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Commentary: 1, 2 or 3 arterial grafts? One is not enough!

2020; Elsevier BV; Volume: 5; Linguagem: Inglês

10.1016/j.xjon.2020.11.004

2666-2736

Thomas A. Schwann, Daniel T. Engelman,

Cardiac Structural Anomalies and Repair

Central MessageIn our continual quest for quality, the traditional single arterial CABG is no longer enough."There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain of its success, than to take the lead in the introduction of a new order of things."—Niccolò Machiavelli, The Prince, 1532See Article page 66. In our continual quest for quality, the traditional single arterial CABG is no longer enough. See Article page 66. Gilmore and colleagues1Gilmore T. Rocha R.V. Fremes S.E. Evidence-based selection of the second and third arterial conduit.J Thorac Cardiovasc Surg Open. 2021; 5: 66-69Google Scholar summarize the latest literature informing the decision to use a second or third arterial graft in coronary artery bypass grafting (CABG). They review the complementary, rather than competitive, attributes of the right internal thoracic artery, the radial artery (RA), and the gastroepiploic artery when used in conjunction with the left internal thoracic artery (LITA). Despite the equivalent long-term survival on an intention-to-treat basis of the ART trial between bilateral internal thoracic artery (BITA) CABG and single internal thoracic artery–based CABG, the authors correctly point out there has recently emerged fairly compelling data supporting the benefits of multiple arterial CABG whether that be in the form of BITA or LITA with supplemental RA grafts.2Goldstone A.B. Chiu P. Baiocchi M. Wang H. Lingala B. Boyd J.H. et al.Second arterial versus venous conduits for multivessel coronary artery bypass surgery in California.Circulation. 2018; 137: 1698-1707Crossref PubMed Scopus (34) Google Scholar, 3Gaudino M. Benedetto U. Fremes S. Biondi-Zoccai G. Sedrakyan A. Puskas J.D. et al.Radial-artery or saphenous-vein grafts in coronary-artery bypass surgery.N Engl J Med. 2018; 378: 2069-2077Crossref PubMed Scopus (223) Google Scholar, 4Gaudino M. Benedetto U. Fremes S. Ballman K. Biondi-Zoccai G. Sedrakyan A. et al.Association of radial artery graft vs saphenous vein graft with long-term cardiovascular outcomes among patients undergoing coronary artery bypass grafting: a systematic review and meta-analysis.JAMA. 2020; 324: 179Crossref PubMed Scopus (27) Google Scholar, 5Gaudino M. Lorusso R. Rahouma M. Abouarab A. Tam D.Y. Spadaccio C. et al.Radial artery versus right internal thoracic artery versus saphenous vein as the second conduit for coronary artery bypass surgery: a network meta-analysis of clinical outcomes.J Am Heart Assoc. 2019; 8: e010839Crossref PubMed Scopus (24) Google Scholar Of note, the noted BITA survival advantage may not be due to superiority of BITA grafts but rather due to unmeasured confounders that cannot be mitigated by sophisticated statistics.6Gaudino M. Di Franco A. Rahouma M. Tam D.Y. Iannaccone M. Deb S. 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; 7: e008010Crossref PubMed Scopus (70) Google Scholar Further, it should be remembered that BITA grafting is associated with (1) increased risk of deep sternal wound infections, (2) increased operative time inherent in consecutive graft harvesting with BITA rather than concurrent graft harvesting with RA, (3) general easier technical aspects of the RA compared with BITA grafting and most importantly, (4) equivalent long-term survival of BITA versus LITA/RA.5Gaudino M. Lorusso R. Rahouma M. Abouarab A. Tam D.Y. Spadaccio C. et al.Radial artery versus right internal thoracic artery versus saphenous vein as the second conduit for coronary artery bypass surgery: a network meta-analysis of clinical outcomes.J Am Heart Assoc. 