Decision-making for patients with patent left internal thoracic artery grafts to left anterior descending
Sreekumar Subramanian1, Joseph F Sabik, Penny L Houghtaling
1Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA.
Insights
Coronary reintervention does not improve survival for patients with a patent left internal thoracic artery graft to the left anterior descending artery experiencing non-LAD jeopardy. Symptomatic relief may be a reason for reintervention, not survival benefit.
Area of Science:
- Cardiology
- Vascular Surgery
- Interventional Cardiology
Background:
- Assessing survival benefits of coronary reintervention in patients with a patent left internal thoracic artery (LITA) graft to the left anterior descending (LAD) coronary artery.
- Investigating outcomes for patients with non-LAD territory jeopardy despite a patent LITA-LAD graft.
Purpose of the Study:
- To compare survival rates among medical therapy, percutaneous intervention, and reoperative coronary artery bypass grafting (CABG) in patients with a patent LITA-LAD graft and non-LAD jeopardy.
- To determine if reintervention offers a survival advantage in this specific patient population.
Main Methods:
- Retrospective analysis of 4,640 patients with prior CABG including LITA-LAD graft from 1971-2000.
- Two survival analyses: intent-to-treat (reoperative CABG, percutaneous intervention, or medical management) and competing risk/crossover analysis.
Main Results:
- Intent-to-treat analysis showed similar early survival (<1 year) but slightly better late survival with percutaneous intervention versus medical management.
- Competing risk/crossover analysis indicated best early survival with medical management, with similar late survival across all three groups.
Conclusions:
- Reintervention in patients with a patent LITA-LAD graft and non-LAD jeopardy does not confer a survival benefit.
- Reintervention may be considered for symptom relief rather than for improving survival outcomes in this patient group.
Background:
It is unknown whether coronary reintervention confers a survival advantage when a previously placed left internal thoracic artery graft to the left anterior descending coronary artery (LAD) is patent. We compared survival after medical therapy, percutaneous intervention, and reoperative coronary artery bypass grafting in such patients who developed non-LAD territory jeopardy.
Methods:
From 1971 to 2000, 4,640 patients with prior coronary artery bypass grafting that included left internal thoracic artery to LAD grafting were found on angiography during active follow-up to have a patent left internal thoracic artery to LAD graft, but at least 50% stenosis of non-LAD territories or grafts to them. Two survival analyses were performed: (1) intent-to-treat, which included patients undergoing reoperative coronary artery bypass grafting (n = 731) or percutaneous intervention (n = 994) within 6 weeks of angiography or medical management (n = 2,782), and (2) competing risk/crossover, in which patients were classified as medically managed until crossover to coronary artery bypass grafting or percutaneous intervention.
Results:
In the intent-to-treat analysis, propensity-adjusted early (<1 year) survival was similar for all patients, but late survival was slightly better after percutaneous intervention than with medical management (p < or = 0.05). In the competing risk/crossover analysis, adjusted survival was best for medically treated patients early; however, late survival was similar among all three groups.
Conclusions:
Patients with patent left internal thoracic artery to LAD grafts who develop non-LAD territory jeopardy derive no survival benefit from reintervention, consistent with previous observations that for coronary reintervention to improve survival, the LAD territory must be jeopardized. Reintervention in patients with a patent left internal thoracic artery to LAD graft may be warranted to relieve symptoms, without expecting a survival benefit.
Related Concept Videos
01:27Peripheral Artery Disease III: Interprofessional Care
01:23Peripheral Artery Disease V: Postoperative Nursing Management
01:24Cardiac Catheterization III: Left Heart Catheterization
01:29Cardiomyopathy V: Interprofessional Care
01:25Aortic Regurgitation III: Medical Management
01:27Coronary Artery Disease V: Interprofessional Care