In the current era, complete revascularization improves survival after coronary artery bypass surgery

Thomas Kleisli, Wen Cheng, Milagros J Jacobs, James Mirocha, Michele A Derobertis, Robert M Kass, Carlos Blanche, Gregory P Fontana, Sharo S Raissi, Kathy E Magliato, Alfredo Trento
Journal of Thoracic and Cardiovascular Surgery 2005, 129 (6): 1283-91

BACKGROUND: Complete revascularization has been the standard for coronary bypass grafting. However, surgical intervention has evolved with increasing use of arterial conduits and off-pump techniques.

METHODS: Patients undergoing non-redo bypass surgery from January 1998 through December 2000 were followed up with questionnaires and telephone contact. Incomplete revascularization was defined as absence of bypass grafts placed to a coronary territory supplied by a vessel with 50% or greater stenosis.

RESULTS: One thousand thirty-four patients were followed for a mean of 3.3 +/- 1.6 years. Complete revascularization was found in 937 (90.6%) patients, and incomplete revascularization was found in 97 (9.4%) patients. Eight hundred twenty-seven (80.4%) patients underwent on-pump operations, and 207 (19.6%) underwent off-pump operations. Incomplete revascularization was more prevalent in off-pump versus on-pump operations (21.7% vs 6.3%, P < .001). Multivariable Cox regression analysis indicated that in-hospital cerebrovascular accidents (hazard ratio, 5.49; P < .001), chronic obstructive pulmonary disease (hazard ratio, 1.97; P = .019), and incomplete revascularization (hazard ratio, 1.85; P = .040) predicted an increased hazard (risk) of cardiac death. Left internal thoracic artery (hazard ratio, 0.38; P = .047), right internal thoracic artery (hazard ratio, 0.25; P = .019), and radial artery (hazard ratio, 0.36; P < .001) grafting reduced the risk of cardiac death. The 5-year unadjusted survival rate was 52.6% versus 82.4% in patients undergoing incomplete and complete revascularization ( P < .001), with cardiac survival rates of 74.5% versus 93.1%, respectively ( P < .001). However, this difference in cardiac survival was smaller in octogenarians with incomplete versus complete revascularizations (77.4% vs 87.6%, P = .101) and was essentially absent in off-pump versus on-pump operations if complete revascularization was achieved in both cases (93.6% vs 93.1%, P > .200).

CONCLUSIONS: Complete revascularization and arterial grafting improve 5-year survival. Off-pump techniques do not affect survival. Complete revascularization should be performed whenever possible.

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