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Gianni D Angelini - One of the best experts on this subject based on the ideXlab platform.
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is the right internal thoracic artery superior to saphenous vein for grafting the right coronary artery a propensity score based analysis
The Journal of Thoracic and Cardiovascular Surgery, 2017Co-Authors: Umberto Benedetto, Massimo Caputo, Mario Gaudino, Alan J Bryan, Giovanni Mariscalco, Gianni D AngeliniAbstract:Abstract Objectives Although the use of the right internal thoracic artery (RITA) as second Arterial Conduit to graft the left coronary system consistently has been shown to provide a survival benefit compared with the saphenous vein graft (SVG), the choice of Conduit for the right coronary artery (RCA) system remains controversial. We compared long-term (>15 years) survival in patients who underwent RITA-RCA versus SVG-RCA grafting at a single institution. Methods The study population consisted of 7223 patients undergoing coronary artery bypass graft surgery. Of them 245 (3.4%) and 6978 (96.6%) received RITA-RCA and SVG-RCA graft, respectively. Propensity score matching and time-segmented Cox regression were used to compare the 2 groups. Results Survival probability at 5, 10, and 15 years were 95.9% (95% confidence interval [CI], 93.4-98.4) versus 96.0% (95% CI, 94.3-97.8), 89.8% (95% CI, 85.9-93.7) versus 88.0% (95% CI, 85.0-91.0) and 82.9% (95% CI, 77.6-88.2) versus 76.3 (95% CI, 72.0-80.5) in the RITA-RCA and SVG-RCA group, respectively. Time-segmented Cox regression showed that during the first 9 years, the 2 strategies were associated with comparable risk of death (hazard ratio, 1.13; 95% confidence interval, 0.67-1.90; P = .65) but beyond 9 years, the RITA-RCA was associated with a significantly lower risk of death (hazard ratio, 0.43; 95% confidence interval, 0.22-0.84; P = .01). Conclusions Revascularization of the RCA system with the RITA was associated with superior late survival compared with SVG. This supports the view that, the use of RITA to graft the RCA should be encouraged, especially in patients with long life expectancy.
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right internal thoracic artery or radial artery a propensity matched comparison on the second best Arterial Conduit
The Journal of Thoracic and Cardiovascular Surgery, 2017Co-Authors: Massimo Caputo, Umberto Benedetto, Mario Gaudino, Roberto Marsico, Cha Rajakaruna, Alan J Bryan, Gianni D AngeliniAbstract:Abstract Objectives We conducted propensity score matching to determine whether the use of the right internal thoracic artery (RITA) confers a survival advantage when compared with the radial artery (RA) as second Arterial Conduit in coronary artery bypass grafting. Methods The study population included a highly selected low-risk group of patients who received the RITA (n = 764) or the RA (n = 1990) as second Arterial Conduit. We obtained 764 matched pairs that were comparable for all pretreatment variables. A time-segmented Cox regression model that stratified on the matched pairs was used to investigate the effect of treatment on late mortality. Results After a mean follow-up of 10.2 ± 4.5 years (maximum 17.3 years), survival probabilities at 5, 10, and 15 years were 96.4% ± 0.7% versus 95.4% ± 0.7%, 91.0% ± 1.1% versus 89.1% ± 1.2%, and 82.4% ± 1.9% versus 77.2% ± 2.5% in the RITA and RA groups, respectively. During the first 4 years, RITA and RA were comparable in terms of mortality (hazard ratio [HR], 1.00; 95% confidence interval [CI], 0.56-1.78; P = .98). However, after 4 years RITA was associated with a significant reduction in late mortality (HR, 0.67; 95% CI, 0.48-0.95; P = .02). RITA was superior to RA when the experimental Conduit was used to graft the left coronary system (HR, 0.69; 95% CI, 0.47-0.99; P = .04) but not the right coronary system (HR, 0.98; 95% CI, 0.59-1.62; P = .93). Conclusions In a highly selected low-risk group of patients, the use of the RITA as second Arterial Conduit instead of the RA was associated with better survival when used to graft the left but not the right coronary artery.
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right internal thoracic artery versus radial artery as the second best Arterial Conduit insights from a meta analysis of propensity matched data on long term survival
The Journal of Thoracic and Cardiovascular Surgery, 2016Co-Authors: Umberto Benedetto, Massimo Caputo, Mario Gaudino, Robert F Tranbaugh, Antonino Di Franco, Colin Ng, Leonard N Girardi, Gianni D AngeliniAbstract:Abstract Objective(s) We conducted a meta-analysis of propensity score-matching (PSM) studies comparing long-term survival of patients receiving right internal thoracic artery (RITA) versus radial artery (RA) as a second Arterial Conduit for coronary artery bypass grafting. Methods A literature search was conducted using MEDLINE, EMBASE, and Web of Science to identify relevant articles. Primary endpoint was long-term mortality. Secondary endpoints were operative mortality, incidence of sternal wound infection, and repeat revascularization. Binary events were pooled using the DerSimonian and Laird method. For time-to-event outcomes, estimates of log hazard ratio (HR) and standard errors obtained were combined using the generic inverse-variance method. Results A total of 8 PSM studies were finally selected including 15,374 patients (RITA, 6739; RA, 8635) with 2992 matched pairs for final comparison. Mean follow-up time ranged from 45 to 168 months. When compared with RA, RITA was associated with a lower risk reduction of late death (HR, 0.75; 95% confidence interval [CI], 0.58-0.97; P = .028) and repeat revascularization (HR, 0.37; 95% CI, 0.16-0.85; P = .03). On the other hand, RITA did not increase operative mortality (odds ratio [OR], 1.53; 95% CI, 0.97-2.39; P = .07). RITA was associated with an increased risk of sternal wound complication when pedicled harvesting was used (OR, 3.18; 95% CI, 1.34-7.57), but not with skeletonized harvesting (OR, 1.07; 95% CI, 0.67-1.71). Conclusions The present PSM data meta-analysis suggests that the use of RITA compared with RA was associated with superior long-term survival and freedom from repeat revascularization, with similar operative mortality and incidence of sternal wound complication when the skeletonized harvesting technique was used.
