Scholar, 16Glineur D. D'hoore W. de Kerchove L. et al.Angiographic predictors of 3-year patency of bypass grafts implanted on the right coronary artery system: a prospective randomized comparison of gastroepiploic artery, saphenous vein, and right internal thoracic artery grafts.J Thorac Cardiovasc Surg. 2011; 142: 980-988Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar, 17Gaudino M. Cellini C. Pragliola C. et al.Arterial versus venous bypass grafts in patients with in-stent restenosis.Circulation. 2005; 112: I265-I269Crossref PubMed Scopus (1) Google ScholarTable 2Summary of randomized control trials comparing graft conduits for coronary artery bypass graftingTrialTotal patients (N)ComparisonMean follow-up (y)Main findingsArterial Revascularization Trial (ART)6Taggart D.P. Benedetto U. Gerry S. et al.Bilateral versus single internal-thoracic-artery grafts at 10 years.N Engl J Med. 2019; 380: 437-446Crossref PubMed Scopus (191) Google Scholar1548BITA vs SITA10Intention-to-treat analysis: mortality for BITA vs SITA: HR, 0.96; 95% CI, 0.82-1.12.As-treated analysis: mortality for BITA vs SITA: HR, 0.81; 95% CI, 0.68-0.95.Petrovic7Petrovic I. Nezic D. Peric M. et al.Radial artery vs saphenous vein graft used as the second conduit for surgical myocardial revascularization: long-term clinical follow-up.J Cardiothorac Surg. 2015; 10: 127Crossref PubMed Scopus (27) Google Scholar200RA vs SV8No significant difference in survival between RA vs SV (P = .979).No difference in the composite of cardiac death, nonfatal myocardial infarction, and repeat revascularization between RA and SV (P = .509).Radial Artery Patency and Clinical Outcomes (RAPCO)8Hayward P.A.R. Gordon I.R. Hare D.L. et al.Comparable patencies of the radial artery and right internal thoracic artery or saphenous vein beyond 5 years: results from the radial artery patency and clinical outcomes trial.J Thorac Cardiovasc Surg. 2010; 139 ([discussion: 65-7]): 60-65Abstract Full Text Full Text PDF PubMed Scopus (127) Google Scholar649Group 1: RITA vs RA (age 70)5.5Patencies were similar for either conduit in each group (log-rank P = .06 and P = .54, respectively).Radial Artery Patency Study (RAPS)9Deb S. Cohen E.A. Singh S.K. Une D. Laupacis A. Fremes S.E. RAPS InvestigatorsRadial artery and saphenous vein patency more than 5 years after coronary artery bypass surgery: results from RAPS (Radial Artery Patency Study).J Am Coll Cardiol. 2012; 60: 28-35Crossref PubMed Scopus (173) Google Scholar510RA vs SV7.7 ± 1.5Frequency of functional graft occlusion was lower in RA vs SV: 28 of 234 (12.0%) vs 46 of 234 (19.7%; P = .03).Frequency of total graft occlusion significantly lower in RA vs SV: 24 of 269 (8.9%) vs 50 of 269 (18.6%; P = .002).Stand-in-Y10Nasso G. Coppola R. Bonifazi R. Piancone F. Bozzetti G. Speziale G. Arterial revascularization in primary coronary artery bypass grafting: direct comparison of 4 strategies—results of the Stand-in-Y Mammary study.J Thorac Cardiovasc Surg. 2009; 137: 1093-1100Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar815LITA + RALITA + SVBITA2.0 ± 0.81Survival at 2 years was not different among groups (P = .59).Cardiac event-free survival was better in patients receiving 2 arterial grafts (P < .0001), even among elderly patients (P = .02).Song11Song S.-W. Sul S.-Y. Lee H.-J. Yoo K.J. Comparison of the radial artery and saphenous vein as composite grafts in off-pump coronary artery bypass grafting in elderly patients: a randomized controlled trial.Korean Circ J. 2012; 42: 107-112Crossref PubMed Scopus (34) Google Scholar60RA vs SV1No difference in postoperative mortality, patency, and survival between RA and SV.Goldman12Goldman S. Sethi G.K. Holman W. et al.Radial artery grafts vs saphenous vein grafts in coronary artery bypass surgery: a randomized trial.JAMA. 2011; 305: 167-174Crossref PubMed Scopus (172) Google Scholar757RA vs SV1No significant difference in graft patency at 1 year after CABG for RA vs SV (adjusted OR, 0.99; 95% CI, 0.56-1.74; P = .98).SAphenous VEin versus Right Internal Thoracic Artery as a Y-Composite Graft trial (SAVE-RITA)13Kim M.