Conduit Selection Strategy Determines The Long-term Results Of Coronary Surgery For Triple Vessel Disease: Results Over 10 Years
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OBJECTIVE: To evaluate 6 different conduit grafting strategies, all with the left internal thoracic artery (LITA) to the left anterior descending (LAD) incorporated within them, with respect to which achieves the best long-term survival in coronary bypass surgery for patients with triple vessel disease.
METHODS: Six different conduit strategies were evaluated in 5,941 matched patients with triple vessel coronary disease undergoing first time coronary artery surgery. The patients were operated between 1994 to 2003, during which time radial artery (RA) grafting was routine. Patients were computer matched for 15 parameters including age, gender, diabetes, hypertension, LV function, acuity, renal impairment, vascular disease. All patients had a least 1 ITA graft. Follow-up was available for all patients by direct office visit, phone or questionnaire. The National Death Register was checked for any unknown deaths. Mean follow-up was 62 months.
The 6 conduit combinations were bilateral ITA plus single RA (BITA + SRA), bilateral ITA and saphenous vein graft (BITA + VG), single ITA plus bilateral radials (SITA + BRA), single ITA plus single RA (SITA + RA), single ITA plus single RA plus saphenous vein graft (SITA + SRA + VG), and single ITA plus vein graft only (SITA + VG). All operations studied were performed on cardiopulmonary bypass. Patient survival was analyzed by the Kaplan Meier method for all cause mortality. Comparison of survival between groups was with the Log-rank test.
RESULTS: The mean age at surgery was 66.3 years, there was a mean of 3.5 anastomoses per patient. Operative and 30 day mortality was 1.1% - similar in all groups.
The 8-year survival in the different conduit strategy groups (total n = 5,941) in declining order were:-
Conduit Strategies and 8 Yr Survival (n = 5941)| Conduit Strategy | n | 8 Yr Survival | | P |
| BITA + SRA | 778 | 94% | | |
| BITA + VG | 840 | 90% | pns | |
| SITA + BRA | 1196 | 91% | | |
| | | | p < 0.001 |
| SITA + SRA | 565 | 77% | | |
| SITA + SRA + VG | 1068 | 80% | pns | |
| SITA + VG | 1494 | 75% | | |
| Triple Vessel Coronary Disease |
Overall 8 year survival when both ITAs or at least 3 arterial conduits were used (n = 2814) was 91.5%.
Overall 8 year survival when only one ITA was used with single RA or VG (n = 3127) was 77%, p < 0.001.
CONCLUSION: Conduit strategies where either both ITAs, or where at least 3 arterial conduits were used, resulted in superior 8-year survival by comparison to where only 1 ITA was used whether in combination with a RA or VG. When bilateral ITAs were not possible, left ITA together with bilateral radial arteries provided similar excellent 8-year survival.
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