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are three arteries better than two impact of using the radial artery in addition to bilateral internal thoracic artery grafting on long term survival
The Journal of Thoracic and Cardiovascular Surgery, 2016Co-Authors: Umberto Benedetto, Massimo Caputo, Alan J Bryan, Mustafa Zakkar, Gianni D AngeliniAbstract:Abstract Objective Whether radial artery (RA) as third Arterial Conduit in addition to bilateral internal thoracic artery (BITA) is associated with better survival than saphenous vein (SV) remains undetermined. Methods Study population included a selected low-risk group of 275 subjects undergoing BITA grafting with RA as third Arterial Conduit (BITA+RA) and 489 undergoing BITA grafting with additional SV graft (BITA+SV). RA was considered only for target stenosis of at least 75%. We finally obtained 275 propensity score–matched pairs for comparison. Results Operative mortalities were 1 (0.3%) and 2 (0.7%) for BITA+RA and BITA+SV, respectively ( P = .56). After mean follow-up of 10.6 ± 4.8 years, BITA+RA survivals were 97.4% ± 0.9%, 90.3% ± 2.0%, and 81.7% ± 3.2% at 5, 10, and 15 years, respectively, versus 97.0% ± 1.0%, 94.1% ± 1.5%, and 82.1% ± 3.4% (log-rank P = .54; hazard ratio, 1.16; 95% confidence interval, 0.71-1.9). Strategies showed comparable survivals when RA or SV was used to graft the right ( P = .79) or left ( P = .55) coronary system only. Lack of survival advantage for BITA+RA was confirmed in patients 60 years and younger ( P = .80) and older than 60 years ( P = .53), with and without diabetes mellitus ( P = .89 and P = .54, respectively), and with or without left ventricular dysfunction ( P = .95 and P = .65, respectively). Conclusions Long-term survival in selected low-risk patients undergoing BITA grafting was not extended by using RA as third Arterial Conduit in preference to SV.
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radial versus right internal thoracic artery as a second Arterial Conduit for coronary surgery early and midterm outcomes
The Journal of Thoracic and Cardiovascular Surgery, 2003Co-Authors: Massimo Caputo, Barnaby C Reeves, Balakrishnan Mahesh, Giovanni Marchetto, Gianni D AngeliniAbstract:OBJECTIVE: We sought to compare early and midterm clinical outcomes in patients receiving a right internal thoracic artery or a radial artery as the second Arterial Conduit for myocardial revascularization. METHODS: Data prospectively collected for all patients who underwent coronary artery bypass surgery between April 1996 and May 2001 and who received both a left internal thoracic artery graft and either a right internal thoracic artery (n = 336) or a radial artery graft (n = 325) were analyzed. Patients in the radial artery group were older, with a greater body mass index, poorer ejection fraction, greater prevalence of diabetes, and higher New York Heart Association class than those in the right internal thoracic artery group. RESULTS: Odds ratios for perioperative myocardial infarction, atrial fibrillation, postoperative transfusion, and intensive care unit stay all showed a statistically significant benefit in the radial artery group compared with results in the right internal thoracic artery group (P
Umberto Benedetto - One of the best experts on this subject based on the ideXlab platform.
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is the right internal thoracic artery superior to saphenous vein for grafting the right coronary artery a propensity score based analysis
The Journal of Thoracic and Cardiovascular Surgery, 2017Co-Authors: Umberto Benedetto, Massimo Caputo, Mario Gaudino, Alan J Bryan, Giovanni Mariscalco, Gianni D AngeliniAbstract:Abstract Objectives Although the use of the right internal thoracic artery (RITA) as second Arterial Conduit to graft the left coronary system consistently has been shown to provide a survival benefit compared with the saphenous vein graft (SVG), the choice of Conduit for the right coronary artery (RCA) system remains controversial. We compared long-term (>15 years) survival in patients who underwent RITA-RCA versus SVG-RCA grafting at a single institution. Methods The study population consisted of 7223 patients undergoing coronary artery bypass graft surgery. Of them 245 (3.4%) and 6978 (96.6%) received RITA-RCA and SVG-RCA graft, respectively. Propensity score matching and time-segmented Cox regression were used to compare the 2 groups. Results Survival probability at 5, 10, and 15 years were 95.9% (95% confidence interval [CI], 93.4-98.4) versus 96.0% (95% CI, 94.3-97.8), 89.8% (95% CI, 85.9-93.7) versus 88.0% (95% CI, 85.0-91.0) and 82.9% (95% CI, 77.6-88.2) versus 76.3 (95% CI, 72.0-80.5) in the RITA-RCA and SVG-RCA group, respectively. Time-segmented Cox regression showed that during the first 9 years, the 2 strategies were associated with comparable risk of death (hazard ratio, 1.13; 95% confidence interval, 0.67-1.90; P = .65) but beyond 9 years, the RITA-RCA was associated with a significantly lower risk of death (hazard ratio, 0.43; 95% confidence interval, 0.22-0.84; P = .01). Conclusions Revascularization of the RCA system with the RITA was associated with superior late survival compared with SVG. This supports the view that, the use of RITA to graft the RCA should be encouraged, especially in patients with long life expectancy.
