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All-Venous Grafting and Very Long-Term Survival After Coronary Artery Bypass Grafting
John J Squiers1, Emily Shih1, J Michael DiMaio2
1Department of Cardiothoracic Surgery, Baylor Scott & White, The Heart Hospital, Plano, Texas.
Insights
Single-arterial grafting in coronary artery bypass grafting (CABG) shows superior survival outcomes compared to all-venous grafting. This large Medicare study confirms that using at least one arterial graft improves long-term patient survival.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Medical Outcomes Research
Background:
- Observational studies suggest single-arterial grafting yields better outcomes than all-venous grafting in coronary artery bypass grafting (CABG).
- Current guidelines recommend single-arterial grafting (Class I), but lack of powered randomized controlled trials and contemporary very long-term data persist.
- This study addresses the need for robust evidence on contemporary conduit strategies in CABG.
Purpose of the Study:
- To compare survival outcomes between all-venous grafting and single-arterial grafting in Medicare beneficiaries undergoing CABG.
- To evaluate the long-term effectiveness of different arterial conduit strategies in CABG.
- To provide evidence supporting current guideline recommendations for arterial grafting in CABG.
Main Methods:
- Retrospective analysis of Medicare beneficiaries who underwent CABG between 1999 and 2004.
- Comparison of survival using restricted mean survival times (RMST) between all-venous and single-arterial grafting groups.
- Risk adjustment for covariates using overlap propensity score weighting to ensure robust comparisons.
Main Results:
- The study included 640,116 CABG beneficiaries: 15.8% received all-venous grafts and 84.2% received single-arterial grafts.
- All-venous grafting was associated with significantly worse risk-adjusted operative survival (30-day RMST difference: 0.73 days), short-term survival (1-year RMST difference: 14 days), and very long-term survival (20-year RMST difference: 1.21 years).
- P-values for all survival comparisons were < .001, indicating statistical significance.
Conclusions:
- Medicare beneficiaries undergoing CABG with all-venous grafting experienced inferior risk-adjusted survival compared to those receiving single-arterial grafting.
- These findings strongly support the current guideline recommendations for a Class I indication for using at least one arterial graft in CABG.
- The study reinforces the importance of arterial conduits for improved long-term survival in CABG patients.
Background:
Observational studies of coronary artery bypass grafting (CABG) have associated single-arterial grafting with superior outcomes compared with all-venous grafting. Current guidelines assign single-arterial grafting a class I recommendation. However, no adequately powered randomized controlled trials were undertaken to confirm this benefit, and very long-term data on outcomes of various conduit strategies from more contemporary eras remain lacking.
Methods:
This study retrospectively analyzed Medicare beneficiaries who underwent CABG from 1999 to 2004, the period immediately preceding the first publication of guidelines affording single-arterial grafting a class I indication. The study compared survival between beneficiaries undergoing all-venous grafting and those undergoing single-arterial grafting by using restricted mean survival times (RMSTs). Risk adjustment was performed for all available covariates by using overlap propensity score weighting.
Results:
Among 640,116 Medicare beneficiaries, 101,120 (15.8%) underwent all-venous grafting and 538,996 (84.2%) underwent single-arterial grafting. Beneficiaries undergoing all-venous grafting, vs single-arterial grafting, were noted to have worse risk-adjusted operative survival (30-day RMST, 28.6 [95% CI: 28.6-28.7] days vs 29.3 [95% CI: 29.2-29.3] days; difference, 0.73 [95% CI: 0.73-0.73] days; P < .001), short-term survival (1-year RMST, 324 [95% CI: 324-325] days vs 339 [95% CI: 338-339] days; difference, 14 [95% CI: 13-15] days; P < .001), and very long-term survival (20-year RMST, 8.34 [95% CI: 8.30-8.38] vs 9.55 [95% CI: 9.51-9.59] years; difference, 1.21 years; P < .001).
Conclusions:
Medicare beneficiaries undergoing CABG with all-venous grafting had inferior risk-adjusted survival compared with patients receiving single-arterial grafting. These findings support current multidisciplinary guideline recommendations offering a class I indication for use of at least 1 arterial graft during CABG.
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