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Total and Multiple Arterial Revascularization

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Cardiac Surgery

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Abstract

Total arterial revascularization (TAR) or multiple arterial bypass grafting (MABG) maximizes long term survival, whilst minimizing interval events—recurrent angina, myocardial infarction, re-intervention, and mortality. Saphenous vein grafts (SVGs) have failure rates of 25% at 1 year, and 50% at 10 years, in the modern era, despite statins. Conversely arterial grafts always have better patency whether left or right internal thoracic arteries (ITAs), radial artery (RA) or right gastroepiploic (RGEA)—especially if there is spasm prophylaxis, and competitive flow is avoided. This has been documented in numerous reports, meta-analyses, and randomized studies over 30 years. TAR and/or MABG can be performed with identical low perioperative mortality (1%) and morbidity as for LITA + SVG. Arterial grafts have patency rates of 90–95% at 10 years and 85–90% at 20 years. Arterial graft patency determines long term outcomes. For every 100 patients having CABG, 10 more will be alive at 10 years if they had TAR or MABG (80–88% versus 70–78%). This holds true for patient subsets including women, older patients, and those with diabetes, or preoperative renal dysfunction. Strategies for arterial graft deployment can vary—one or two ITAs, one or two RAs, RGEA—in various combinations, on-pump or off-pump, single, sequential, or Y-grafts. Important principles are to target the most important coronaries (usually the left anterior descending and circumflex) minimizing aortic manipulation, spasm prophylaxis and avoidance of competitive flow, especially for RA and RGEA. TAR and MABG should be in every cardiac surgeon’s repertoire. This chapter provides an overview of rationale, technical aspects and outcomes of TAR.

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References

  1. Favaloro G. Saphenous vein auto graft replacement of severe segmental coronary artery occlusion: operative technique. Ann Thorac Surg. 1968;5:334–9.

    Article  CAS  PubMed  Google Scholar 

  2. Loop FD, Lytle BW, Cosgrove DM, et al. Inference of the internal mammary artery graft on 10 year survival and other cardiac events. N Engl J Med. 1986;314:1–6.

    Article  CAS  PubMed  Google Scholar 

  3. Schwann TA, Tatoulis J, Puskas J, et al. Worldwide trends in multi arterial CABG surgery 2004–2016: a tale of two continents. Semin Thorac Cardiovasc Surg. 2017;29:273–80.

    Article  PubMed  Google Scholar 

  4. Mehta RF, Ferguson TB, Lopes RD, et al. Saphenous vein grafts with multiple versus single distal targets in patients undergoing coronary artery bypass graft surgery: 1 year graft failure and 5 year outcomes from the project of ex-vivo vein graft engineering via transfection. (PREVENT) trial. Circulation. 2011;124:280–8.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Tatoulis J, Buxton BF, Fuller JA. Patencies of 2,127 arterial to coronary conduits over 15 years. Ann Thorac Surg. 2004;77:93–101.

    Article  PubMed  Google Scholar 

  6. Gaudino M, Tondi P, Benedetto U, et al. The radial artery as a coronary artery bypass conduit. 20 year results. J Am Coll Cardiol. 2016;68:603–10.

    Article  PubMed  Google Scholar 

  7. Locker C, Schaff HV, Dearani JA, Daly RC. Multiple arterial grafts improve late survival of patients undergoing coronary artery bypass surgery: analysis of 8,622 patients with multi vessel disease. Circulation. 2012;126:1023–30.

    Article  PubMed  Google Scholar 

  8. Yi G, Shine B, Rehamn SM, Altman DG, Taggart DP. Effect of bilateral internal mammary artery grafts on long term survival: a meta-analysis approach. Circulation. 2014;130:539–45.

    Article  PubMed  Google Scholar 

  9. Dimitrova KR, Hoffman DM, Geller CN, et al. Arterial grafts protect the native coronary vessels from atherosclerotic disease progression. Ann Thorac Surg. 2012;94:475–81.