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right internal thoracic artery or radial artery a propensity matched comparison on the second best Arterial Conduit
The Journal of Thoracic and Cardiovascular Surgery, 2017Co-Authors: Massimo Caputo, Umberto Benedetto, Mario Gaudino, Roberto Marsico, Cha Rajakaruna, Alan J Bryan, Gianni D AngeliniAbstract:Abstract Objectives We conducted propensity score matching to determine whether the use of the right internal thoracic artery (RITA) confers a survival advantage when compared with the radial artery (RA) as second Arterial Conduit in coronary artery bypass grafting. Methods The study population included a highly selected low-risk group of patients who received the RITA (n = 764) or the RA (n = 1990) as second Arterial Conduit. We obtained 764 matched pairs that were comparable for all pretreatment variables. A time-segmented Cox regression model that stratified on the matched pairs was used to investigate the effect of treatment on late mortality. Results After a mean follow-up of 10.2 ± 4.5 years (maximum 17.3 years), survival probabilities at 5, 10, and 15 years were 96.4% ± 0.7% versus 95.4% ± 0.7%, 91.0% ± 1.1% versus 89.1% ± 1.2%, and 82.4% ± 1.9% versus 77.2% ± 2.5% in the RITA and RA groups, respectively. During the first 4 years, RITA and RA were comparable in terms of mortality (hazard ratio [HR], 1.00; 95% confidence interval [CI], 0.56-1.78; P = .98). However, after 4 years RITA was associated with a significant reduction in late mortality (HR, 0.67; 95% CI, 0.48-0.95; P = .02). RITA was superior to RA when the experimental Conduit was used to graft the left coronary system (HR, 0.69; 95% CI, 0.47-0.99; P = .04) but not the right coronary system (HR, 0.98; 95% CI, 0.59-1.62; P = .93). Conclusions In a highly selected low-risk group of patients, the use of the RITA as second Arterial Conduit instead of the RA was associated with better survival when used to graft the left but not the right coronary artery.
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right internal thoracic artery versus radial artery as the second best Arterial Conduit insights from a meta analysis of propensity matched data on long term survival
The Journal of Thoracic and Cardiovascular Surgery, 2016Co-Authors: Umberto Benedetto, Massimo Caputo, Mario Gaudino, Robert F Tranbaugh, Antonino Di Franco, Colin Ng, Leonard N Girardi, Gianni D AngeliniAbstract:Abstract Objective(s) We conducted a meta-analysis of propensity score-matching (PSM) studies comparing long-term survival of patients receiving right internal thoracic artery (RITA) versus radial artery (RA) as a second Arterial Conduit for coronary artery bypass grafting. Methods A literature search was conducted using MEDLINE, EMBASE, and Web of Science to identify relevant articles. Primary endpoint was long-term mortality. Secondary endpoints were operative mortality, incidence of sternal wound infection, and repeat revascularization. Binary events were pooled using the DerSimonian and Laird method. For time-to-event outcomes, estimates of log hazard ratio (HR) and standard errors obtained were combined using the generic inverse-variance method. Results A total of 8 PSM studies were finally selected including 15,374 patients (RITA, 6739; RA, 8635) with 2992 matched pairs for final comparison. Mean follow-up time ranged from 45 to 168 months. When compared with RA, RITA was associated with a lower risk reduction of late death (HR, 0.75; 95% confidence interval [CI], 0.58-0.97; P = .028) and repeat revascularization (HR, 0.37; 95% CI, 0.16-0.85; P = .03). On the other hand, RITA did not increase operative mortality (odds ratio [OR], 1.53; 95% CI, 0.97-2.39; P = .07). RITA was associated with an increased risk of sternal wound complication when pedicled harvesting was used (OR, 3.18; 95% CI, 1.34-7.57), but not with skeletonized harvesting (OR, 1.07; 95% CI, 0.67-1.71). Conclusions The present PSM data meta-analysis suggests that the use of RITA compared with RA was associated with superior long-term survival and freedom from repeat revascularization, with similar operative mortality and incidence of sternal wound complication when the skeletonized harvesting technique was used.
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are three arteries better than two impact of using the radial artery in addition to bilateral internal thoracic artery grafting on long term survival
The Journal of Thoracic and Cardiovascular Surgery, 2016Co-Authors: Umberto Benedetto, Massimo Caputo, Alan J Bryan, Mustafa Zakkar, Gianni D AngeliniAbstract:Abstract Objective Whether radial artery (RA) as third Arterial Conduit in addition to bilateral internal thoracic artery (BITA) is associated with better survival than saphenous vein (SV) remains undetermined. Methods Study population included a selected low-risk group of 275 subjects undergoing BITA grafting with RA as third Arterial Conduit (BITA+RA) and 489 undergoing BITA grafting with additional SV graft (BITA+SV). RA was considered only for target stenosis of at least 75%. We finally obtained 275 propensity score–matched pairs for comparison. Results Operative mortalities were 1 (0.3%) and 2 (0.7%) for BITA+RA and BITA+SV, respectively ( P = .56). After mean follow-up of 10.6 ± 4.8 years, BITA+RA survivals were 97.4% ± 0.9%, 90.3% ± 2.0%, and 81.7% ± 3.2% at 5, 10, and 15 years, respectively, versus 97.0% ± 1.0%, 94.1% ± 1.5%, and 82.1% ± 3.4% (log-rank P = .54; hazard ratio, 1.16; 95% confidence interval, 0.71-1.9). Strategies showed comparable survivals when RA or SV was used to graft the right ( P = .79) or left ( P = .55) coronary system only. Lack of survival advantage for BITA+RA was confirmed in patients 60 years and younger ( P = .80) and older than 60 years ( P = .53), with and without diabetes mellitus ( P = .89 and P = .54, respectively), and with or without left ventricular dysfunction ( P = .95 and P = .65, respectively). Conclusions Long-term survival in selected low-risk patients undergoing BITA grafting was not extended by using RA as third Arterial Conduit in preference to SV.
