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What constitutes optimal surgical revascularization? Answers from the Bypass Angioplasty Revascularization
Thomas J Vander Salm1, Kevin E Kip, Robert H Jones
1Division of Thoracic and Cardiac Surgery, University of Massachusetts Medical School, Worcester, Massachusetts 01655-3304, USA. vanderst@ummhc.org
Insights
Defining complete revascularization in coronary artery bypass surgery is crucial. The study found that multiple grafts to non-left anterior descending coronary artery systems offer no survival benefit and may be harmful.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
- Clinical Outcomes Research
Background:
- Complete revascularization is a key goal in coronary artery bypass surgery (CABG).
- Existing definitions of complete revascularization lack standardization.
- Optimal definition impacts long-term patient outcomes.
Purpose of the Study:
- To determine the optimal definition of complete revascularization in CABG.
- To identify definitions that best discriminate long-term outcomes.
- To analyze the impact of graft strategy on patient survival.
Main Methods:
- Retrospective analysis of 1,507 patients from the Bypass Angioplasty Revascularization Investigation (BARI) trial.
- Application of four distinct definitions of complete revascularization.
- Evaluation of long-term (seven-year) survival and myocardial infarction rates.
Main Results:
- Traditional and functional complete revascularization showed no survival advantage over incomplete revascularization.
- No survival benefit was observed for three tested definitions based on graft-to-diseased segment ratios.
- More than one graft to non-left anterior descending (LAD) coronary artery systems was associated with increased mortality (32.9% vs. unspecified).
Conclusions:
- Constructing multiple grafts to non-LAD coronary artery systems provides no long-term survival advantage.
- Excessive grafting to non-LAD systems may be detrimental to patient outcomes.
- The optimal definition of complete revascularization may involve specific strategies for the LAD territory.
Objectives:
The study was done to derive the optimum definition of complete revascularization in coronary artery bypass surgery.
Background:
"Complete revascularization" has been considered the goal of coronary artery bypass operations, but various definitions of completeness exist.
Methods:
We evaluated the Bypass Angioplasty Revascularization Investigation (BARI) surgical results in the seven years after operation. Different definitions of completeness of revascularization were retrospectively applied to the 1,507 patients in the combined randomized/registry group to derive the definition of complete operative revascularization with the best discrimination in long-term results between those with and without complete revascularization as defined. Four definitions were evaluated: 1) traditional complete revascularization with one graft to each major diseased artery system; 2) functional complete revascularization with one graft to all diseased major or primary segmental vessels; 3) number of distal anastomoses greater than, equal to or less than the number of diseased coronary segments; and 4) number of distal anastomoses to the major coronary systems equal to 1 or greater than 1.
Results:
No independent survival advantage existed for traditional or functional complete revascularization as compared with incomplete revascularization. No survival advantage existed for any of the three arms of definition 3. For definition 4, seven-year death/myocardial infarction was highest (32.9%) when more than one anastomosis was constructed to any non-left anterior descending coronary artery (LAD) system (relative risk 1.37, p = 0.03). No increased risk was associated with constructing more than one anastomosis into the LAD system.
Conclusions:
The construction of more than one graft to any system other than the LAD appears to confer no long-term advantage, and may actually be deleterious.
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