This study aimed to investigate the impact of complete(CR) and incomplete(IR) revascularization on long term survival in patients undergoing isolated coronary artery bypass grafting(CABG) using ...either multiple arterial graft(MAG) or single artery with saphenous vein grafts(SAG) .
Between January 2006 and December 2020, 12625 patients had CABG and were divided into four groups: MAG CR(n=1066), MAG IR(n=286), SAG CR(n=8360) and SAG IR(n=2913). Inverse probability of treatment weighting(IPTW) based on the generalized propensity score was used to minimize imbalance between the groups.
In the weighted cohort, median follow up time was 8.35 years(interquartile range:5.01–11.6). MAG CR was associated with similar long term survival when compared to MAG IR(HR:0.79;95%CI:0.60 1.03;P=0.084). SAG CR was associated with improved long term survival when compared to SAG IR(HR:0.67;95%CI:0.52 0.84;P=0.01). MAG CR was associated with better long term survival when compared to SAG CR(HR:0.45;95%CI:0.35 0.57;P<0.001)(Figure 2). Moreover, MAG IR was protective when compared with SAG IR(HR:0.62;95%CI:0.45 0.85;P=0.033). Additional analysis was performed comparing perfect CR vs imperfect CR vs IR in MAG and SAG, separately. In the weighted sample of MAG, there were no differences in the long term survival between perfect CR, imperfect CR and IR. However, in the weighted sample of SAG cohort, SAG perfect CR was associated with improved survival compared to SAG imperfect CR(HR:0.81;95%CI:0.0.72 0.92;P=0.001). Whereas, both SAG perfect CR and SAG imperfect CR were associated with improved survival compared to SAG IR(HR:0.51;95%CI:0.0.35 0.87;P=0.006) and (HR:0.72;95%CI:0.64 0.82;P<0.001),respectively.
MAG CR is associated with better survival compared to SAG CR. If IR is inevitable, patients with MAG IR had better long term survival when compared to patients receiving SAG IR. Moreover, similar long term survival is observed whether perfect CR, imperfect CR or IR is achieved in the MAG population but not in SAG.
SUMMARY
The primary hypothesis of the ROMA trial is that in patients undergoing primary isolated non-emergent coronary artery bypass grafting, the use of 2 or more arterial grafts compared with a ...single arterial graft (SAG) is associated with a reduction in the composite outcome of death from any cause, any stroke, post-discharge myocardial infarction and/or repeat revascularization.
The secondary hypothesis is that in these patients, the use of 2 or more arterial grafts compared with a SAG is associated with improved survival. The ROMA trial is a prospective, unblinded, randomized event-driven multicentre trial comprising at least 4300 subjects. Patients younger than 70 years with left main and/or multivessel disease will be randomized to a SAG or multiple arterial grafts to the left coronary system in a 1:1 fashion. Permuted block randomization stratified by the centre and the type of second arterial graft will be used. The primary outcome will be a composite of death from any cause, any stroke, post-discharge myocardial infarction and/or repeat revascularization. The secondary outcome will be all-cause mortality. The primary safety outcome will be a composite of death from any cause, any stroke and any myocardial infarction. In all patients, 1 internal thoracic artery will be anastomosed to the left anterior descending coronary artery. For patients randomized to the SAG group, saphenous vein grafts will be used for all non-left anterior descending target vessels. For patients randomized to the multiple arterial graft group, the main target vessel of the lateral wall will be grafted with either a radial artery or a second internal thoracic artery. Additional grafts for the multiple arterial graft group can be saphenous veins or supplemental arterial conduits. To detect a 20% relative reduction in the primary outcome, with 90% power at 5% alpha and assuming a time-to-event analysis, the sample size must include 845 events (and 3650 patients). To detect a 20% relative reduction in the secondary outcome, with 80% power at 5% alpha, the sample size must include 631 events (and 3650 patients). To be conservative, the sample size will be set at 4300 patients. The primary outcome will be tested according to the intention-to-treat principle. The primary analysis will be a Cox proportional hazards regression model, with the treatment arm included as a covariate. If non-proportional hazards are observed, alternatives to Cox proportional hazards regression will be explored.
Abstract
OBJECTIVES
This study sought to evaluate the long-term differences in survival between multiple arterial grafts (MAG) and single arterial grafts (SAG) in patients who underwent coronary ...artery bypass grafting (CABG) in the SYNTAX study.
