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Original Investigation
February 19, 2020

Long-term Outcomes Associated With Total Arterial Revascularization vs Non–Total Arterial Revascularization

Author Affiliations
  • 1Schulich Heart Centre, Sunnybrook Health Sciences Centre, Division of Cardiac Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
  • 2Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
  • 3Cardiovascular Program, ICES, Toronto, Ontario, Canada
  • 4Schulich Heart Centre, Sunnybrook Health Sciences Centre, Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  • 5Department of Cardio-Thoracic Surgery, Weill Cornell Medicine, New York, New York
  • 6Division of Cardiac Surgery, Royal Melbourne Hospital, Parkville, Victoria, Australia
  • 7Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
JAMA Cardiol. Published online February 19, 2020. doi:10.1001/jamacardio.2019.6104
Key Points

Question  What are the short-term and long-term outcomes of total arterial revascularization at a population-based level?

Findings  In this cohort study of 49 404 patients, compared with the coronary artery bypass with at least 1 arterial and 1 saphenous venous graft, total arterial revascularization was associated with improved long-term freedom from major adverse cardiac and cerebrovascular events, death, and myocardial infarction.

Meaning  Total arterial revascularization may be the procedure of choice for patients with reasonable life expectancy requiring coronary artery bypass grafting.

Abstract

Importance  The optimal conduits for coronary artery bypass grafting (CABG) remain controversial in multivessel coronary artery disease.

Objective  To compare the long-term clinical outcomes of total arterial revascularization (TAR) vs non-TAR (CABG with at least 1 arterial and 1 saphenous vein graft) in a multicenter population-based study.

Design, Setting, and Participants  This multicenter population-based cohort study using propensity score matching took place from October 2008 to March 2017 in Ontario, Canada, with a mean and maximum follow-up of 4.6 and 9.0 years, respectively. Individuals with primary isolated CABG were identified, with at least 1 arterial graft. Exclusion criteria were individuals from out of province and younger than 18 years. Patients undergoing a cardiac reoperation or those in cardiogenic shock were also excluded because these conditions would potentially bias the surgeon toward not performing TAR. Analysis began April 2019.

Exposures  Total arterial revascularization.

Main Outcomes and Measures  Primary outcome was time to first event of a composite of death, myocardial infarction, stroke, or repeated revascularization (major adverse cardiac and cerebrovascular events). Secondary outcomes included the individual components of the primary outcome.

Results  Of 49 404 individuals with primary isolated CABG, 2433 (4.9%) received TAR, with the total number of bypasses being 2, 3, and 4 or more vessels in 1521 (62.5%), 865 (35.6%), and 47 individuals (1.9%), respectively. The mean (SD) age was 61.2 (10.4) years and 1983 (81.5%) were men. After propensity score matching, 2132 patient pairs were formed, with equal total number of bypasses (mean [SD], 2.4 [0.5]) but with more arterial grafts in the TAR group (mean [SD], 2.4 [0.5] vs 1.2 [0.4]; P < .01). In-hospital death (15 [0.7%] vs 21 [1.0%]; P = .32) did not differ between TAR vs non-TAR groups after propensity score matching. Throughout 8 years, TAR was associated with improved freedom from major adverse cardiac and cerebrovascular events (hazard ratio, 0.78; 95% CI, 0.68-0.89), death (hazard ratio, 0.80; 95% CI, 0.66-0.97), and myocardial infarction (hazard ratio, 0.69; 95% CI, 0.51-0.92). There was no difference in stroke and repeated revascularization.

Conclusions and Relevance  Total arterial revascularization was associated with improved long-term freedom from major adverse cardiac and cerebrovascular events, death, and myocardial infarction and may be the procedure of choice for patients with reasonable life expectancy requiring CABG.

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