-S. Hwang H.Y. Kim J.S. Oh S.J. Jang M.J. Kim K.B. Saphenous vein versus right internal thoracic artery as a Y-composite graft: five-year angiographic and clinical results of a randomized trial.J Thorac Cardiovasc Surg. 2018; 156: 1424-1433.e1Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar224RITA vs SV5.1 ± 0.4No difference in graft occlusion rate (P = .910) between RITA vs SV.No difference in overall survival (P = .439) and freedom from major adverse cardiac and cerebrovascular event rates (P = .354) at 5 and 8 years between the 2 groups.Muneretto14Muneretto C. Bisleri G. Negri A. et al.Left internal thoracic artery-radial artery composite grafts as the technique of choice for myocardial revascularization in elderly patients: a prospective randomized evaluation.J Thorac Cardiovasc Surg. 2004; 127: 179-184Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar160RA vs SV1.3 ± 0.2SV was an independent predictor for graft occlusion (OR, 1.11; 95% CI, 1.06-1.16) and angina recurrence (HR, 2.45; 95% CI, 1.67-3.19).Radial artery versus Saphenous Vein Patency randomized trial (RVSP)15Collins P. Webb C.M. Chong C.F. Moat N.E. Radial Artery Versus Saphenous Vein Patency (RSVP) Trial InvestigatorsRadial artery versus saphenous vein patency randomized trial: five-year angiographic follow-up.Circulation. 2008; 117: 2859-2864Crossref PubMed Scopus (213) Google Scholar142RA vs SV5.6 ± 0.8At 5 years, 98.3% of RA grafts and 86.4% of SV grafts were patent (P = .04).Graft narrowing occurred in 10% of patent RA grafts and in 23% of patent SV grafts (P = .01).Glineur16Glineur D. D'hoore W. de Kerchove L. et al.Angiographic predictors of 3-year patency of bypass grafts implanted on the right coronary artery system: a prospective randomized comparison of gastroepiploic artery, saphenous vein, and right internal thoracic artery grafts.J Thorac Cardiovasc Surg. 2011; 142: 980-988Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar210RITA vs SV vs RGEA for the right coronary system3SV was associated with superior graft functionality compared with the other conduits (OR, 6.1; 95% CI, 2.4-15).Gaudino17Gaudino M. Cellini C. Pragliola C. et al.Arterial versus venous bypass grafts in patients with in-stent restenosis.Circulation. 2005; 112: I265-I269Crossref PubMed Scopus (1) Google Scholar120RA vs RITA vs SV in patients with in-stent restenosis4.3 ± 0.7SV grafts had a lower patency rate than arterial grafts and a high failure rate in patients with previous in-stent restenosis (P = .001).BITA, Bilateral internal thoracic arteries; SITA, single internal thoracic artery; HR, hazard ratio; CI, confidence interval; RA, radial artery; SV, saphenous vein; LITA, left internal thoracic artery; CABG, coronary artery bypass grafting; OR, odds ratio; RITA, right internal thoracic artery; RGEA, right gastroepiploic artery. Open table in a new tab BITA, Bilateral internal thoracic arteries; SITA, single internal thoracic artery; HR, hazard ratio; CI, confidence interval; RA, radial artery; SV, saphenous vein; LITA, left internal thoracic artery; CABG, coronary artery bypass grafting; OR, odds ratio; RITA, right internal thoracic artery; RGEA, right gastroepiploic artery. On the other hand, observational studies comparing different surgical interventions are open to treatment allocation bias18Gaudino M. Di Franco A. Rahouma M. et al.Unmeasured confounders in observational studies comparing bilateral versus single internal thoracic artery for coronary artery bypass grafting: a meta-analysis.J Am Heart Assoc. 2018; 7e008010Crossref PubMed Scopus (73) Google Scholar so that hidden confounders, rather than true biological effect, may explain the observed differences (ie, the patients with the likeliest long-term longevity receive MAGs). In addition, although a pooled analysis of 6 randomized trials showed a lower risk of adverse cardiac events at 5 years of follow-up with the use of the RA instead of the saphenous vein for CABG,19Gaudino M. Benedetto U. Fremes S. et al.Radial-artery or saphenous-vein grafts in coronary-artery bypass surgery.N Engl J Med. 2018; 378: 2069-2077Crossref PubMed Scopus (251) Google Scholar the intention-to-treat analysis of the large Arterial Revascularization Trial (ART) found no difference in survival between patients receiving a single internal thoracic artery (SITA) and bilateral ITAs (BITAs) at 10 years of follow-up.6Taggart D.P. Benedetto U. Gerry S. et al.Bilateral versus single internal-thoracic-artery grafts at 10 years.N Engl J Med. 2019; 380: 437-446Crossref PubMed Scopus (191) Google Scholar ART reported a high (14%) crossover rate from the BITA group to the SITA graft group and a frequent use (>20%) of the RA in the control group. Both of these factors may have diluted the treatment effect of BITA grafting20Gaudino M. Fremes S.E. Ruel M. et al.Prevalence and impact of treatment crossover in cardiac surgery randomized trials: a meta-epidemiologic study.J Am Heart Assoc. 