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right internal mammary artery versus radial artery as second Arterial Conduit in coronary artery bypass grafting a case control study of 1526 patients
International Journal of Surgery, 2015Co-Authors: Shahzad G Raja, Umberto Benedetto, Anand Jothidasan, Raju Krishnam Jujjavarapu, Uchenna Franklin Ukwu, Fabio De Robertis, Toufan Bahrami, Jullien Gaer, Mohamed AmraniAbstract:Objective: Additional Arterial grafts such as the right internal mammary artery (RIMA) or the radial artery (RA) have been proposed to improve long term outcomes in coronary artery bypass grafting (CABG). RA is largely preferred over RIMA as it is less technically demanding and there is a perception that bilateral IMA usage increases the risk of sternal wound complications. However, there is a paucity of direct comparison of the two Conduits to guide surgeons to choose the best second Arterial Conduit for CABG. Methods: A propensity score adjusted analysis of patients undergoing multiple Arterial grafting with RIMA (n ¼ 747) and RA (n ¼ 779) during the study period (2001e2013) was conducted to investigate the impact of the two strategies on early and late outcomes. Results: RIMA did not increase the incidence of postoperative complications including deep sternal wound infection (P ¼ 0.8). Compared to the RIMA, the RA was associated with an increased risk for late mortality (Hazard Ratio [HR] 1.9; 95% confidence interval (CI) 1.2e3.1; P ¼ 0.008) and repeat revascularization (HR 1.5; 95% CI 1.0e2.2; P ¼ 0.044). A trend towards an extra risk for late mortality from RA over RIMA was observed among diabetic (HR 3.3; 95% CI 1.1e9.7) and obese patients (HR 2.1; 95% CI 0.8e5.46). Conclusions: RIMA as a second Conduit did not increase the operative risk including sternal wound complications and improved long term outcomes including overall survival when compared to RA. This advantage was stronger among diabetic and obese patients. These findings strongly support RIMA as the first choice second Arterial Conduit in CABG. Further randomized studies with angiographic control and long-term follow-up are needed to address this issue.
Mario Gaudino - One of the best experts on this subject based on the ideXlab platform.
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right internal thoracic or radial artery as the second Arterial Conduit for coronary artery bypass surgery
Current Opinion in Cardiology, 2019Co-Authors: Stephen E Fremes, Cristiano Spadaccio, Mario GaudinoAbstract:Purpose of review To summarize the available evidence on the use of the right internal thoracic artery (RITA) and the radial artery as the second Arterial graft in coronary artery bypass surgery. Recent findings The current data support the equipoise of the two Conduits in terms of clinical and angiographic outcomes. Both RITA and radial artery have better patency than saphenous vein grafts. The use of the RITA carries an increased risk of deep sternal wound infection (DSWI) if the artery is harvested as pedicle. Bilateral internal thoracic artery grafting is more technically demanding than radial artery use and there is a volume-outcome relationship in terms of mortality and incidence of DSWI. The radial artery is preferable over RITA in right-sided or distal circumflex artery targets with high-degree stenosis and in patients at higher risk for DSWI, whereas it is not recommended to graft vessels with moderate stenosis and in cases of insufficient collateralization from the ulnar artery or previous transradial procedures. Summary The patency rate and clinical outcomes of radial artery and RITA are similar. The use of one or the other should be based on a careful evaluation of the patient's coronary anatomy and comorbidities, the Conduit availability and the surgeon's and center's experience.
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is the right internal thoracic artery superior to saphenous vein for grafting the right coronary artery a propensity score based analysis
The Journal of Thoracic and Cardiovascular Surgery, 2017Co-Authors: Umberto Benedetto, Massimo Caputo, Mario Gaudino, Alan J Bryan, Giovanni Mariscalco, Gianni D AngeliniAbstract:Abstract Objectives Although the use of the right internal thoracic artery (RITA) as second Arterial Conduit to graft the left coronary system consistently has been shown to provide a survival benefit compared with the saphenous vein graft (SVG), the choice of Conduit for the right coronary artery (RCA) system remains controversial. We compared long-term (>15 years) survival in patients who underwent RITA-RCA versus SVG-RCA grafting at a single institution. Methods The study population consisted of 7223 patients undergoing coronary artery bypass graft surgery. Of them 245 (3.4%) and 6978 (96.6%) received RITA-RCA and SVG-RCA graft, respectively. Propensity score matching and time-segmented Cox regression were used to compare the 2 groups. Results Survival probability at 5, 10, and 15 years were 95.9% (95% confidence interval [CI], 93.4-98.4) versus 96.0% (95% CI, 94.3-97.8), 89.8% (95% CI, 85.9-93.7) versus 88.0% (95% CI, 85.0-91.0) and 82.9% (95% CI, 77.6-88.2) versus 76.3 (95% CI, 72.0-80.5) in the RITA-RCA and SVG-RCA group, respectively. Time-segmented Cox regression showed that during the first 9 years, the 2 strategies were associated with comparable risk of death (hazard ratio, 1.13; 95% confidence interval, 0.67-1.90; P = .65) but beyond 9 years, the RITA-RCA was associated with a significantly lower risk of death (hazard ratio, 0.43; 95% confidence interval, 0.22-0.84; P = .01). Conclusions Revascularization of the RCA system with the RITA was associated with superior late survival compared with SVG. This supports the view that, the use of RITA to graft the RCA should be encouraged, especially in patients with long life expectancy.