METHODS
The present analysis included the randomized and registry-treated CABG patients (n = 1509) from the SYNTAX Extended Survival study (SYNTAXES). Patients with only venous (n = 42) or synthetic grafts (n = 1) were excluded. The primary end point was all-cause death at the longest follow-up. Multivariable Cox regression was used to adjust for differences in baseline characteristics. Sensitivity analysis using propensity matching with inverse probability for treatment weights was performed.
RESULTS
Of the 1466 included patients, 465 (31.7%) received MAG and 1001 (68.3%) SAG. Patients receiving MAG were younger and at lower risk. At the longest follow-up of 12.6 years, all-cause death occurred in 23.6% of MAG and 40.0% of SAG patients adjusted hazard ratio (HR) 0.74, 95% confidence interval (CI) (0.55–0.98); P = 0.038, which was confirmed by sensitivity analysis. MAG in patients with the three-vessel disease was associated with significant lower unadjusted and adjusted all-cause death at 12.6 years adjusted HR 0.65, 95% CI (0.44–0.97); P = 0.033. In contrast, no significance was observed after risk adjustment in patients with the left main disease, with and without diabetes, or among SYNTAX score tertiles.
CONCLUSIONS
In the present post hoc analysis of all-comers patients from the SYNTAX trial, MAG resulted in markedly lower all-cause death at 12.6-year follow-up compared to a SAG strategy. Hence, this striking long-term survival benefit of MAG over SAG encourages more extensive use of multiple arterial grafting in selected patients with reasonable life expectancy.
Trial registration
SYNTAXES ClinicalTrials.gov reference: NCT03417050; SYNTAX ClinicalTrials.gov reference: NCT00114972.
Whether coronary artery bypass grafting (CABG) should be performed with multiple arterial grafts (MAG) in patients requiring bypass surgery remains fiercely debated.
Background:The use of bilateral internal thoracic artery (BITA) grafting concomitant with other cardiac operations is regarded as a risky strategy and the long-term advantages of BITA use remain ...unproven.Methods and Results:Pooled results from 3 series of patients (totaling 1,123 patients; mean age, 71.3 years; mean EuroSCORE II, 7.4%) undergoing combined coronary surgery using BITA were reviewed. Predictors of immediate and long-term adverse outcomes were identified by multivariable analyses. In-hospital and 30-day mortality was 7.9% and 6.3%, respectively. Diabetes on insulin (P=0.045), severe renal impairment (P<0.0001), extracardiac arteriopathy (P=0.0058), New York Heart Association class III−IV (P=0.017), recent myocardial infarction (P=0.0009), left ventricular dysfunction (P=0.0054), pulmonary hypertension (P=0.0016), active infective endocarditis (P=0.0011), and prolonged cross-clamp time (P=0.04) were predictors of in-hospital death. Multiple transfusions (27.3%), prolonged mechanical ventilation or reintubation (16.7%), acute kidney injury (11.5%), and sternal wound infections (10.4%) were relevant postoperative complications. Any neurological dysfunction occurred in 5.4% of cases. Median follow-up was 4.2 years. Female sex, chronic dialysis, extracardiac arteriopathy, and left ventricular dysfunction were predictors of both cardiac/cerebrovascular death and major adverse cardiac/cerebrovascular events (MACCE). The 10-year adjusted survival free of cardiac/cerebrovascular death, cerebrovascular accident after discharge, and MACCE was 84.2%, 94.8% and 54.6%, respectively.Conclusions:BITA grafting concomitant with other cardiac operations may be performed with satisfactory results. Long-term outcomes mostly depend on sex, preoperative comorbidities, and baseline cardiac function.
The study objective was to determine the impact on outcome associated with using the second internal thoracic artery as a free compared with an in situ graft among patients who received the first ...internal thoracic artery as an in situ internal thoracic artery to the left anterior descending artery.
Among 2600 patients who underwent bilateral internal thoracic artery with an in situ internal thoracic artery to the left anterior descending artery, the second internal thoracic artery was used as a free graft bilateral internal thoracic artery in 136 patients and as an in situ graft (in situ bilateral internal thoracic artery) in 2464 patients. One-to-many propensity score matching was performed to produce a cohort of 134 patients with a second free graft internal thoracic artery matched to 2359 patients with a second in situ internal thoracic artery. Early and long-term outcomes including survival, hospital readmission, and repeat revascularization up to a maximum of 25.8 years were compared.