2019; 8e013711Crossref PubMed Scopus (6) Google Scholar and worked in favor of the null hypothesis. Indeed, a post hoc nonrandomized comparison of patients who received MAG vs a single arterial graft (SAG) in the ART trial showed MAG was associated with a significant clinical benefit.6Taggart D.P. Benedetto U. Gerry S. et al.Bilateral versus single internal-thoracic-artery grafts at 10 years.N Engl J Med. 2019; 380: 437-446Crossref PubMed Scopus (191) Google Scholar Currently, a second large trial, Randomized comparison of the Outcome of single versus Multiple Arterial grafts (ROMA), comparing the use of MAGs (using a second ITA or RA) vs 1 ITA and vein is underway.21Gaudino M. Alexander J.H. Bakaeen F.G. et al.Randomized comparison of the clinical outcome of single versus multiple arterial grafts: the ROMA trial-rationale and study protocol.Eur J Cardiothorac Surg. 2017; 52: 1031-1040Crossref PubMed Google Scholar he results of ROMA are expected in 2025; however, we here aim to report the attitude of the surgical community toward the use of MAGs in North America and in Europe. Data on the use of MAG are relatively limited for both North America and Europe (Table 3).22Schwann T.A. Habib R.H. Wallace A. et al.Operative outcomes of multiple-arterial versus single-arterial coronary bypass grafting.Ann Thorac Surg. 2018; 105: 1109-1119Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar, 23Goldstone A.B. Chiu P. Baiocchi M. et al.Second arterial versus venous conduits for multivessel coronary artery bypass surgery in California.Circulation. 2018; 137: 1698-1707Crossref PubMed Scopus (37) Google Scholar, 24Samadashvili Z. Sundt T.M. Wechsler A. et al.Multiple versus single arterial coronary bypass graft surgery for multivessel disease.J Am Coll Cardiol. 2019; 74: 1275-1285Crossref PubMed Scopus (36) Google Scholar, 25Chikwe J. Sun E. Hannan E.L. et al.Outcomes of second arterial conduits in patients undergoing multivessel coronary artery bypass graft surgery.J Am Coll Cardiol. 2019; 74: 2238-2248Crossref PubMed Scopus (37) Google Scholar, 26Guru V. Fremes S.E. Tu J.V. How many arterial grafts are enough? A population-based study of midterm outcomes.J Thorac Cardiovasc Surg. 2006; 131: 1021-1028Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar, 27Pu A. Ding L. Shin J. et al.Long-term outcomes of multiple arterial coronary artery bypass grafting: a population-based study of patients in British Columbia, Canada.JAMA Cardiol. 2017; 2: 1187-1196Crossref PubMed Scopus (29) Google Scholar, 28Rocha R.V. Tam D.Y. Karkhanis R. et al.Multiple arterial grafting is associated with better outcomes for coronary artery bypass grafting patients.Circulation. 2018; 138: 2081-2090Crossref PubMed Scopus (37) Google Scholar, 29Janiec M. Dimberg A. Nazari Shafti T.Z. Lagerqvist B. Lindblom R.P.F. No improvements in long-term outcome after coronary artery bypass grafting with arterial grafts as a second conduit: a Swedish nationwide registry study.Eur J Cardiothorac Surg. 2018; 53: 448-454Crossref PubMed Scopus (14) Google Scholar, 30Holm M. Biancari F. Khodabandeh S. et al.Bleeding in patients treated with ticagrelor or clopidogrel before coronary artery bypass grafting.Ann Thorac Surg. 2019; 107: 1690-1698Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar In a review of The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery database including 1,493,470 patients undergoing CABG between 2004 and 2015, Schwann and colleagues22Schwann T.A. Habib R.H. Wallace A. et al.Operative outcomes of multiple-arterial versus single-arterial coronary bypass grafting.Ann Thorac Surg. 2018; 105: 1109-1119Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar reported a rate of MAG of 11.3%, with a significant decrease from 