Taggart David P, Gaudino Mario F, Gerry Stephen, Gray Alastair, Lees Belinda, Dimagli Arnaldo, Puskas John D, Zamvar Vipin, Pawlaczyk Rafał, Royse Alistair G, Flather Marcus, Benedetto Umberto
Nuffield Department of Surgical Sciences, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom.
Cardiothoracic Surgery at Weill Cornell Medical Center, New York, NY.
J Thorac Cardiovasc Surg. 2022 Mar;163(3):1002-1009.e6. doi: 10.1016/j.jtcvs.2020.03.013. Epub 2020 Mar 19.
The Arterial Revascularization Trial (ART) was designed to compare 10-year survival in bilateral versus single internal thoracic artery grafts. The intention-to-treat analysis has showed comparable outcomes between the 2 groups but an explanatory analysis suggested that those receiving 2 or more arterial grafts had better survival. Whether the exclusive use of arterial grafts provide further benefit is unclear.
We performed an exploratory analysis of the ART based on conduits actually received (as-treated principle). From ART cohort, only patients receiving at least 3 grafts were included. The final population consisted of 1084, 1010, and 390 patients in the single arterial graft (SAG) group, in the multiple arterial graft (MAG) group (2 or more arterial grafts with additional saphenous veins) and total arterial graft (TAG) group (3 or more arterial grafts only) respectively. Inverse probability of treatment weighting was used for comparison.
When compared with the SAG group, there was a significant trend toward a reduction of 10-year mortality in the MAG and TAG group (test for trend P = .02). The TAG group was associated with the lowest risk of late mortality (hazard ratio, 0.68; 95% confidence interval, 0.48-0.96; P = .03) and with a significant risk reduction of the composite of death/myocardial infarction/stroke and repeat revascularization (hazard ratio, 0.71; 95% confidence interval, 0.53-0.94; P = .02).
When compared with SAG, both MAG and TAG represent valuable strategies to improve clinical outcomes following coronary artery bypass grafting but TAG can potentially provide further benefit.
动脉血运重建试验（ART）旨在比较双侧与单侧胸廓内动脉移植的10年生存率。意向性分析显示两组结果相当，但一项解释性分析表明，接受2根或更多动脉移植的患者生存率更高。单纯使用动脉移植是否能带来更多益处尚不清楚。
我们基于实际接受的血管 conduit（即治疗原则）对ART进行了探索性分析。从ART队列中，仅纳入接受至少3根移植血管的患者。最终人群分别包括单动脉移植（SAG）组、多动脉移植（MAG）组（2根或更多动脉移植加用大隐静脉）和全动脉移植（TAG）组（仅3根或更多动脉移植）中的1084例、1010例和390例患者。采用治疗权重的逆概率进行比较。
与SAG组相比，MAG组和TAG组10年死亡率有显著下降趋势（趋势检验P = 0.02）。TAG组与最低的晚期死亡风险相关（风险比，0.68；95%置信区间，0.48 - 0.96；P = 0.03），且死亡/心肌梗死/中风及再次血运重建复合终点的风险显著降低（风险比，0.71；95%置信区间，0.53 - 0.94；P = 0.02）。
与SAG相比，MAG和TAG都是改善冠状动脉旁路移植术后临床结局的有价值策略，但TAG可能会带来更多益处。
