Evaluation of Graft Patency in Multiple Arterial Revascularization: Long-term Outcome Investigation among 1654 Patients at Risk
Elfriede Ruttmann-Ulmer, Marion Dietl, Gudrun M. Feuchtner, Juliane Kilo, Carola Frey, Orest Chevtchik, Bernhard Metzler, Nikolaos Bonaros, Hanno Ulmer.
Innsbruck Medical University, Innsbruck, Austria.
OBJECTIVE: Multiple arterial revascularization (MAR) using right internal thoracic arteries (RITA) and radial arteries (RA) in addition to a left internal thoracic artery (LITA) has become a mainstay for surgical revascularization.
METHODS: This prospective longitudinal follow up study was implemented to investigate the long term performance of MAR. IRB permitted the conduction of this study and patients were followed up in 4 to 5 year intervals after CABG procedure. All MACCE events and coronary diagnostic procedures during follow-up, either conducted by coronary angiography (CA) or coronary computed tomography (CTA) were evaluated and independent predictors for graft patency were calculated by Kaplan-Meier survival analysis and COX proportional hazards model. Graft stenosis of more than 70%, string phenomenon and graft occlusion were defined as non-functioning grafts.
RESULTS: The study population consisted of a total of 1654 consecutive patients receiving first, non-emergent MAR with a mean follow up of 7.4 ± 4.0 years (11 914 patient years). BITA grafting was performed in 910 patients (55.0%), 744 patients (45.0%) received LITA together with at least one RA. Among BITA patients, 187 patients received a RA as a third arterial conduit (187 patients, 20.6%). Among 455 patients (27.5%), 373 CA and 82 CTAs were performed. Graft analysis included 475 LITA (33.8%), 146 RITA (10.4%), 372 RA (26.5%) and 411 SVG (29.3%) at risk. Cumulative graft patency was highest among ITA grafts (LITA vs. RITA: log-rank p=0.47), and RA grafts were superior regarding graft patency compared to SVG (RA vs. SVG: log-rank p<0.001). Moreover in situ RITA grafting was associated with significantly higher patency rate compared to RITA free grafts (94.7% vs. 83.9%, p=0.039). Multivariable graft patency analysis of non ITA grafts revealed RA grafting (HR: 1.89; 95% CI 1.37 - 2.60; p<0.001), male gender (HR: 1.83; 95% CI 1.18 - 2.85; p=0.007) and non-smoking (HR: 1.49; 95% CI 1.09 - 2.02; p=0.009) to be independent predictors of long term graft patency.
CONCLUSIONS: In MAR, in situ RITA grafting showed similar long term patency compared to LITA grafts. RA patency rates were superior compared to SVG with cumulative patency rates diverging beyond 5 years after CABG.
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