Department of Surgery, University of Toledo, Toledo, Ohio.
The Society of Thoracic Surgeons Research Center, Chicago, Illinois.
Ann Thorac Surg. 2018 Apr;105(4):1109-1119. doi: 10.1016/j.athoracsur.2017.10.058. Epub 2018 Feb 14.
More than 90% of coronary artery bypass grafting (CABG) is performed with a single-arterial bypass graft (SABG), based on the left internal thoracic artery (ITA) with supplemental vein grafts. This practice, often justified by safety concerns with multiple-arterial grafting (MABG), defies evidence of improved late survival achieved with bilateral ITA (BITA-MABG) or left ITA plus radial artery (RA-MABG). We hypothesized that MABG and SABG are equally safe.
We analyzed The Society of Thoracic Surgeons National Database (2004 to 2015) to assess the operative safety of BITA-MABG (n = 73,054) and RA-MABG (n = 97,623) vs SABG (n = 1,334,511). Primary end points were operative (30-day or same hospitalization) mortality (OM) and deep sternal wound infections (DSWI). Risk-adjusted odds ratios (AOR) and 95% confidence intervals (CIs) were derived from by logistic regression with sensitivity analyses in multiple subcohorts including MABG use rate.
SABG (73.8% men; median age, 66 years), BITA-MABG (85.1% men; median age, 59 years), and RA-MABG (82.5% men; median age, 61 years) showed distinctly different patient characteristics. Compared with SABG (1.91% OM; 0.73% DSWI), observed OM was lower for BITA-MABG (1.19%, p < 0.001) and RA-MABG (1.19%, p < 0.001). DSWI was higher among BITA-MABG (1.08%, p < 0.001) and similar for RA-MABG (0.71%, p = 0.55). BITA-MABG showed marginally increased, likely not clinically significant, OM (AOR, 1.14; 95% CI, 1.00 to 1.30; p = 0.05) and doubled DSWI (AOR, 2.09; 95% CI, 1.80 to 2.43; p < 0.001). RA-MABG had similar OM (AOR, 1.01; 95% CI, 0.89 to 1.15; p = 0.85) and DSWI (AOR, 0.97; 95% CI, 0.83 to 1.13; p = 0.70). Results were consistent across multiple subcohorts. A U-shaped OM vs BITA use relation was documented, with worse OM at hospitals with low (<5%: AOR, 1.38; 95% CI, 1.18 to 1.61; p < 0.001) and high (≥40%: AOR, 1.31; 95% CI, 1.00 to 1.70; p = 0.049) BITA use.
MABG in the United States is associated with OM comparable to SABG and increased DSWI risk with BITA-MABG. Our findings highlight the importance of surgeon and institutional experience and careful patient selection for BITA-MABG. Our short-term results should not in any way dissuade the use of MABG, given its well-established long-term survival advantage.
超过 90%的冠状动脉旁路移植术（CABG）采用单动脉旁路移植术（SABG）进行，基于左内乳动脉（ITA）和补充静脉移植物。这种做法通常基于对多动脉移植术（MABG）的安全考虑，而不考虑双侧 ITA（BITA-MABG）或左 ITA 加桡动脉（RA-MABG）带来的晚期生存改善的证据。我们假设 MABG 和 SABG 同样安全。
我们分析了胸外科医师学会国家数据库（2004 年至 2015 年），以评估 BITA-MABG（n=73054）和 RA-MABG（n=97623）与 SABG（n=1334511）的手术安全性。主要终点是手术（30 天或同一住院期间）死亡率（OM）和深部胸骨伤口感染（DSWI）。风险调整的优势比（AOR）和 95%置信区间（CI）来自于逻辑回归，通过在包括 MABG 使用率在内的多个亚组中进行敏感性分析得出。
SABG（73.8%男性；中位年龄 66 岁）、BITA-MABG（85.1%男性；中位年龄 59 岁）和 RA-MABG（82.5%男性；中位年龄 61 岁）表现出明显不同的患者特征。与 SABG（1.91%OM；0.73%DSWI）相比，观察到的 OM 较低为 BITA-MABG（1.19%，p<0.001）和 RA-MABG（1.19%，p<0.001）。DSWI 在 BITA-MABG 中较高（1.08%，p<0.001），而在 RA-MABG 中相似（0.71%，p=0.55）。BITA-MABG 显示出略微增加的 OM（AOR，1.14；95%CI，1.00 至 1.30；p=0.05）和双倍的 DSWI（AOR，2.09；95%CI，1.80 至 2.43；p<0.001）。RA-MABG 具有相似的 OM（AOR，1.01；95%CI，0.89 至 1.15；p=0.85）和 DSWI（AOR，0.97；95%CI，0.83 至 1.13；p=0.70）。结果在多个亚组中一致。记录了 OM 与 BITA 使用之间的 U 形关系，低（<5%：AOR，1.38；95%CI，1.18 至 1.61；p<0.001）和高（≥40%：AOR，1.31；95%CI，1.00 至 1.70；p=0.049）BITA 使用的医院 OM 更差。
美国的 MABG 与 SABG 相关联的 OM 相当，并且与 BITA-MABG 相关联的 DSWI 风险增加。我们的发现强调了外科医生和机构经验的重要性以及对 BITA-MABG 的患者选择的重要性。我们的短期结果不应以任何方式劝阻使用 MABG，因为它具有既定的长期生存优势。