16% in 2004 to 9% in 2015. In another report from the STS database focused on low-risk patients most likely to benefit from MAG (age <70 years, no or mild chronic lung disease, body mass index <30 kg/m2, and absence of diabetes), Lapar and colleagues31LaPar D.J. Crosby I.K. Rich J.B. et al.Bilateral internal mammary artery use for coronary artery bypass grafting remains underutilized: a propensity-matched multi-institution analysis.Ann Thorac Surg. 2015; 100 (discussion: 14-5): 8-14Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar reported a BITA use rate of 6%.Table 3Main series reporting the use of multiple arterial grafting in North America and EuropeStudyRegistryVariablePercentageUnited States and Canada Schwann,22Schwann T.A. Habib R.H. Wallace A. et al.Operative outcomes of multiple-arterial versus single-arterial coronary bypass grafting.Ann Thorac Surg. 2018; 105: 1109-1119Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar 2018The Society of Thoracic Surgeons Adult Cardiac Surgery Database%MAG11.3 Goldstone,23Goldstone A.B. Chiu P. Baiocchi M. et al.Second arterial versus venous conduits for multivessel coronary artery bypass surgery in California.Circulation. 2018; 137: 1698-1707Crossref PubMed Scopus (37) Google Scholar 2018California State registry%MAG9.9 Samadashvili,24Samadashvili Z. Sundt T.M. Wechsler A. et al.Multiple versus single arterial coronary bypass graft surgery for multivessel disease.J Am Coll Cardiol. 2019; 74: 1275-1285Crossref PubMed Scopus (36) Google Scholar 2019New York's Cardiac Surgery Reporting System and New York's Vital Statistics%MAG20.0 Chikwe,25Chikwe J. Sun E. Hannan E.L. et al.Outcomes of second arterial conduits in patients undergoing multivessel coronary artery bypass graft surgery.J Am Coll Cardiol. 2019; 74: 2238-2248Crossref PubMed Scopus (37) Google Scholar 2019New Jersey Cardiac Catheterization Registry, New Jersey Discharge Data Collection System%MAG14.0 Guru,26Guru V. Fremes S.E. Tu J.V. How many arterial grafts are enough? A population-based study of midterm outcomes.J Thorac Cardiovasc Surg. 2006; 131: 1021-1028Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar 2006Cardiac Care Network database (Canada)%MAG12.1 Pu,27Pu A. Ding L. Shin J. et al.Long-term outcomes of multiple arterial coronary artery bypass grafting: a population-based study of patients in British Columbia, Canada.JAMA Cardiol. 2017; 2: 1187-1196Crossref PubMed Scopus (29) Google Scholar 2017Cardiac Services British Columbia registry (Canada)%MAG27.8 Rocha,28Rocha R.V. Tam D.Y. Karkhanis R. et al.Multiple arterial grafting is associated with better outcomes for coronary artery bypass grafting patients.Circulation. 2018; 138: 2081-2090Crossref PubMed Scopus (37) Google Scholar 2018CorHealth Registry (Canada)%MAG22.4Europe Janiec,29Janiec M. Dimberg A. Nazari Shafti T.Z. Lagerqvist B. Lindblom R.P.F. No improvements in long-term outcome after coronary artery bypass grafting with arterial grafts as a second conduit: a Swedish nationwide registry study.Eur J Cardiothorac Surg. 2018; 53: 448-454Crossref PubMed Scopus (14) Google Scholar 2017SWEDEHEART registry%MAG3.9 Holm,30Holm M. Biancari F. Khodabandeh S. et al.Bleeding in patients treated with ticagrelor or clopidogrel before coronary artery bypass grafting.Ann Thorac Surg. 2019; 107: 1690-1698Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar 2019European Multicenter Study on Coronary Artery Bypass Grafting registry%BITA34.2 Austrian Society for Cardiac and Thoracic-Vascular SurgeryAustrian Society for Cardiac and Thoracic-Vascular Surgery Registry%MAG16.7MAG, Multiple arterial graft; SWEDEHEART, Swedish Websystem for Enhancement of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies; BITA, bilateral internal thoracic artery. Open table in a new tab MAG, Multiple arterial graft; SWEDEHEART, Swedish Websystem for Enhancement of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies; BITA, bilateral internal thoracic artery. Goldstone and colleagues23Goldstone A.B. Chiu P. Baiocchi M. et al.Second arterial versus venous conduits for multivessel coronary artery bypass surgery in California.Circulation. 