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Published on: March 27, 2018
Long-term survival after coronary bypass surgery with multiple versus single arterial grafts
Daniel J F M Thuijs1, Piroze Davierwala2,3,4, Milan Milojevic1,5
1Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, Netherlands.
Insights
Multiple arterial grafts (MAG) significantly improve long-term survival after coronary artery bypass grafting (CABG) compared to single arterial grafts (SAG). This study highlights the benefit of MAG in reducing all-cause mortality in CABG patients.
Area of Science:
- Cardiovascular Surgery
- Clinical Trials
- Grafting Techniques
Background:
- Coronary artery bypass grafting (CABG) is a common procedure for treating coronary artery disease.
- The choice of arterial graft (multiple vs. single) may impact long-term patient survival.
- The SYNTAX study provided a platform for evaluating different revascularization strategies.
Purpose of the Study:
- To compare the long-term survival rates between patients receiving multiple arterial grafts (MAG) and single arterial grafts (SAG) after CABG.
- To analyze the impact of graft choice on all-cause mortality in a large cohort of CABG patients.
Main Methods:
- Analysis of 1466 patients from the SYNTAX Extended Survival (SYNTAXES) study, excluding those with venous or synthetic grafts.
- Primary endpoint: all-cause death at longest follow-up (12.6 years).
- Statistical analysis included multivariable Cox regression and propensity score matching with inverse probability of treatment weights.
Main Results:
- Patients receiving MAG (31.7%) were younger and at lower risk than those receiving SAG (68.3%).
- MAG was associated with significantly lower all-cause death at 12.6 years (23.6% vs. 40.0%; adjusted HR 0.74, P=0.038).
- A significant survival benefit for MAG was observed in patients with three-vessel disease but not in those with left main disease.
Conclusions:
- Multiple arterial grafts (MAG) demonstrate a significant long-term survival advantage over single arterial grafts (SAG) in CABG patients.
- The findings support increased utilization of MAG in selected patients with favorable life expectancy.
- Further research may refine patient selection for optimal outcomes with MAG.
Objectives:
This study sought to evaluate the long-term differences in survival between multiple arterial grafts (MAG) and single arterial grafts (SAG) in patients who underwent coronary artery bypass grafting (CABG) in the SYNTAX study.
Methods:
The present analysis included the randomized and registry-treated CABG patients (n = 1509) from the SYNTAX Extended Survival study (SYNTAXES). Patients with only venous (n = 42) or synthetic grafts (n = 1) were excluded. The primary end point was all-cause death at the longest follow-up. Multivariable Cox regression was used to adjust for differences in baseline characteristics. Sensitivity analysis using propensity matching with inverse probability for treatment weights was performed.
Results:
Of the 1466 included patients, 465 (31.7%) received MAG and 1001 (68.3%) SAG. Patients receiving MAG were younger and at lower risk. At the longest follow-up of 12.6 years, all-cause death occurred in 23.6% of MAG and 40.0% of SAG patients [adjusted hazard ratio (HR) 0.74, 95% confidence interval (CI) (0.55-0.98); P = 0.038], which was confirmed by sensitivity analysis. MAG in patients with the three-vessel disease was associated with significant lower unadjusted and adjusted all-cause death at 12.6 years [adjusted HR 0.65, 95% CI (0.44-0.97); P = 0.033]. In contrast, no significance was observed after risk adjustment in patients with the left main disease, with and without diabetes, or among SYNTAX score tertiles.
Conclusions:
In the present post hoc analysis of all-comers patients from the SYNTAX trial, MAG resulted in markedly lower all-cause death at 12.6-year follow-up compared to a SAG strategy. Hence, this striking long-term survival benefit of MAG over SAG encourages more extensive use of multiple arterial grafting in selected patients with reasonable life expectancy.
Trial Registration:
SYNTAXES ClinicalTrials.gov reference: NCT03417050; SYNTAX ClinicalTrials.gov reference: NCT00114972.