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right internal thoracic artery or radial artery a propensity matched comparison on the second best Arterial Conduit
The Journal of Thoracic and Cardiovascular Surgery, 2017Co-Authors: Massimo Caputo, Umberto Benedetto, Mario Gaudino, Roberto Marsico, Cha Rajakaruna, Alan J Bryan, Gianni D AngeliniAbstract:Abstract Objectives We conducted propensity score matching to determine whether the use of the right internal thoracic artery (RITA) confers a survival advantage when compared with the radial artery (RA) as second Arterial Conduit in coronary artery bypass grafting. Methods The study population included a highly selected low-risk group of patients who received the RITA (n = 764) or the RA (n = 1990) as second Arterial Conduit. We obtained 764 matched pairs that were comparable for all pretreatment variables. A time-segmented Cox regression model that stratified on the matched pairs was used to investigate the effect of treatment on late mortality. Results After a mean follow-up of 10.2 ± 4.5 years (maximum 17.3 years), survival probabilities at 5, 10, and 15 years were 96.4% ± 0.7% versus 95.4% ± 0.7%, 91.0% ± 1.1% versus 89.1% ± 1.2%, and 82.4% ± 1.9% versus 77.2% ± 2.5% in the RITA and RA groups, respectively. During the first 4 years, RITA and RA were comparable in terms of mortality (hazard ratio [HR], 1.00; 95% confidence interval [CI], 0.56-1.78; P = .98). However, after 4 years RITA was associated with a significant reduction in late mortality (HR, 0.67; 95% CI, 0.48-0.95; P = .02). RITA was superior to RA when the experimental Conduit was used to graft the left coronary system (HR, 0.69; 95% CI, 0.47-0.99; P = .04) but not the right coronary system (HR, 0.98; 95% CI, 0.59-1.62; P = .93). Conclusions In a highly selected low-risk group of patients, the use of the RITA as second Arterial Conduit instead of the RA was associated with better survival when used to graft the left but not the right coronary artery.
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right internal thoracic artery versus radial artery as the second best Arterial Conduit insights from a meta analysis of propensity matched data on long term survival
The Journal of Thoracic and Cardiovascular Surgery, 2016Co-Authors: Umberto Benedetto, Massimo Caputo, Mario Gaudino, Robert F Tranbaugh, Antonino Di Franco, Colin Ng, Leonard N Girardi, Gianni D AngeliniAbstract:Abstract Objective(s) We conducted a meta-analysis of propensity score-matching (PSM) studies comparing long-term survival of patients receiving right internal thoracic artery (RITA) versus radial artery (RA) as a second Arterial Conduit for coronary artery bypass grafting. Methods A literature search was conducted using MEDLINE, EMBASE, and Web of Science to identify relevant articles. Primary endpoint was long-term mortality. Secondary endpoints were operative mortality, incidence of sternal wound infection, and repeat revascularization. Binary events were pooled using the DerSimonian and Laird method. For time-to-event outcomes, estimates of log hazard ratio (HR) and standard errors obtained were combined using the generic inverse-variance method. Results A total of 8 PSM studies were finally selected including 15,374 patients (RITA, 6739; RA, 8635) with 2992 matched pairs for final comparison. Mean follow-up time ranged from 45 to 168 months. When compared with RA, RITA was associated with a lower risk reduction of late death (HR, 0.75; 95% confidence interval [CI], 0.58-0.97; P = .028) and repeat revascularization (HR, 0.37; 95% CI, 0.16-0.85; P = .03). On the other hand, RITA did not increase operative mortality (odds ratio [OR], 1.53; 95% CI, 0.97-2.39; P = .07). RITA was associated with an increased risk of sternal wound complication when pedicled harvesting was used (OR, 3.18; 95% CI, 1.34-7.57), but not with skeletonized harvesting (OR, 1.07; 95% CI, 0.67-1.71). Conclusions The present PSM data meta-analysis suggests that the use of RITA compared with RA was associated with superior long-term survival and freedom from repeat revascularization, with similar operative mortality and incidence of sternal wound complication when the skeletonized harvesting technique was used.
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Arterial versus venous bypass grafts in patients with in stent restenosis
Circulation, 2005Co-Authors: Mario Gaudino, Giuseppe Nasso, Carlo Cellini, Claudio Pragliola, Carlo Trani, Francesco Burzotta, Giovanni Schiavoni, Gianfederico PossatiAbstract:Background— In patients who develop in-stent restenosis, successful revascularization can be difficult to achieve using percutaneous methods. This study was designed to verify the surgical results in this setting and to evaluate the potential beneficial role of Arterial bypass Conduits. Methods and Results— Sixty consecutive coronary artery bypass patients with previous in-stent restenosis and 60 control cases were randomly assigned to receive an Arterial Conduit (either right internal thoracic or radial artery; study group) or a great saphenous vein graft (control group) on the first obtuse marginal artery to complete the surgical revascularization procedure. At a mean follow-up of 52±11 months, patients were reassessed clinically and by angiography. Freedom from clinical and instrumental evidence of ischemia recurrence was found in 19 of 60 subjects in the study group versus 45 of 60 in the control series ( P =0.01). The results of the Arterial grafts were excellent in both the study and control groups (right internal thoracic artery patency rate, 19 of 20 for both, and radial artery patency rate, 20 of 20 versus 19 of 20; P =0.99). Saphenous vein grafts showed lower patency rate than Arterial grafts in both series and had extremely high failure rate in the study group (patency rate, 10 of 20 in the study group versus 18 of 20 in the control group; P =0.001). Use of venous graft was an independent predictor of failure in the study group, whereas hypercholesterolemia was associated with graft failure in both series. Conclusions— Venous grafts have an high incidence of failure among cases who previously developed in-stent restenosis, whereas the use of Arterial Conduits can improve the angiographic and clinical results. Arterial grafts should probably be the first surgical choice in this patient population.
Brian F Buxton - One of the best experts on this subject based on the ideXlab platform.