2018; 137: 1698-1707Crossref PubMed Scopus (37) Google Scholar analyzed a state-maintained clinical registry including all 126 nonfederal hospitals in California between 2006 and 2011 and found the percentage of MAG use was 9.9%, decreasing significantly from 10.7% to 9.1% over the study period. In the mandatory clinical New York State registry, a MAG rate of 20% was reported among patients who underwent CABG between the year 2005 and 2014 compared with 14% in the mandatory New Jersey clinical registry between 2005 and 2012.7Petrovic I. Nezic D. Peric M. et al.Radial artery vs saphenous vein graft used as the second conduit for surgical myocardial revascularization: long-term clinical follow-up.J Cardiothorac Surg. 2015; 10: 127Crossref PubMed Scopus (27) Google Scholar,32Puskas J.D. Sadiq A. Vassiliades T.A. Kilgo P.D. Lattouf O.M. Bilateral internal thoracic artery grafting is associated with significantly improved long-term survival, even among diabetic patients.Ann Thorac Surg. 2012; 94 (discussion: 715-6): 710-715Abstract Full Text Full Text PDF PubMed Scopus (146) Google Scholar Guru and colleagues26Guru V. Fremes S.E. Tu J.V. How many arterial grafts are enough? A population-based study of midterm outcomes.J Thorac Cardiovasc Surg. 2006; 131: 1021-1028Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar studied CABG patients in Ontario using the Cardiac Care Network database and reported an overall MAG rate of 12.1% between 1991 and 2003, having increased from 3.0% to 26.5%. Rocha and colleagues,28Rocha R.V. Tam D.Y. Karkhanis R. et al.Multiple arterial grafting is associated with better outcomes for coronary artery bypass grafting patients.Circulation. 2018; 138: 2081-2090Crossref PubMed Scopus (37) Google Scholar using the same registry, reported MAG in 22.4% of patients between 2008 and 2016. In another Canadian study, Pu and colleagues27Pu A. Ding L. Shin J. et al.Long-term outcomes of multiple arterial coronary artery bypass grafting: a population-based study of patients in British Columbia, Canada.JAMA Cardiol. 2017; 2: 1187-1196Crossref PubMed Scopus (29) Google Scholar studied patients in the province of British Columbia from 2000 to 2014 and reported a MAG rate of 27.8%, decreasing from 29% to 25% over the study period. In Europe, Holm and colleagues30Holm M. Biancari F. Khodabandeh S. et al.Bleeding in patients treated with ticagrelor or clopidogrel before coronary artery bypass grafting.Ann Thorac Surg. 2019; 107: 1690-1698Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar reported a BITA grafting rate of 34.2% in patients undergoing CABG in Finland, France, Germany, Italy, Sweden, and the United Kingdom from 2015 to 2017 using the European Multicenter Registry on Coronary Artery Bypass Grafting. Janiec and colleagues29Janiec M. Dimberg A. Nazari Shafti T.Z. Lagerqvist B. Lindblom R.P.F. No improvements in long-term outcome after coronary artery bypass grafting with arterial grafts as a second conduit: a Swedish nationwide registry study.Eur J Cardiothorac Surg. 2018; 53: 448-454Crossref PubMed Scopus (14) Google Scholar reported a MAG rate of 3.9% using the Swedish Web System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART) registry. The Austrian Society for Cardiac and Thoracic-Vascular Surgery reported an overall MAG rate of 16.7% in the period from 2009 to 2018, increasing from 13.4% in 2009 to 25.0% in 2018. Recent data from Germany's Institute for Quality Assurance and Transparency in Healthcare for the years 2015 and 2016 show a BITA rate of 24.4% and 25.5%, respectively, and a use of the RA at approximately 9%. One route to understanding the reason for low rates of multiarterial revascularization in the United States (US) and Europe is to analyze the practice of individual surgeons. The national rates of multiarterial revascularization conceal wide extremes of practice variation between individual providers.24Samadashvili Z. Sundt T.M. Wechsler A. et al.Multiple versus single arterial coronary bypass graft surgery for multivessel disease.J Am Coll Cardiol. 2019; 74: 1275-1285Crossref PubMed Scopus (36) Google Scholar,25Chikwe J. Sun E. Hannan E.L. et al.Outcomes of second arterial conduits in patients undergoing multivessel coronary artery bypass graft surgery.J Am Coll Cardiol. 