how many arterial grafts is enough? bruce lytle md baylor plano heart hospital
TRANSCRIPT
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How Many Arterial Grafts is Enough?
Bruce Lytle MD
Baylor Plano Heart Hospital
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100
90
80
70
100
90
80
70
100
90
80
70
ITA vs SVG 10-Year Survival by Extent of Disease
2 4 6 8 10 2 4 6 8 10 2 4 6 8 10
Pe
rce
nt
93.4
P=0.05
79.5
90.0
82.6
71.0
P=0.0001 P=0.0001
ITA N=332Vein N=440
ITA N=714Vein N=1,063
ITA N=1,249Vein N=2,116
88.0
One-Vessel(LAD) Two-Vessel(LAD) Three-VesselLoop. et al: NEJM 314:1-6. 1986
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Patency of ITA and SVG to the LAD at One-Year Intervals
100
90
80
70
60
0 1 2 3 4 5 6 7 8 9 10 11 12 13
Per
cen
t P
aten
t
Catheterization Intervals (Years)
168 48 57 5141 27
238 8
76 26044
302 431 93
62
69 82
73
47
20
13
34
5363
96
Internal Thoracic Artery N=855 GraftsSaphenous Vein N=1445 Grafts
Loop, et al; NEJM 314:1-6, 1986
44
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Are Two ITA Grafts Better Than One?
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100
80
60
40
20
0
Survival
Reoperation
(1786)
(2969)
(2889)
(1763)
BITA n=1989SITA n=4147
P<0.001
Su
rviv
al %
Reo
peratio
n (%
) / year)
5
4
3
2
1
0
328
453
401
302
0 2 4 6 8 10 12
Years After CABG
Survival and Reoperation 1 vs 2 ITA Grafts
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Matched Survival
BITA
SITA
20
40
60
80
100
0 6 12 18
%
Years
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What is the Magnitude of the Benefit ?
And How Many Patients Benefit?
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Survival Difference
8070
6050
4030
AGE0
5
10
1520
YEARS
d_surviv
-10
-5
0
5
10
15
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The Incremental Benefit of the LITA-LAD vs SVG is, for most patients, greater than that for BITA vs LITA-LAD
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Skeletonize the ITAs
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ITA Preparation Pedicled
Cohen et al: JTCS 1999
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ITA Preparation Skeletonized
Cohen et al: JTCS 1999
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Sequential ITA Grafts Add Substantial Complexity
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The more ITA grafts have been done the less benefit
further ITA grafts add
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Radial Artery vs Saphenous Vein (RAPS)
Functional Graft Occlusions
Radial 12%
SVG 19.7%
Complete Graft Occlusion
Radial 8.9%
SVG 18.6%
510 Patients – 9 Canadian Center269 Late Angiography (7.7 years)
P = 0.03
P = 0.002
Deb et al JACC: 2012
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Probability of Graft Patency100
80
60
40
20
00 3 6 9 12 15
LITA
RITA
SVG
RA
Number of years following surgery
Pro
bab
ility
of
gra
ft p
aten
cy (
%)
LITA graft n=2443RITA graft n=991Radial graft n=1108SVG graft n=3238
Tatoulis et al. 2011
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For All Arterial Grafts Patency is Related to
Coronary Stenosis
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Risk Factors ITA Occlusion
Factor P
Lesser Proximal Stenosis <.0001
Time after CABG
Non-LAD <.0001
LAD .5
Right ITA <.0001
Smoking <.0001
Female Gender .0003
Later Date of Surgery.01
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Graft Patency vs Coronary Stenosis
100
80
60
40
20
0
%
<60
Tatoulis et al (2004)
>60
LITA<60 >60
RITA<60 >60
RA
P<0.01 P<0.001 P<0.01
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The Most Common Cause of a Failed Arterial Graft is
Competitive Flow
But the decrement in patency is not large
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Failed bypass grafts do not appear to compromise
survival
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How Many Arterial Grafts?
• LITA-LAD for Everyone• A second ITA graft to the second most
important stenotic vessel further improves outcomes
• Radial artery grafts increase operative complexity little
• Complex ITA grafting, RGEA grafting are not generic operations
• Do an operation that will work on that day
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100
80
60
40
20
00 5 10 15 20 25
%
Years
LITA - LADSurvival & Revascularization
CompleteIncomplete (n = 791)
97%91%
81%
69%
93%
82%
68%
52%