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is a third Arterial Conduit necessary comparison of the radial artery and saphenous vein in patients receiving bilateral internal thoracic arteries for triple vessel coronary disease
European Journal of Cardio-Thoracic Surgery, 2016Co-Authors: James Tatoulis, Brian F Buxton, Andrew E Newcomb, Alexander Rosalion, John A FullerAbstract:OBJECTIVES: The use of bilateral internal thoracic arteries (BITAs) is associated with improved long-term survival after coronary artery bypass grafting (CABG). However, it is unclear whether the addition of a radial artery (RA) in patients already receiving BITA confers any additional survival benefit over that of a saphenous vein (SV). As such, we reviewed our multicentre experience and compared both strategies. METHODS: From 1995 to 2010, 1497 patients underwent primary isolated CABG for three-vessel coronary disease using BITAs. An SV was used as a third Conduit in 460 (31%) patients and an RA in 1037 (69%). A total of 1258 distal anastomoses were performed using RAs and these were to the diagonal territory in 169, the circumflex in 454 and the right coronary in 635. Survival data were obtained using the National Death Index and propensity-score matching was used for risk-adjustment. RESULTS: The overall cohort was young (mean age 61 ± 9 years). Patients receiving RAs were more likely to be younger, and were less likely to have experienced a prior myocardial infarction. At 30 days, mortality was similar (BITA + SV: 5, 1.1% vs BITA + RA: 9, 0.9%, P = 0.77). At 15 years, BITA + RA patients experienced improved unadjusted survival (BITA + SV: 67 ± 4.6% vs BITA + RA: 82 ± 3.2%, P 0.99). However, at 15 years, BITA + RA patients experienced improved risk-adjusted survival (BITA + SV: 72 ± 6.0% vs BITA + RA: 82 ± 5.2%, P = 0.021). The RA was associated with better risk-adjusted survival for grafting of the right coronary and its branches (148 matched pairs; SV-RCA: 74 ± 7.8% vs RA-RCA: 86 ± 6.5%, P = 0.0046 at 15 years). CONCLUSIONS: The addition of an RA graft even in patients already receiving BITAs is associated with a survival benefit. In younger patients with a reasonable long-term life expectancy, surgeons should strive to achieve total Arterial revascularization with BITAs and radial arteries.
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which Arterial Conduit radial artery versus free right internal thoracic artery six year clinical results of a randomized controlled trial
The Annals of Thoracic Surgery, 2007Co-Authors: Philip A R Hayward, David L Hare, Ian Gordon, George Matalanis, Brian F BuxtonAbstract:Background To investigate the optimum revascularization Conduit for coronary territories other than that of the left anterior descending artery, long-term clinical outcomes after use of a radial artery or right internal thoracic artery were evaluated as part of the Radial Artery Patency and Clinical Outcomes (RAPCO) study. Methods As part of a 10-year prospective randomized single-center trial, patients aged less than 70 years undergoing primary coronary surgery were randomly allocated to the use of the radial artery (n = 198) or free right internal thoracic artery (n = 196) for grafting the largest target other than the left anterior descending artery. Annual follow-up documented death, myocardial infarction, or revascularization as primary endpoints. Analysis was on an intention-to-treat basis. Results There were no significant differences in the preoperative status of the two groups including age, sex, diabetes mellitus, hypertension, and urgency of surgery. One hundred eighty-six of 198 patients in the radial artery group and 179 of 196 patients in the right internal thoracic artery group received the intended Conduit. Mean number of grafts was 3.1 ± 0.8 and 3.2 ± 0.9 in the radial artery and the right internal thoracic artery groups, respectively. During surveillance of as long as 10.4 years (mean, 6.0), absolute survival and event-free survival were equivalent between groups, with 13 versus 18 deaths and 24 versus 37 events (death, myocardial infarction, or revascularization) in the radial artery and the right internal thoracic artery groups, respectively (log rank: p = 0.36 for survival, p = 0.08 for event-free survival). Conclusions These two Arterial Conduits may yield equivalent clinical outcomes at 5 or more years. That finding will be compared with mean 5-year angiographic patency when available. For now, equivalent clinical results offer surgeons flexibility in planning revascularization.
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the radial artery in coronary surgery a 5 year experience clinical and angiographic results
The Annals of Thoracic Surgery, 2002Co-Authors: James Tatoulis, Alistair Royse, Brian F Buxton, John A Fuller, Peter D Skillington, John Goldblatt, Robin Brown, Michael RowlandAbstract:Abstract Background . The radial artery (RA) has been used extensively by us as a way of reducing the use of the saphenous vein. It has been hoped that the RA will maintain greater late patency than the saphenous vein. We evaluated our initial 5-year experience with the RA in coronary surgery. Methods . We studied 6,646 consecutive patients who had a single RA (4,872), or bilateral RA (1,774), as coronary grafts, from June 1995 to June 2000. Angiograms were performed mostly in symptomatic patients, or as part of a research project in asymptomatic patients. Results . The patients' mean age was 65.1 years; 23% had diabetes, 14% had unstable angina, and 42% had prior myocardial infarction. An average of 3.3 grafts per patient were performed, 87% from Arterial Conduit. Conduits used were RA (8,420), left internal thoracic artery (6,296), and right internal thoracic artery (1,076). Operative mortality occurred in 58 (0.9%) patients, stroke in 92 (1.4%), deep sternal infection in 97 (1.4%), reoperation for hemorrhage in 56 (0.9%), and myocardial infarction in 52 (0.8%). Peak mean postoperative creatine kinase MB (CKMB) was 16.5 IU/L. Two patients developed fingertip ischemia. Postoperative angiographic RA patency was 90.2% (333 of 369 distal anastomoses). Conclusions . Good early clinical and angiographic results can be achieved by using the RA in coronary surgery.