2019; 74: 2238-2248Crossref PubMed Scopus (37) Google Scholar For example, in a recent analysis of 26,124 patients who underwent CABG in the US between 2005 and 2012, the prevalence of MAG was 14%: however, many surgeons performed MAG in fewer than 10% of patients, while a small minority of enthusiasts performed MAG in most patients (Figure 1).23Goldstone A.B. Chiu P. Baiocchi M. et al.Second arterial versus venous conduits for multivessel coronary artery bypass surgery in California.Circulation. 2018; 137: 1698-1707Crossref PubMed Scopus (37) Google Scholar Even wider practice variation was described within the ART trial, in which unplanned conversion rates from bilateral to SITA grafts ranged from 1.9% for one outlier to 100% in almost one-third of surgeons, suggesting ample variability in the level of confidence with the BITA procedure (Figure 2).6Taggart D.P. Benedetto U. Gerry S. et al.Bilateral versus single internal-thoracic-artery grafts at 10 years.N Engl J Med. 2019; 380: 437-446Crossref PubMed Scopus (191) Google Scholar,33Benedetto U. Altman D.G. Flather M. et al.Incidence and clinical implications of intraoperative bilateral internal thoracic artery graft conversion: insights from the arterial revascularization trial.J Thorac Cardiovasc Surg. 2018; 155: 2346-2355.e6Abstract Full Text Full Text PDF PubMed Scopus (22) Google ScholarFigure 2Rate of unplanned conversion from bilateral to single internal mammary artery by individual surgeon, stratified by number of patients randomized in the Arterial Revascularization Trial.(From New England Journal of Medicine; Taggart DP, Benedetto U, Gerry S, Altman DG, Gray AM, Lees B, Gaudino M, Zamvar V, Bochenek A, Buxton B, Choong C, Clark S, Deja M, Desai J, Hasan R, Jasinski M, O'Keefe P, Moraes F, Pepper J, Seevanayagam S, Sudarshan C, Trivedi U, Wos S, Puskas J, Flather M; Arterial Revascularization Trial Investigators. Bilateral versus single internal-thoracic-artery grafts at 10 years; 380:437-46. Copyright © (2019) Massachusetts Medical Society. Reprinted with permission.)View Large Image Figure ViewerDownload Hi-res image Download (PPT) These extremes of practice may be explained in terms of evidence, expertise, and incentives. The absence of compelling evidence was cited by almost one-third of United Kingdom surgeons when asked in 2018 what issues limited use of BITA grafts in clinical practice.34Jayakumar S. Gasparini M. Treasure T. Burdett C. Cardiothoracic Trainees Research CollaborativeHow do surgeons decide? Conduit choice in coronary artery bypass graft surgery in the UK.Interact Cardiovasc Thorac Surg. 2019; 29: 179-186Crossref Scopus (12) Google Scholar As discussed, although a large body of observational data suggests that a second arterial conduit is associated with improved survival, graft patency, and freedom from reintervention, the findings of randomized studies have been equivocal.4Gaudino M. Rahouma M. Abouarab A. et al.Radial artery versus saphenous vein as the second conduit for coronary artery bypass surgery: a meta-analysis.J Thorac Cardiovasc Surg. 2019; 157: 1819-1825.e10Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar, 5Buttar S.N. Yan T.D. Taggart D.P. Tian D.H. Long-term and short-term outcomes of using bilateral internal mammary artery grafting versus left internal mammary artery grafting: a meta-analysis.Heart. 2017; 103: 1419-1426Crossref PubMed Scopus (100) Google Scholar, 6Taggart D.P. Benedetto U. Gerry S. et al.Bilateral versus single internal-thoracic-artery grafts at 10 years.N Engl J Med. 2019; 380: 437-446Crossref PubMed Scopus (191) Google Scholar,17Gaudino M. Cellini C. Pragliola C. et al.Arterial versus venous bypass grafts in patients with in-stent restenosis.Circulation. 2005; 112: I265-I269Crossref PubMed Scopus (1) Google Scholar,18Gaudino M. Di Franco A. Rahouma M. et al.Unmeasured confounders in observational studies comparing bilateral versus single internal thoracic artery for coronary artery bypass grafting: a meta-analysis.J Am Heart Assoc. 2018; 7e008010Crossref PubMed Scopus (73) Google Scholar,20Gaudino M. Fremes S.E. Ruel M. et al.Prevalence and impact of treatment crossover in cardiac surgery randomized trials: a meta-epidemiologic study.J Am Heart Assoc. 