2019; 8: e010839Crossref PubMed Scopus (24) Google Scholar Hence, the RA may be an easier starting point for surgeons beginning their journey from single arterial CABG to multiarterial CABG. Given the title of this manuscript, a natural logical question is whether there is incremental value of additional arterial grafts beyond two? Given the less than 10% use rate of multiple arterial grafting in contemporary CABG, not surprisingly, extended (>2) arterial grafting is quite rare, with only 0.5% of patients within the Society of Thoracic Surgeons Database receiving 3 or more arterial grafts.7Schwann T.A. Tatoulis J. Puskas J. Bonnell M. Taggart D. Kurlansky P. et al.Worldwide trends in multi-arterial coronary artery bypass grafting surgery 2004-2014: a tale of 2 continents.Semin Thorac Cardiovasc Surg. 2017; 29: 273-280Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar Although data on the value of extended arterial grafting are sparse, there are reports documenting survival benefits of 3 versus 2 arterial grafts.8Gaudino M. Puskas J.D. Di Franco A. Ohmes L.B. Iannaccone M. Barbero U. et al.Three arterial grafts improve late survival: a meta-analysis of propensity-matched studies.Circulation. 2017; 135: 1036-1044Crossref PubMed Scopus (62) Google Scholar, 9Schwann T.A. El Hage Sleiman A.K.M. Yammine M.B. Tranbaugh R.F. Engoren M. Bonnell M.R. et al.The incremental value of three or more arterial grafts in CABG: the effect of native vessel disease.Ann Thorac Surg. 2018; 106: 1071-1078Abstract Full Text Full Text PDF Scopus (3) Google Scholar, 10Taggart D.P. Altman D.G. Flather M. Gerry S. Gray A. Lees B. et al.Associations between adding a radial artery graft to single and bilateral internal thoracic artery grafts and outcomes: insights from the Arterial Revascularization Trial.Circulation. 2017; 136: 454-463Crossref PubMed Scopus (35) Google Scholar Importantly, there are no reports of adverse outcomes with increasing arterial grafts. Driving change and innovation is difficult yet essential for the continued relevancy of our specialty and in the interests of our patients. Transitioning from traditional single arterial CABG to multiarterial CABG may prevent 10,000 annual deaths among patients undergoing CABG and add an additional 64,000 patient years of life over a decade.11Tranbaugh R.F. Lucido D.J. Dimitrova K.R. Hoffman D.M. Geller C.M. Dincheva G.R. et al.Multiple arterial bypass grafting should be routine.J Thorac Cardiovasc Surg. 2015; 150 (discussion 1544-5): 1537-1544Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar Moreover, only multiarterial CABG, in contradistinction to single arterial CABG, has been shown to have superior outcomes to percutaneous revascularization techniques.12Habib R.H. Dimitrova K.R. Badour S.A. Yammine M.B. El-Hage-Sleiman A.K. Hoffman D.M. et al.CABG versus PCI.J Am Coll Cardiol. 2015; 66: 1417-1427Crossref PubMed Scopus (66) Google Scholar Transitioning from single arterial to multiarterial grafting will need to be tailored to the specific culture, the surgical experience, and available resources of a given organization. It should be a gradual, sustained, multidisciplinary team-based process rather than sporadic, occasional, and individual-based, as there is compelling data showing that occasional multi arterial use is problematic.13Gaudino M. Bakaeen F. Benedetto U. Rahouma M. Di Franco A. Tam D.Y. et al.Use rate and outcome in bilateral internal thoracic artery grafting: insights from a systematic review and meta-analysis.J Am Heart Assoc. 2018; 7: e009361Crossref PubMed Scopus (33) Google Scholar,14Schwann T.A. Habib R.H. Wallace A. Shahian D.M. O'Brien S. Jacobs J.P. 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 (64) Google Scholar In the value-based health care of the 21st century, one arterial graft is simply not enough. Evidence-based selection of the second and third arterial conduitJTCVS OpenVol. 5PreviewFeature Editor Note—Few topics in cardiac surgery have been investigated more extensively that the use of multiple arterial grafts for coronary bypass surgery. After more than 4 decades of research, we have solid evidence than the patency rate of the radial artery is better than the patency rate of the saphenous vein at mid- and long-term follow-up. The evidence for the other arterial conduits is less robust. The clinical consequences of the improved patency are still unclear, due to the high level of treatment allocation bias in observational studies and the inconclusive results of the limited randomized evidence. Full-Text PDF Open Access