There were no differences between the 2 matched groups' preoperative baseline characteristics and early adverse events. Long-term survival at 5, 10, and 15 years was significantly higher among patients with an in situ bilateral internal thoracic artery compared with patients with a free graft bilateral internal thoracic artery (hazard ratio free graft bilateral internal thoracic artery vs in situ bilateral internal thoracic artery, 1.53; 95% confidence interval, 1.14-2.10; P = .004). However, the long-term risk of readmission to the hospital for cardiovascular reasons and need for repeat revascularization were not significantly different between the 2 matched groups.
In a small, propensity-matched cohort of patients undergoing coronary artery bypass grafting, the use of a second in situ internal thoracic artery was associated with an increase in late survival compared with the use of a second internal thoracic artery as a free graft. However, the risk of late hospital readmission and the need for repeat revascularization were similar.
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Hemodialysis access has been considered as a support for end-stage renal patients. We measured the hemodynamic changes of the distal part of the upper extremity immediately after providing the AVGs ...in each method mentioned above and then compared the results. This method is a novel one and hasn’t been used in any other studies before. We studied 32 patients referred to the vascular surgery department of Rasht Razi Hospital between 2019-2020 (using the Convenient Sampling method). This study is a case-control study. Out of 32 patients referred to the vascular surgery department of the hospital, 68.8% were male, and their mean age was 53.41±12.75 years, ranging from 28 to 78 years. Changes in distal arterial hemodynamics of the upper limb before and after clamping in dialysis venoarterial loop versus straight grafts are different in studied patients (P<0.05). The mean hemodynamic changes before and after clamping in loop venoarterial grafts (19.5000) are less than straight grafts. In dialysis patients who do not have any superficial vein suitable for venous, arterial fistula, surgical placement of artificial grafts in the upper limb is appropriate. Based on the results of this study, the loop method seems to have lesser ischemic Complications and can be applied to dialysis patients.
The development of vascular bioengineering has led to a variety of novel treatment strategies for patients with cardiovascular disease. Notably, combining biodegradable scaffolds with autologous cell ...seeding to create tissue-engineered vascular grafts (TEVG) allows for in situ formation of organized neovascular tissue and we have demonstrated the clinical viability of this technique in patients with congenital heart defects. The role of the scaffold is to provide a temporary 3-dimensional structure for cells, but applying TEVG strategy to the arterial system requires scaffolds that can also endure arterial pressure. Both biodegradable synthetic polymers and extracellular matrix-based natural materials can be used to generate arterial scaffolds that satisfy these requirements. Furthermore, the role of specific cell types in tissue remodeling is crucial and as a result many different cell sources, from matured somatic cells to stem cells, are now used in a variety of arterial TEVG techniques. However, despite great progress in the field over the past decade, clinical effectiveness of small-diameter arterial TEVG (<6mm) has remained elusive. To achieve successful translation of this complex multidisciplinary technology to the clinic, active participation of biologists, engineers, and clinicians is required. (Circ J 2014; 78: 12–19)
Diltiazem has been used during the perioperative period in patients undergoing coronary artery bypass grafting (CABG) to prevent arterial graft spasm. However, its long-term outcome effects remain ...unclear.
Patient records obtained from the Society of Thoracic Surgeons and the Geisinger Clinic electronic health records between October 2008 and October 2018 were screened. Adult patients who had isolated CABG with cardiopulmonary bypass were included. Cohorts of patients who received diltiazem (DILT) and those who did not (non-DILT) were matched by propensity scores based on age, gender, surgical year, Society of Thoracic Surgeons mortality and morbidity scores, and number of arterial grafts. Incidence rate ratios (IRRs) were estimated for DILT vs non-DILT on short-term adverse outcomes. Long-term survival over time was compared between DILT vs non-DILT using Kaplan–Meier curves.
Among the 1004 patients included in the analyses, IRRs for the DILT group relative to the non-DILT group were: 30-day all-cause mortality, IRR: 2.33, 95% confidence interval (CI): 0.91–5.96, P=0.07; postoperative myocardial ischaemia, IRR: 1.10, 95% CI: 0.60–2.02, P=0.75; new onset atrial fibrillation, IRR: 1.06, 95% CI: 0.78–1.43, P=0.73; stroke/transient ischaemic attack, IRR: 0.76, 95% CI: 0.17–3.38, P=0.71. For long-term survival, Kaplan–Meier curves stratified by diltiazem revealed no differences in survival rates between DILT and non-DILT groups.
For patients undergoing on-pump CABG, perioperative diltiazem therapy did not show significant short- or long-term outcome advantages over those who did not receive diltiazem.
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