Multiple arterial coronary artery bypass grafting : perioperative complications, clinical and angiographic evolution

Multiple arterial coronary artery bypass grafting is a controversial surgical procedure that is still uncommon worldwide. The aim of our study was to determine the outcomes and perioperative complications of the multiple arterial myocardial revascularization and their predictive factors, the mid-term and long term clinical and angiographic prognosis of the studied patients.

This was a single center study of the cardiovascular department of The Rabta hospital. Patients included had serial multiple arterial coronary artery bypass grafting between January 2008 and December 2014. A statistical univariate and multivariate analysis had been conducted to identify complications and their predictive factors and a Kaplan-Meier study was done for the clinical and angiographic late outcomes.

We included 322 patients mean aged 58 years, sex-ratio was 7.7 with a preserved left ventricle ejection fraction (LVEF) in 68.94% of cases. On-pump 1109 bypasses were made, among them 788 arterial grafts were used. Left internal thoracic artery (LIMA) was used in 100% of patients. Patency of the LIMA was 100%, 94.7%, 91.6% and 73.3% at 1, 3, 5 and 8 years respectively. RIMA (right internal thoracic artery) was used in 87.2% of patients, anastomosed to the left coronary system via the Theile sinus, anastomosed to the LIMA to make a Y shape configuration, or anastomosed in situ to the right coronary artery. Its patency was 98.3%, 86.2%, 68% and 57.9%. There was no significance between configuration patencies except the RIMA anastomosed to the lateral braches of the circumflex artery (p=0.003). Early mortality was 5.9 %, its main predictors were post operative intra aortic balloon pump (OR=22.18), re intervention for bleeding (OR=30.57), post operative myocardial infarction (OR=29.49), aortic clamping >= 60 minutes (OR=10.89), post operative high level of catecholamine (OR=9.1) and mediastinitis (OR=7.15). Main early complications were pulmonary infection (20.2%), acute renal failure (5.3%) and mediastinitis (5%). Data of long term following could be collected only in 39.4% of cases. Major Adverse Cardiologic and Cerebral Events (MACCE) occurred in 30.71% controlled patients. Free-MACCE survival was 52.9% at 5. Initially total arterial bypass grafting was superior to other configurations in free-MACCE survival (p=0.036) but we lost significance beyond 5-years following because of selection bias.

Multi arterial coronary artery bypass grafting was secure in early morbidity and mortality. Long term prognosis seemed to be better in case of total arterial revascularization.