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Published on: May 14, 2013
Single versus multiple arterial grafting in diabetic patients at 10 years: the Arterial Revascularization Trial
David P Taggart1, Katia Audisio2, Stephen Gerry3
1Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, UK.
Insights
Multiple arterial grafting (MAG) significantly reduced 10-year mortality in diabetic patients undergoing coronary artery bypass grafting compared to single arterial grafting (SAG). However, MAG was linked to a higher risk of deep sternal wound infections, particularly in insulin-dependent individuals.
Area of Science:
- Cardiovascular Surgery
- Diabetology
- Clinical Outcomes Research
Background:
- Coronary artery bypass grafting (CABG) is a standard treatment for coronary artery disease.
- The choice between multiple arterial grafting (MAG) and single arterial grafting (SAG) may influence long-term outcomes, especially in patients with diabetes mellitus (DM).
- The Arterial Revascularization Trial (ART) provides valuable data for evaluating surgical strategies.
Purpose of the Study:
- To compare the 10-year efficacy and safety of MAG versus SAG in patients with diabetes mellitus (DM) undergoing CABG.
- To analyze mortality and major adverse cardiac events (MACE) based on grafting strategy and diabetes status.
Main Methods:
- A post hoc analysis of the Arterial Revascularization Trial (ART) dataset.
- Patients were stratified into non-diabetic and diabetic groups, and by grafting strategy (MAG vs. SAG).
- Primary endpoint: all-cause mortality; Secondary endpoint: composite MACE at 10-year follow-up.
Main Results:
- Multiple arterial grafting (MAG) was associated with significantly lower 10-year mortality in diabetic patients (21.5% vs. 29.9% with SAG; adjusted HR 0.65).
- MAG also showed a trend towards lower mortality in non-diabetic patients and reduced MACE in both groups.
- Deep sternal wound infections (DSWI) were more frequent with MAG (7.9% vs. 4.8% in DM patients), especially in insulin-treated diabetic patients (9.6% vs. 6.3% with SAG).
Conclusions:
- Multiple arterial grafting (MAG) offers a substantial survival benefit at 10 years for diabetic patients undergoing coronary artery bypass grafting.
- The increased risk of deep sternal wound infections with MAG in diabetic patients, particularly those on insulin, requires careful consideration.
Aims:
To evaluate the impact of multiple arterial grafting (MAG) vs. single arterial grafting (SAG) in a post hoc analysis of 10-year outcomes in patients with diabetes mellitus (DM) from the Arterial Revascularization Trial (ART).
Methods And Results:
The primary endpoint was all-cause mortality and the secondary endpoint was a composite of major adverse cardiac events (MACE) at 10-year follow-up. Patients were stratified by diabetes status (non-DM and DM) and grafting strategy (MAG vs. SAG). A total of 3020 patients were included in the analysis; 716 (23.7%) had DM. Overall, 55.8% non-DM patients received MAG and 44.2% received SAG, while 56.6% DM patients received MAG and 43.4% received SAG. The use of MAG compared with SAG was associated with lower 10-year mortality for both non-DM [17.7 vs. 21.0%, adjusted hazard ratio (HR) 0.87, 95% confidence interval (CI) 0.72-1.06] and DM patients (21.5 vs. 29.9%, adjusted HR 0.65, 95% CI 0.48-0.89; P for interaction = 0.12). For both groups, the rate of 10-year MACE was also lower for MAG vs. SAG. Overall, deep sternal wound infections (DSWIs) were uncommon but more frequent in the MAG vs. SAG group in both non-DM (3.3 vs. 2.1%) and DM patients (7.9 vs. 4.8%). The highest rates of DSWI were in insulin-treated patients receiving MAG (9.6 vs. 6.3%, when compared with SAG).
Conclusion:
In this post hoc analysis of the ART, MAG was associated with substantially lower mortality rates at 10 years after coronary artery bypass grafting in patients with DM. Patients with DM receiving MAG had a higher incidence of DSWI, especially if insulin dependent.