    Article  PubMed  Google Scholar 

  10. Krane M, Voss B, Hiebinger A, et al. Twenty years of cardiac surgery in patients aged 80 and older: risks and benefits. Ann Thorac Surg. 2011;91:506–13.

    Article  PubMed  Google Scholar 

  11. Sabik JF, Lytle BW, Blackstone EH, Kahn N, Houghtaling BL, Cosgrove DM. Does competitive flow reduce internal thoracic artery graft patency? Ann Thorac Surg. 2003;76:1490–6.

    Article  PubMed  Google Scholar 

  12. Tatoulis J, Buxton BF, Fuller JA. The right internal thoracic artery: the forgotten conduit. 5,766 patients and 991 angiograms. Ann Thorac Surg. 2011;92:9–17.

    Article  PubMed  Google Scholar 

  13. He GW. Contractility of the human internal mammary artery at the distal section increases towards the end. Emphasis on not using the end of the internal mammary artery for grafting. J Thorac Cardiovasc Surg. 1993;106:406–11.

    Article  CAS  PubMed  Google Scholar 

  14. Sasso S, James D, Vecht JA, et al. Effect of skeletonization of internal thoracic artery for coronary revascularization on the incidence of sternal wound infection. Ann Thorac Surg. 2010;89:661–70.

    Article  Google Scholar 

  15. Tatoulis J, Buxton BF, Fuller JA, et al. Long-term patency of 1108 radial arterial-coronary angiograms over 10 years. Ann Thorac Surg. 2009;88:23–30.

    Article  PubMed  Google Scholar 

  16. Acar C, Jebara VA, Portoghese M, et al. Revival of the radial artery for coronary artery bypass grafting. Ann Thorac Surg. 1992;54:652–60.

    Article  CAS  PubMed  Google Scholar 

  17. Athanasiou T, Sasso S, Rao C, et al. Radial artery versus saphenous vein conduits for coronary bypass surgery 40 years of competition, which conduit offers better patency? A systematic review and meta-analysis. Eur J Cardiothorac Surg. 2011;40:208–20.

    Article  PubMed  Google Scholar 

  18. Tranbaugh RF, Dimitrova KR, Lucido DJ, et al. The second best arterial graft: a propensity analysis of the radial artery versus the free right internal thoracic artery to bypass the circumflex coronary artery. J Thorac Cardiovasc Surg. 2014;147:133–42.

    Article  PubMed  Google Scholar 

  19. Gaudino M, Prati F, Caradonna E, et al. Implantation in coronary circulation induces morphofunctional transformation of radial grafts from muscular to elastomuscular. Circulation. 2005;112:I208–11.

    PubMed  Google Scholar 

  20. Ruzieh M, Moza A, Siddegowda Bangalore B, Schwann T, Tinkel JL. Effect of transradial catheterisation on patency rates of radial arteries used as a conduit for coronary bypass. Heart Lung Circ. 2017;26:296–300.

    Article  PubMed  Google Scholar 

  21. Suma H. Gastroepiploic artery graft in coronary artery bypass grafting. Ann Cardiothorac Surg. 2013;2:493–8.

    PubMed  PubMed Central  Google Scholar 

  22. Schwann TA, Hashim SW, Badou S, et al. Equipoise between radial artery and right internal thoracic artery as the second arterial conduit in left internal thoracic artery base coronary artery bypass graft surgery: a multi institutional study. Eur J Cardiothorac Surg. 2016;49:188–95.

    Article  PubMed  Google Scholar 

  23. Benedetto U, Raja SG, Albanese A, et al. Searching for the second-best graft in coronary artery bypass surgery: a network meta-analysis of randomized controlled trials. Eur J Cardiothorac Surg. 2015;47:59–65.

    Article  PubMed  Google Scholar 

  24. Hayward PA, Gordon IR, Hare DL, 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;139:60–5.

    Article  PubMed  Google Scholar 

  25. Cooper EA, Edelman JJ, Black D. Anaortic off-pump coronary artery bypass grafting in the elderly and very elderly. Heart Lung Circ. 2013;22:989–95.

