Featured Articles in the October 2014 Issue of The Journal of Thoracic and Cardiovascular Surgery
One of the primary features of the October issue of JTCVS is the topic of multiple arterial revascularization. This issue begins the study with an editorial and follows up with several articles on revascularization accompanied by commentaries. The next issue of Seminars in Thoracic and Cardiovascular Surgery will continue to highlight this topic through commentaries written by the authors of the revascularization papers listed below. Each commentary will discuss the content, results, and implications of the other papers. Multiple arterial grafting may be the next frontier for cardiac surgery.
Editorial
Coronary bypass: Is it time to take the next step—the routine use of the second arterial graft?
Michael E. Halkos and Robert A. Guyton
In this issue, 3 studies from highly experienced coronary centers lend further support for a multiarterial grafting strategy. Graft patency and even long-term survival may be improved by this strategy. The evidence, although not level A, is persuasive; a second arterial graft should become routine in most cases.
Acquired Cardiovascular Disease
Total arterial revascularization with internal thoracic and radial artery grafts in triple-vessel coronary artery disease is associated with improved survival
Brian F. Buxton, William Y. Shi, James Tatoulis, John A. Fuller, Alexander Rosalion, and Philip A. Hayward
Total arterial revascularization using internal thoracic and radial artery conduits was associated with improved late survival in patients with 3-vessel coronary artery disease compared with conventional single internal thoracic and saphenous vein grafts. This benefit may result in superior graft patency and protection of the native circulation.
▶ Buxton and colleagues from Australia reviewed over 6,000 isolated CABG patients with 3 vessel CAD over a 15 year period (1995-2010) and propensity matched 384 pairs of patients with either all arterial grafting vs. the use of one IMA and SVG. They found a highly significant survival advantage at 15 years in the total arterial revascularization group vs. the one IMA with SVG group (Kaplan Meier, following multivariable Cox regression, and after propensity matching). The authors concluded that, “total arterial revascularization should be encouraged in patients with a reasonable life expectancy”. Interestingly, only 36% of patients had use of bilateral IMA grafts, 97% of patients had at least one radial artery graft (52% had single radial grafts and 48% had bilateral grafts), and only 51% of RIMA grafts were used in-situ. The authors highlighted the potential benefit derived from use of the radial artery graft. This article is of particular interest because it involved a large number of patients (propensity matched) over a 15 year period, and it nicely demonstrated a highly significant benefit to long term survival when arterial grafting was utilized. [Summary and Comment by Dr. Jennifer Lawton, associate medical editor, Thoracic Surgery News].
Editorial Commentary in JTCVS: Total arterial revascularization: When will its time come?
Todd K. Rosengart
The long-term impact of diabetes on graft patency after coronary artery bypass grafting surgery: A substudy of the multicenter Radial Artery Patency Study
Saswata Deb, Steve K. Singh, Fuad Moussa, Hideki Tsubota, Dai Une, Alex Kiss, George Tomlinson, Mehdi Afshar, Ryan Sless, Eric A. Cohen, Sam Radhakrishnan, James Dubbin, Leonard Schwartz, and Stephen E. Fremes on behalf of the Radial Artery Patency Study Investigators
Radial artery grafts compared with saphenous vein grafts were associated with a lower rate of late graft occlusion in diabetic patients after coronary artery bypass surgery. Predictors against late graft occlusion included the use of radial arteries and high-grade target vessel stenosis. The type of conduit and late occlusion were influenced by diabetic status.
▶ Deb and colleagues from Toronto, Ottawa, and Texas Heart Institute reviewed patency rates in 269 low risk (<80 yrs, elective, EF>35%) isolated CABG patients (with 3 vessel CAD) from the Radial Artery Patency Study (each patient underwent randomization dictating use of radial artery or vein graft to separate territories). Patients underwent diagnostic angiography (N=234) or CT angio (N=35) at least 5 years postoperatively. New data presented are long term (>5 yr) patency in diabetics. The authors noted that the proportion of complete graft occlusion was significantly lower in radial artery grafts vs. saphenous grafts in diabetics; however, it was similar in non-diabetics. Interestingly, there was no difference in the occlusion rate of the IMA graft in diabetics compared to non-diabetics. Multivariate modeling demonstrated female sex, smoking history, and elevated creatinine as increased risk factors for late graft occlusion; whereas use of the radial artery and high grade target stenosis (>90% vs. 70-89% stenosis) were protective. The authors concluded that the study supports the use of the radial artery as a second conduit is appropriate in diabetic patients. Using blinded angiographic follow-up, this study importantly supports the use of arterial grafting, and specifically the use of the radial artery, in diabetic patients. [Summary and Comment by Dr. Jennifer Lawton, associate medical editor, Thoracic Surgery News].