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right internal thoracic artery versus radial artery as the second best Arterial Conduit insights from a meta analysis of propensity matched data on long term survival
The Journal of Thoracic and Cardiovascular Surgery, 2016Co-Authors: Umberto Benedetto, Massimo Caputo, Mario Gaudino, Robert F Tranbaugh, Antonino Di Franco, Colin Ng, Leonard N Girardi, Gianni D AngeliniAbstract:Abstract Objective(s) We conducted a meta-analysis of propensity score-matching (PSM) studies comparing long-term survival of patients receiving right internal thoracic artery (RITA) versus radial artery (RA) as a second Arterial Conduit for coronary artery bypass grafting. Methods A literature search was conducted using MEDLINE, EMBASE, and Web of Science to identify relevant articles. Primary endpoint was long-term mortality. Secondary endpoints were operative mortality, incidence of sternal wound infection, and repeat revascularization. Binary events were pooled using the DerSimonian and Laird method. For time-to-event outcomes, estimates of log hazard ratio (HR) and standard errors obtained were combined using the generic inverse-variance method. Results A total of 8 PSM studies were finally selected including 15,374 patients (RITA, 6739; RA, 8635) with 2992 matched pairs for final comparison. Mean follow-up time ranged from 45 to 168 months. When compared with RA, RITA was associated with a lower risk reduction of late death (HR, 0.75; 95% confidence interval [CI], 0.58-0.97; P = .028) and repeat revascularization (HR, 0.37; 95% CI, 0.16-0.85; P = .03). On the other hand, RITA did not increase operative mortality (odds ratio [OR], 1.53; 95% CI, 0.97-2.39; P = .07). RITA was associated with an increased risk of sternal wound complication when pedicled harvesting was used (OR, 3.18; 95% CI, 1.34-7.57), but not with skeletonized harvesting (OR, 1.07; 95% CI, 0.67-1.71). Conclusions The present PSM data meta-analysis suggests that the use of RITA compared with RA was associated with superior long-term survival and freedom from repeat revascularization, with similar operative mortality and incidence of sternal wound complication when the skeletonized harvesting technique was used.
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equipoise between radial artery and right internal thoracic artery as the second Arterial Conduit in left internal thoracic artery based coronary artery bypass graft surgery a multi institutional study
European Journal of Cardio-Thoracic Surgery, 2016Co-Authors: Thomas A Schwann, Robert F Tranbaugh, Sabet W Hashim, Sanaa Badour, Mounir Obeid, Milo Engoren, Mark R Bonnell, Robert H HabibAbstract:OBJECTIVES: Multiple Arterial coronary artery grafting (MABG) improves long-term survival compared with single Arterial CABG (SABG), yet the best second Arterial Conduit to be used with the left internal thoracic artery (LITA) remains undefined. Outcomes in patients grafted with radial artery (RA-MABG) versus right internal thoracic artery (RITA-MABG) as the second Arterial graft were compared with SABG. METHODS: Multi-institutional, retrospective analysis of non-emergent isolated LITA to left anterior descending coronary artery CABG patients was performed using institutional Society of Thoracic Surgeon National Adult Cardiac Surgery Databases. 4484 (54.5%) SABG [LITA ± saphenous vein grafts (SVG)], 3095 (37.6%) RA-MABG (RA ± SVG) and 641 (7.9%) RITA-MABG (RITA ± SVG) patients were included. The RITA was used as a free (68%) or in situ (32%) graft. RA grafts were principally anastomosed to the ascending aorta. Long-term survival was ascertained from US Social Security Death Index and institutional follow-up. Triplet propensity matching and covariate-adjusted multivariate logistic regression were used to adjust for baseline differences between study cohorts. RESULTS: Compared with the SABG cohort, the RITA-MABG cohort was younger (58.6 ± 10.2vs65.9 ± 10.4, P < 0.001), had a higher prevalence of males (87% vs 65%, P < 0.001) and was generally healthier (MI: 36.7% vs 56.7%, P < 0.001, smoking: 56.8% vs 61.1%, IDDM: 3.0% vs 14.4%, CVA: 2.6% vs 10.0%). The RA-MABG cohort was generally characterized by a risk profile intermediate to that of SABG and RlTA-MABG. Unadjusted 5-, 10- and 15-year survival rates were best in RITA-MABG (95.2%, 89% and 82%), intermediate in RA-MABG (89%, 74%, 57%) and worst in SABG (82%, 61% and 44%) cohorts (all P < 0.001). Propensity matching yielded 551 RA-MABG, RITA-MABG and SABG triplets, which showed similar 30-day mortality. Late survival (16 years) was equivalent in the RA-MABG and RITA-MABG cohorts [68.2% vs 66.7%, P = 0.127, hazard ratio (HR) = 1.28 (0.96-1.71)] and both significantly better than SABG (61.1%). The corresponding SABG versus RITA-MABG and SABG versus RA-MABG HRs (95% confidence interval) were 1.52 (1.18-1.96) and 1.31 (1.01-1.69) with P < 0.002 and P = 0.038, respectively. CONCLUSIONS: RA-MABG or RITA-MABG equally improve long-term survival compared with SABG and thus should be embraced by the Heart Team as the therapy of choice in LITA-based coronary artery bypass surgery.
