Lower 10-year mortality with multiple arterial CABGs in diabetes: ART

The findings are “generating hypotheses,” but should encourage the wider use of multiple arterial transplants, says Faisal Bakain.

Multiple arterial transplantation results in lower mortality at 10 years after CABG in patients with diabetes compared to the single arterial transplant approach, according to a post hoc analysis of the arterial revascularization study (ART).

The findings contrast with what is observed in the process main results of treatment intention, which did not show a benefit for bilateral internal thoracic artery (ITA) grafts compared to a single arterial graft strategy, plus vein or radial artery grafts, in a population of all. However, with a high crossover rate in the original study and a number of levels of surgeons’ experience, treated analyzes showed better results with multiple grafts, especially in the hands of experts.

Lead author David Taggart, MD, PhD (Oxford University, England), told TCTMD that he was “pleasantly surprised” by what this analysis showed.

“We have always believed that patients with diabetes have more severe coronary artery disease, and therefore the potential for the arteries to be more beneficial would be intuitive,” he said. “Of course, the patients were obviously not randomized to diabetes or not. But when we looked at the results, we saw that, in general, the use of multiple arterial grafts was beneficial in all patients, but the effect was even greater in patients with diabetes. And that would be intuitive in the sense that patients with diabetes tend to have more generalized endothelial dysfunction and usually have more severe coronary artery disease.

Commenting on the findings for TCTMD, Faisal Bakaeen, MD (Cleveland Clinic, OH), told TCTMD that multiple arterial transplants are the standard of care in his high-volume institution. However, he said, “multiarterial transplantation is not for every patient and it is also not for every surgeon. Regarding the correct selection of patients, you need to make sure that the risk / benefit ratio is present and. . . know that in your hands you will achieve a good result. ”

As much as he believes in the superiority of using multiple arterial grafts, for now, the data may not necessarily be practical, according to Bakaeen, especially for a surgeon who is inexperienced in this more complex procedure. “We feel that diabetics [patients] “We will especially benefit from this approach due to the aggressiveness of the disease and its diffusion, and we believe that ITAs will be resistant to atherosclerosis in the long run, but again, all this generates hypotheses,” he said.

Diabetic subanalysis

For the analysis published online this month in European Heart JournalTaggart and colleagues included data from 3,020 patients in ART, of whom 23.7% had diabetes.

In 55.8% of non-diabetic patients and 56.6% of diabetic patients who received multiple arterial grafting, 10-year mortality (primary endpoint) and MACE (secondary composite endpoint, defined as death, MI, and stroke) ) were lower than those who received only single arterial grafts.

10-year results of the arterial transplant strategy

Multiple

Unmarried

Corrected HR

95% CI

P for Interaction

Mortality

Diabetes

21.5%

29.9%

0.65

0.48-0.89

0.12

No diabetes

17.7%

21.0%

0.87

0.72-1.06

MACE

Diabetes

28.9%

35.4%

0.80

0.61-1.05

0.93

No diabetes

21.9%

26.9%

0.79

0.67-0.94

Deep wound infections of the sternum are an unusual complication, but occur more frequently in those who have received multiple arterial grafts compared to single arterial grafts in cohorts with diabetes (7.9% vs. 4.8%) and non-diabetics. 3.3% vs. 2.1%). The highest levels of deep sternal wound infections were observed in diabetic patients treated with insulin receiving multiple versus single arterial grafting (9.6% vs. 6.3%).

Taggart said this result was not unexpected because “there are certain groups of patients who are at higher risk, [including] obese patients with diabetes, obese women and patients with poor lungs. They tend to spend more time on fans, “he explained.

Bakain also said he had a “spectrum” of deep sternal wound infections. At one end of this spectrum are those “where you can just put a vacuum cleaner for wounds [on] and put them on antibiotics and the patient recovers with minimal long-term impact on his appearance and abilities and quality of life and psyche “, while on the other hand there are cases that are” destructive [and] destructive. . . where you have to take them to the operating room, do a resection of their sternum, do a radical debridement and then do plastic reconstructions that will leave them essentially deformed and permanently scarred, psychologically and physically. ” The latter are rarer, he said, adding that “the deepest chest wound infection is now susceptible to a more conservative approach.”

Call for more arterial grafts

The impact of the surgeon’s experience with multiple arterial grafts is still under discussion, although most believe there is a strong link to the results. In ART, there was a clear relationship between the surgeon’s volume and the frequency of crossings, according to Taggart.

“We know that if you use an arterial graft well, it will have a very good effect on the patient in the long run,” he said. “On the other hand, a bad artery is worse than a good venous graft. If you can’t take the artery properly or position it correctly, then this is not a great option for the patient, despite the biological rationale for it. It has to be done by someone who knows what they are doing. ”

However, because many CABG centers perform only 50 to 100 cases a year by two or three surgeons, it is very difficult for them to give individual experience to such a small number to build a suitable experience, “Taggart added.

At the time, Taggart said there was enough published data to support the many arterial transplants that are becoming standard CABG practice for both diabetics and the general population. “Most people believe that many arterial grafts are better for you because we know that their patency of up to 10 years is much better than a venous graft,” he said. “Many people were disappointed with the ART experience because it didn’t prove it, but the problem with the ART experience was that it was confused by a lot of crossovers, a lot of use of radial [instead of mammary] arteries, [and] very high use of optimal medical therapies. “

Designed more than 20 years ago, ART does not reflect current practice, he continued. “We still hope to see an effect with longer tracking of the benefits of these grafts,” Taggart said, adding that he expects the 15-year data to be published soon.

Because surgeons expect more definite answers from ROMA process, Bakaeen said they certainly talk more about multiple arterial transplants, but the number of cases “is relatively equal in the last 10 years. There is a suggestion or hint that they are starting to get stronger, especially for the radial arteries, but at the moment this is very fine. “

Taggart said he would like to see surgeons become more confident in using multiple arterial grafts so they can use the strategy more, especially for those who are more likely to benefit as younger patients, those with diabetes and patients with more severe coronary heart disease. “The problem is also that there is no real initiative to encourage the use of more arterial grafts,” he said, adding that groups such as the American Association of Thoracic Surgery and the Society of Thoracic Surgeons “should gradually try to recommend increasing the number of arterial grafts. “

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