2019; 8e013711Crossref PubMed Scopus (6) Google Scholar, 21Gaudino M. Alexander J.H. Bakaeen F.G. et al.Randomized comparison of the clinical outcome of single versus multiple arterial grafts: the ROMA trial-rationale and study protocol.Eur J Cardiothorac Surg. 2017; 52: 1031-1040Crossref PubMed Google Scholar, 22Schwann T.A. Habib R.H. Wallace A. et al.Operative outcomes of multiple-arterial versus single-arterial coronary bypass grafting.Ann Thorac Surg. 2018; 105: 1109-1119Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar, 23Goldstone A.B. Chiu P. Baiocchi M. et al.Second arterial versus venous conduits for multivessel coronary artery bypass surgery in California.Circulation. 2018; 137: 1698-1707Crossref PubMed Scopus (37) Google Scholar, 24Samadashvili Z. Sundt T.M. Wechsler A. et al.Multiple versus single arterial coronary bypass graft surgery for multivessel disease.J Am Coll Cardiol. 2019; 74: 1275-1285Crossref PubMed Scopus (36) Google Scholar, 25Chikwe J. Sun E. Hannan E.L. et al.Outcomes of second arterial conduits in patients undergoing multivessel coronary artery bypass graft surgery.J Am Coll Cardiol. 2019; 74: 2238-2248Crossref PubMed Scopus (37) Google Scholar, 26Guru V. Fremes S.E. Tu J.V. How many arterial grafts are enough? A population-based study of midterm outcomes.J Thorac Cardiovasc Surg. 2006; 131: 1021-1028Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar, 27Pu A. Ding L. Shin J. et al.Long-term outcomes of multiple arterial coronary artery bypass grafting: a population-based study of patients in British Columbia, Canada.JAMA Cardiol. 2017; 2: 1187-1196Crossref PubMed Scopus (29) Google Scholar, 28Rocha R.V. Tam D.Y. Karkhanis R. et al.Multiple arterial grafting is associated with better outcomes for coronary artery bypass grafting patients.Circulation. 2018; 138: 2081-2090Crossref PubMed Scopus (37) Google Scholar,31LaPar D.J. Crosby I.K. Rich J.B. et al.Bilateral internal mammary artery use for coronary artery bypass grafting remains underutilized: a propensity-matched multi-institution analysis.Ann Thorac Surg. 2015; 100 (discussion: 14-5): 8-14Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar For those surgeons convinced by the available evidence-base, an important factor limiting use of MAG may be technical expertise. The extent of and reason for this gap in practice are not apparent from simply analyzing surgeon case-volume and revascularization strategy. In 2 US registry studies, for example, no correlation was found between surgeon case-volume and MAG use: high volume surgeons were just as likely to prefer a SAG strategy as their low-volume counterparts.24Samadashvili Z. Sundt T.M. Wechsler A. et al.Multiple versus single arterial coronary bypass graft surgery for multivessel disease.J Am Coll Cardiol. 2019; 74: 1275-1285Crossref PubMed Scopus (36) Google Scholar,25Chikwe J. Sun E. Hannan E.L. et al.Outcomes of second arterial conduits in patients undergoing multivessel coronary artery bypass graft surgery.J Am Coll Cardiol. 2019; 74: 2238-2248Crossref PubMed Scopus (37) Google Scholar Prospectively collected data on intraoperative decision-making influencing MAG vs SAG would be very beneficial. In this context, the data on unplanned conversion from BITA to a SITA graft in the ART trial are particularly important because it prospectively details the technical and clinical challenges that precluded BITA grafting by a group of surgeons specifically selected for their expertise in and enthusiasm for that approach.33Benedetto U. Altman D.G. Flather M. et al.Incidence and clinical implications of intraoperative bilateral internal thoracic artery graft conversion: insights from the arterial revascularization trial.J Thorac Cardiovasc Surg. 2018; 155: 2346-2355.e6Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar The most common reason, reported in 31% of cases, was that the conduit was "unsuitable"; specifically "damaged" in more than half such cases, with "poor flow" in one-third and "too short" in the rest.33Benedetto U. Altman D.G. Flather M. et al.Incidence and clinical implications of intraoperative bilateral internal thoracic artery graft conversion: insights from the arterial revascularization trial.J Thorac Cardiovasc Surg. 2018; 155: 2346-2355.e6Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar It is notable that similar problems were reported in fewer than 1% of patients