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the second best Arterial graft a propensity analysis of the radial artery versus the free right internal thoracic artery to bypass the circumflex coronary artery
The Journal of Thoracic and Cardiovascular Surgery, 2014Co-Authors: Robert F Tranbaugh, Kamellia R Dimitrova, David Lucido, Darryl M Hoffman, Gabriela R Dincheva, Charles M Geller, Sandhya K Balaram, Wilson Ko, Daniel G SwistelAbstract:Objective We sought to determine if the radial artery (RA) or the free right internal thoracic artery (RITA) is the better Conduit to bypass the circumflex coronary artery during coronary artery bypass grafting (CABG) using the left internal thoracic artery (LITA). Methods Propensity matching was performed on 2488 CABG-LITA patients from 2 affiliated centers, resulting in 528 pairs who received either a RA at one center or a free RITA at the other center to bypass the circumflex coronary artery from 1995 to 2009. Results Kaplan Meier estimated 1-, 5-, 10-, and 15-year survival rates were 99%, 95%, 85%, and 76% for RA patients, respectively, and 97%, 92%, 80%, and 71% for RITA patients, respectively ( P = .060). Major adverse events (MAEs) were fewer in the RA group (7.6% vs 14.0%; P = .001) and use of the RA was a significant predictor of reduced MAEs (odds ratio [OR], 0.48; P = .002) in all patients and especially in diabetic (OR, 0.32; P = .003), older (OR, 0.40; P = .009), obese (OR, 0.15; P P = .016) patients. However, survival was better with RA only in COPD (hazard ratio, 0.49; P = .045) and older (hazard ratio, 0.71; P = .050) patients. Overall RA patency (83.9%) was similar to RITA patency (87.4%) at a mean of 5.1 ± 3.8 years ( P = .155). Conclusions Long-term survival is similar in CABG-LITA patients using either a RA or free RITA graft to bypass the circumflex coronary artery. RA grafting has fewer MAEs, a similar patency to RITA, and improves survival in older and COPD patients. The choice of the second Arterial Conduit should be guided by patient profiles and surgeon preferences.
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coronary artery bypass grafting using the radial artery clinical outcomes patency and need for reintervention
Circulation, 2012Co-Authors: Robert F Tranbaugh, Kamellia R Dimitrova, David Lucido, Charles M Geller, Patricia Friedmann, Loren J Harris, Paul Stelzer, Bertram M Cohen, Helbert Decastro, Darryl M HoffmanAbstract:Background— Radial artery (RA) grafts are an attractive second Arterial Conduit after the left internal thoracic artery (LITA) for coronary artery bypass graft (CABG) surgery. However, long-term outcomes and the need for subsequent reintervention have not been defined. Methods and Results— We performed a retrospective cohort study of our single institution's 16-year experience with 1851 consecutive patients (average age, 58 years; 82% men, 36% diabetic) undergoing primary, isolated CABG with the LITA, RA, and saphenous vein as needed. Average grafts per patient were 3.8, with 2.4 Arterial grafts per patient. Survival was determined using the Social Security Death Index. Grafts were nonpatent if they had a >50% stenosis, a string sign, or were occluded. Five patients (0.3%) died in hospital and 0.8% had a myocardial infarction, 1.1% a stroke, and 0.6% renal failure. Kaplan-Meier–estimated 1-, 5-, 10-, and 15-year survival was 99%, 96%, 89%, and 75%, respectively. Of the cohort, 278 symptomatic patients underwent cardiac catheterization at our institution an average of 5.0±3.8 years (range, 0.1–12 years) after CABG. Overall RA (n=420 grafts) patency was 82% and SV (n=364 grafts) patency, 47% ( P <0.0001). LITA (n=287 grafts including 9 sequential grafts) patency was 85% and right internal thoracic artery (n=15 grafts) patency was 80% ( P =0.6). RA patency was not different from LITA patency ( P =0.3). Overall freedom from catheterization, percutaneous coronary intervention, and CABG was 85%, 97%, and 99%, respectively. Conclusions— RA grafting is a highly effective revascularization strategy providing excellent short and long-term outcomes with very low rates of reintervention. RA patency is similar to LITA patency and is much better than SV patency. RA grafting should be more widely utilized in patients undergoing CABG.
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radial artery Conduits improve long term survival after coronary artery bypass grafting
The Annals of Thoracic Surgery, 2010Co-Authors: Robert F Tranbaugh, Kamellia R Dimitrova, Charles M Geller, Patricia Friedmann, Loren J Harris, Paul Stelzer, Bertram I Cohen, Darryl M HoffmanAbstract:Background The second best Conduit for coronary artery bypass graft surgery (CABG) is unclear. We sought to determine if the use of a second Arterial Conduit, the radial artery (RA), would improve long-term survival after CABG using the left internal thoracic artery (LITA) and saphenous vein (SV). Methods We compared the 14-year outcomes in propensity-matched patients undergoing isolated, primary CABG using the LITA, RA, and SV versus CABG using the LITA and only SV. In all, 826 patients from each group had similar propensity-matched demographics and multiple variables. The primary endpoint was all-cause mortality obtained using the Social Security Death Index. Results Perioperative outcomes including in hospital mortality (0.1% for the RA patients and 0.2% for the SV patients) were similar. Kaplan-Meier survival at 1, 5, and 10 years was 98.3%, 93.9%, and 83.1% for the RA group versus 97.2%, 88.7%, and 74.3% for the SV group (log rank, p = 0.0011). Cox proportional hazards models showed a lower all-cause mortality in the RA group (hazard ratio 0.72, confidence interval: 0.56 to 0.92, p = 0.0084). Ten-year survivals showed a 52% increased mortality for the SV patients (25.7%) versus the RA patients (16.9%; p = 0.0011). For symptomatic patients, RA patency was 80.7%, which was not different than the LITA patency rate of 86.4% but was superior to the SV patency rate of 46.7% ( p Conclusions Using the LITA, SV, and a RA Conduit for CABG results in significantly improved long-term survival compared with using the LITA and SV. The use of two Arterial Conduits offers a clear and lasting survival advantage, likely due to the improved patency of RA grafts. We conclude that RA Conduits should be more widely utilized during CABG.