Reevaluating Internal Thoracic Artery Use in Octogenarians Undergoing Multivessel Coronary Artery Bypass Grafting
Allen A Razavi1, Aminah Sallam1, Brian Lim1
1Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA.
Insights
Internal thoracic artery (ITA) use in coronary artery bypass grafting (CABG) for octogenarians did not improve 6-year outcomes. Saphenous vein graft (SVG)-only strategies showed similar major adverse cardiac events and mortality rates.
Area of Science:
- Cardiovascular Surgery
- Geriatric Cardiology
- Health Services Research
Background:
- Internal thoracic artery (ITA) use is a benchmark for coronary artery bypass grafting (CABG) quality.
- Its effectiveness in octogenarians (patients aged 80 and above) undergoing CABG is not well-established.
- This study evaluates mid-term outcomes comparing ITA plus saphenous vein grafts (SVG) versus SVG-only in this elderly population.
Purpose of the Study:
- To compare mid-term major adverse cardiac events (MACE) and all-cause mortality in octogenarians undergoing CABG.
- To assess the value of internal thoracic artery (ITA) use in contemporary CABG practice for the elderly.
- To inform quality metrics for CABG in octogenarian patients.
Main Methods:
- A retrospective analysis of 13,925 octogenarians undergoing isolated, elective CABG with 2-4 grafts (2015-2022) from the US Medicare database.
- Comparison between 12,280 patients receiving ITA+SVG and 1,105 receiving SVG-only.
- Propensity score matching was used to compare 6-year freedom from MACE (death, myocardial infarction, repeat revascularization) and all-cause mortality.
Main Results:
- Propensity matching created 1,101 comparable pairs of octogenarians.
- Six-year freedom from MACE was similar: 49.7% for ITA+SVG versus 48% for SVG-only (adjusted HR: 0.92; p=0.23).
- No significant difference was observed in 6-year all-cause mortality: 54.8% for ITA+SVG versus 52.7% for SVG-only (adjusted HR: 0.90; p=0.19).
Conclusions:
- Internal thoracic artery (ITA) use in octogenarians undergoing elective multivessel CABG was not associated with improved 6-year MACE or mortality.
- Current ITA-based quality metrics may require re-evaluation for octogenarian CABG patients.
- SVG-only strategies appear to offer comparable mid-term results in this specific patient group.
Background:
Internal thoracic artery (ITA) use is a benchmark of quality in coronary artery bypass grafting (CABG), yet its value in contemporary practice among octogenarians remains uncertain. We compared mid-term major adverse cardiac events and all-cause mortality among octogenarians undergoing CABG with ITA plus saphenous vein grafts (SVGs) vs SVG-only.
Methods:
We identified 13,925 octogenarians who underwent isolated first-time elective CABG with 2-4 grafts from 2015 to 2022 in the US Centers for Medicare and Medicaid database validated against individual clinical records: 12,280 received ITA+SVG and 1105 received SVG-only. The primary outcome was 6-year freedom from major adverse cardiac events (MACE) defined as death, myocardial infarction, or repeated revascularisation. The secondary outcome was 6-year all-cause mortality. Median follow-up time was 4.3 years (interquartile range [IQR] 4.2-4.5 years). Outcomes were compared in a Cox proportional hazards model after propensity matching across 28 covariates with an exact number of grafts.
Results:
Patients receiving ITA+SVG were of similar age (81 years [IQR 80-83 years] vs 82 years [IQR 80-84 years]; P = 0.13) and less often female (24% vs 31.1%; P < 0.001). Propensity score matching yielded 1101 well matched pairs. Six-year freedom from MACE was 49.7% in the ITA+SVG group vs 48% in the SVG-only group (adjusted hazard ratio [aHR] 0.92, 95% confidence interval [CI] 0.79-1.06; P = 0.23). There was no difference in 6-year all-cause mortality (54.8% vs 52.7%; aHR 0.90, 95% CI 0.78-1.05; P = 0.19).
Conclusions:
Among octogenarians undergoing elective multivessel CABG, ITA use was not associated with improved 6-year freedom from MACE or all-cause mortality. These findings suggest that universal ITA-based quality metrics may need reassessment for octogenarians.
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