    Article  PubMed  Google Scholar 

  26. Lytle BW, Blackstone EH, Sabik JF, et al. The effect of bilateral internal thoracic artery grafting on survival during 20 postoperative years. Ann Thorac Surg. 2004;78:2005–12; discussion 2012–14.

    Article  PubMed  Google Scholar 

  27. Achouh P, Isselmou KO, Boutekadjirt R, et al. Reappraisal of a 20-year experience with radial artery as a conduit for coronary bypass grafting. Eur J Cardiothorac Surg. 2012;41:87–92.

    Article  PubMed  Google Scholar 

  28. Taggart DP, Altman DG, Gray AM, et al. Randomized trial of bilateral versus single internal-thoracic-artery grafts. N Engl J Med. 2016;375:2540–9.

    Article  PubMed  Google Scholar 

  29. Taggart DP, Altman DG, Flather M, 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;136:454–63.

    Article  PubMed  Google Scholar 

  30. Schwann TA, Trambaugh RF, Dimitrova KR, et al. Time varying survival benefit of radial artery versus venous grafting: a multi institutional analysis. Ann Thorac Surg. 2014;97:1328–34.

    Article  PubMed  Google Scholar 

  31. Buxton BF, Shi WY, Tatoulis J, et al. Total arterial revascularisation with internal thoracic and radial artery grafts in triple vessel coronary artery disease is associated with improved survival. J Thorac Cardiovasc Surg. 2014;148:1238–43.

    Article  PubMed  Google Scholar 

  32. Pu 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;2:1187–96.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Grau JB, Kuschner CE, Johnson CK, et al. The effects of using a radial artery in patients already receiving bilateral internal mammary arteries during coronary bypass grafting: 30 day outcomes and 14 year survival in a propensity matched cohort. Eur J Cardiothorac Surg. 2016;49:203–10.

    Article  PubMed  Google Scholar 

  34. Gaudino M, Benedetto U, Fremes S, et al. Radial artery or saphenous vein grafts in coronary artery bypass surgery. N Engl J Med. 2018;378:2069–77.

    Article  PubMed  Google Scholar 

  35. Kurlansky PA, Traad EA, Dorman MJ, et al. Thirty-year follow-up defines survival benefit for second internal mammary artery in propensity-matched groups. Ann Thorac Surg. 2010;90:101–8.

    Article  PubMed  Google Scholar 

  36. Shi WY, Tatoulis J, Newcomb AE, et al. Is a third arterial conduit necessary? Comparison of the radial artery and saphenous vein in patients receiving bilateral internal thoracic arteries for triple vessel coronary disease. Eur J Cardiothorac Surg. 2016;50:53–60.

    Article  PubMed  Google Scholar 

  37. Glineur D. Importance of the third arterial graft in multiple arterial grafting strategies. Ann Cardiothorac Surg. 2013;2:475–80.

    PubMed  PubMed Central  Google Scholar 

  38. Gaudino M, Puskas JD, Di Franco A, et al. 3 arterial grafts improve late survival. A meta- analysis of propensity matched studies. Circulation. 2017;135:1036–44.

    Article  PubMed  Google Scholar 

  39. Kieser TM, Curran HJ, Rose MS, Norris CM, Graham MM. Arterial grafts balance survival between incomplete and complete revascularization: a series of 1000 consecutive coronary artery bypass graft patients with 98% arterial grafts. J Thorac Cardiovasc Surg. 2014;147:75–83.

    Article  PubMed  Google Scholar 

  40. Shi WY, Hayward PA, Tatoulis J, et al. Is the radial artery associated with improved survival in older patients undergoing coronary artery bypass grafting. Eur J Cardiothorac Surg. 2016;49:196–202.

    Article  PubMed  Google Scholar 

  41. Schwann TA, Engoren M, Bonnell M, et al. Comparison of late CABG survival effects of radial artery versus saphenous vein grafting in male and female patients. Ann Thorac Surg. 2012;94:1485–91.

