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Synergizing Antegrade Endoscopic with Bridging Vein Harvesting for Improvement of Great Saphenous Vein Graft Quality from the Lower Leg
Published on: November 19, 2019
Coronary Artery Bypass Surgery Without Saphenous Vein Grafting: JACC Review Topic of the Week
Alistair Royse1, Justin Ren2, Colin Royse3
1Department of Surgery, University of Melbourne, Melbourne, Victoria, Australia; Royal Melbourne Hospital, Melbourne, Victoria, Australia.
Insights
Total arterial revascularization (TAR) using arterial conduits may improve long-term survival compared to saphenous vein grafts (SVG). Studies show TAR is associated with reduced all-cause mortality in patients undergoing coronary bypass surgery.
Area of Science:
- Cardiovascular Surgery
- Vascular Grafting
- Surgical Outcomes
Background:
- Saphenous vein grafts (SVG) are used in ~95% of coronary bypass surgeries.
- SVGs are prone to accelerated atherosclerosis, stenosis, and occlusion within 10 years.
- Arterial conduits show less evidence of progressive failure compared to SVGs.
Purpose of the Study:
- To investigate if total arterial revascularization (TAR) improves late survival (>5 years) compared to SVG use.
- To evaluate the impact of avoiding SVG on long-term patient mortality.
Main Methods:
- A literature review of 23 studies (N=100,314 matched patients) was conducted.
- An expanded analysis combined the literature review with a new dataset (N=63,288 patients), totaling 127,565 patients.
- Bayesian analysis was employed to assess the probability of TAR-associated mortality reduction.
Main Results:
- A literature review found reduced all-cause mortality for TAR (HR: 0.77; 95% CI: 0.71-0.84; P < 0.001) at a mean 8.8 years postoperatively.
- The expanded analysis confirmed reduced all-cause mortality for TAR (HR: 0.78; 95% CI: 0.72-0.85; P < 0.001).
- Bayesian analysis indicated a high probability of reduced all-cause mortality with TAR.
Conclusions:
- Total arterial revascularization (TAR) is associated with significantly reduced long-term all-cause mortality after coronary bypass surgery.
- Avoiding saphenous vein grafts (SVG) in favor of arterial conduits may lead to better late survival outcomes.
- The findings support the consideration of TAR for improved patient longevity post-coronary artery bypass grafting.
Abstract:
Approximately 95% of patients of any age undergoing contemporary, coronary bypass surgery will receive at least 1 saphenous vein graft (SVG). It is recognized that SVG will develop progressive and accelerated atherosclerosis, resulting in a stenosis, and in occlusion that occurs in 50% by 10 years postoperatively. For arterial conduits, there is little evidence of progressive failure as for SVG. Could avoidance of SVG (total arterial revascularization [TAR]) lead to a different late (>5 year) survival? A literature review of 23 studies (N = 100,314 matched patients) at a mean 8.8 years postoperative found reduced all-cause mortality for TAR (HR: 0.77; 95% CI: 0.71-0.84; P < 0.001). An expanded analysis with a new unpublished data set (N = 63,288 matched patients) was combined with the literature review (N = 127,565). It found reduced all-cause mortality for TAR (HR: 0.78; 95% CI: 0.72-0.85; P < 0.001). Additional Bayesian analysis found a very high probability of a TAR-associated reduction all-cause mortality.
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