allocated to a SITA graft. Successful deployment of the right ITA requires greater technical facility, especially with composite and sequential grafts. Notably, this does not apply to the use of the RA. In fact, in the quoted analysis of the STS database, Schwann and coauthors22Schwann T.A. Habib R.H. Wallace A. et al.Operative outcomes of multiple-arterial versus single-arterial coronary bypass grafting.Ann Thorac Surg. 2018; 105: 1109-1119Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar reported a clear volume-to-outcome relationship for BITA but not RA grafting. Finally, incentive is the third factor potentially driving the wider use of MAG and, specifically, the acceptance of the potential disadvantages of this strategy such as higher risk of sternal or forearm complications, bleeding, longer operative times, and the additional training and planning associated in particular with BITA use.34Jayakumar S. Gasparini M. Treasure T. Burdett C. Cardiothoracic Trainees Research CollaborativeHow do surgeons decide? Conduit choice in coronary artery bypass graft surgery in the UK.Interact Cardiovasc Thorac Surg. 2019; 29: 179-186Crossref Scopus (12) Google Scholar,35Mastrobuoni S. Gawad N. Price J. et al.Use of bilateral internal thoracic artery during coronary artery bypass graft surgery in Canada: the bilateral internal thoracic artery survey.J Thorac Cardiovasc Surg. 2012; 144: 874-879Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar Increased sternal wound infection is a significant disincentive in the US health care setting, especially among diabetic patients, because providers may not receive reimbursement for the additional care associated with wound complications. It is important to note that even among diabetic patients, however, observational data suggest a mortality benefit for BITA over SITA grafting.32Puskas J.D. Sadiq A. Vassiliades T.A. Kilgo P.D. Lattouf O.M. Bilateral internal thoracic artery grafting is associated with significantly improved long-term survival, even among diabetic patients.Ann Thorac Surg. 2012; 94 (discussion: 715-6): 710-715Abstract Full Text Full Text PDF PubMed Scopus (146) Google Scholar Also, 30-day outcomes, including complications and patient satisfaction, are commonly publicly reported and may form part of managed care contracting criteria. There may be real concern that referrals could be targeted elsewhere on the basis of 30-day outcomes rather than putative late survival benefit. On this basis, there are, in our opinion, 4 strategies that could potentially increase the appropriate use of MAG:•Foster a cultural shift from the view of CABG as an entry-level operation for learners toward a specialist operation for experts. Update curricula and operative requirements for professional certification to include current best-practice in MAG with associated advanced training courses.•Revise consensus guidelines to emphasize the role of targeted referral to expert providers offering a high likelihood of MAG and simultaneous low mortality in appropriate patients.•Expand publicly reported CABG benchmarks, such as the STS quality bundle, to include MAG (or documentation of its contraindication) for young patients and compliance with evidence-based prophylactic sternal infection care bundles.•Add appropriateness of intervention to public reporting for surgical revascularization. In conclusion, a substantial body of evidence suggests that MAG may be associated with improved survival, graft patency, and freedom from reintervention. However, lack of clear level I evidence (in particular for BITA grafting), variable surgical expertise, and disincentives linked to short-term outcomes impact public reporting and reimbursement and have led to extreme variation in the use of MAG even in the most appropriate patients. Disseminating consensus guidelines updated to reflect current best practice, especially in younger patients, and expanding quality benchmarks to include appropriateness of the revascularization strategy may help in addressing this knowledge and practice gaps. The authors wish to thank the ÖG-HTG (Österreichische Gesellschaft für Herz und thorakale Gefässchirurgie [Austrian Society for Cardiac and Thoracic-Vascular Surgery]) for their support.

Referência(s)