    Article  PubMed  Google Scholar 

  42. Lawton JS, Barner HB, Bailey MS, et al. Radial artery grafts in women: utilization and results. Ann Thorac Surg. 2005;80:559–63.

    Article  PubMed  Google Scholar 

  43. Deb S, Singh SK, Moussa F, et al. The long-term impact of diabetes on graft patency after coronary artery bypass grafting surgery: a sub-study of the multi center Radial Artery Patency Study. J Thorac Cardiovasc Surg. 2014;148:1246–53.

    Article  PubMed  Google Scholar 

  44. Raza S, Blackstone EH, Houghtaling PL, et al. Similar outcomes in diabetes patients after coronary artery bypass grafting with single internal thoracic artery plus radial artery grafting and bilateral internal thoracic artery grafting. Ann Thorac Surg. 2017;104:1923–32.

    Article  PubMed  Google Scholar 

  45. Kinoshita T, Asai T, Murakami Y, et al. Efficacy of bilateral internal thoracic artery grafting in patients with chronic kidney disease. Ann Thorac Surg. 2010;89:1106–11.

    Article  PubMed  Google Scholar 

  46. Tatoulis J. Coronary revascularization in heart failure – old lessons relearnt: patient outcomes are paramount in the stenting era. Eur J Cardiothorac Surg. 2015;47:322–3.

    Article  PubMed  Google Scholar 

  47. Petrie MC, Jhund PS, She L, et al. Ten-year outcomes after coronary artery bypass grafting according to age in patients with heart failure and left ventricular systolic dysfunction: an analysis of the extended follow-up of the STICH Trial (surgical treatment for ischemic heart failure). Circulation. 2016;134:1314–24.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Tatoulis J, Buxton BF, Fuller JA. The radial artery in reoperative coronary bypass surgery. J Card Surg. 2004;19:296–302.

    Article  CAS  PubMed  Google Scholar 

  49. Zacharias A, Schwann TA, Riordan CJ, et al. Late outcomes after radial artery versus saphenous vein grafting during reoperative coronary bypass surgery. J Thorac Cardiovasc Surg. 2010;139:1511–8.

    Article  PubMed  Google Scholar 

  50. Kim KB, Hwang HY, Hahn S, Kim JS, Oh SJ. A randomized comparison of the saphenous vein versus right internal thoracic artery as a Y-composite graft. (SAVE RITA) trial: one-year angiographic results in mid-term clinical outcomes. J Thorac Cardiovasc Surg. 2014;148:901–7.

    Article  PubMed  Google Scholar 

  51. Souza DR, Dashwood MR, Samano N. Saphenous vein graft harvesting and patency: no-touch harvesting is the answer. J Thorac Cardiovasc Surg. 2017;154:1300–1.

    Article  Google Scholar 

  52. Taggart DP, Amin S, Djordjevic J, et al. A prospective study of external stenting of saphenous vein grafts to the right coronary artery: the VEST II study. Eur J Cardiothorac Surg. 2017;51:952–8.

    Article  PubMed  Google Scholar 

  53. Hayward PA, Buxton BF. Midterm results of the radial artery patency outcomes trial. Ann Cardiothorac Surg. 2013;2:458–66.

    PubMed  PubMed Central  Google Scholar 

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Authors and Affiliations

  1. Department of Cardiothoracic Surgery, The Royal Melbourne Hospital, Melbourne, VIC, Australia

    James Tatoulis

  2. Department of Surgery, University of Melbourne, Melbourne, VIC, Australia

    James Tatoulis

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  1. James Tatoulis
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Correspondence to James Tatoulis .

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Editors and Affiliations

  1. Harefield Hospital, Royal Brompton & Harefield NHS Trust, London, UK

    Shahzad G. Raja

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Tatoulis, J. (2020). Total and Multiple Arterial Revascularization. In: Raja, S. (eds) Cardiac Surgery. Springer, Cham. https://doi.org/10.1007/978-3-030-24174-2_22

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  • DOI: https://doi.org/10.1007/978-3-030-24174-2_22

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