Mario Gaudino1, Katia Audisio1, Mohamed Rahouma1, David Chadow1, Gianmarco Cancelli1, Giovanni J Soletti1, Alastair Gray2, Belinda Lees3, Stephen Gerry4, Umberto Benedetto5, Marcus Flather6, David P Taggart3. 1. Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York. 2. Department of Public Health, Health Economics Research Centre, University of Oxford, Oxford, United Kingdom. 3. Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom. 4. Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom. 5. Bristol Heart Institute, School of Clinical Sciences, University of Bristol, Bristol, United Kingdom. 6. Norwich Medical School, University of East Anglia, Norwich, United Kingdom.
Abstract
Importance: Recent evidence has suggested that skeletonization of the internal thoracic artery (ITA) is associated with worse clinical outcomes in patients undergoing coronary artery bypass surgery (CABG). Objective: To compare the long-term clinical outcomes of skeletonized and pedicled ITA for CABG. Design, Setting, and Participants: The Arterial Revascularization Trial (ART) was a 2-group, multicenter trial comparing the use of a bilateral ITA vs a single ITA for CABG at 10 years. Patients in the ART trial were stratified by ITA harvesting technique: skeletonized vs pedicled. Data were collected from June 2004 to December 2017, and data were analyzed from June to July 2021. Interventions: In this analysis, the 10-year clinical outcomes were compared between patients who received skeletonized vs pedicled ITAs. Main Outcomes and Measures: The primary outcome was all-cause mortality. The secondary outcomes were a composite of major adverse cardiac events (MACE) including all-cause mortality, myocardial infarction, and repeated revascularization and a composite including MACE and sternal wound complication (SWC). Cox regression and propensity score matching were used. Results: Of 2161 included patients, 295 (13.7%) were female, and the median (interquartile range) age was 65.0 (58.0-70.0) years. At 10 years, the risk of all-cause mortality was not significantly different between the pedicled and skeletonized groups (hazard ratio [HR], 1.12; 95% CI, 0.92-1.36; P = .27). However, the long-term risks of the secondary outcomes were significantly higher in the skeletonized group compared with the pedicled group (MACE: HR, 1.25; 95% CI, 1.06-1.47; P = .01; MACE and SWC: HR, 1.22; 95% CI, 1.05-1.43; P = .01). The difference was not seen when considering only patients operated on by surgeons who enrolled 51 patients or more in the trial (MACE: HR, 1.07; 95% CI, 0.82-1.39; P = .62; MACE and SWC: HR, 1.04; 95% CI, 0.80-1.34; P = .78). Conclusions and Relevance: While the long-term survival of patients was not different between groups, the rate of adverse cardiovascular events was consistently higher in the skeletonized group and the difference was associated with surgeon-related factors. Further evidence on the outcome of skeletonized ITA is needed.
Importance: Recent evidence has suggested that skeletonization of the internal thoracic artery (ITA) is associated with worse clinical outcomes in patients undergoing coronary artery bypass surgery (CABG). Objective: To compare the long-term clinical outcomes of skeletonized and pedicled ITA for CABG. Design, Setting, and Participants: The Arterial Revascularization Trial (ART) was a 2-group, multicenter trial comparing the use of a bilateral ITA vs a single ITA for CABG at 10 years. Patients in the ART trial were stratified by ITA harvesting technique: skeletonized vs pedicled. Data were collected from June 2004 to December 2017, and data were analyzed from June to July 2021. Interventions: In this analysis, the 10-year clinical outcomes were compared between patients who received skeletonized vs pedicled ITAs. Main Outcomes and Measures: The primary outcome was all-cause mortality. The secondary outcomes were a composite of major adverse cardiac events (MACE) including all-cause mortality, myocardial infarction, and repeated revascularization and a composite including MACE and sternal wound complication (SWC). Cox regression and propensity score matching were used. Results: Of 2161 included patients, 295 (13.7%) were female, and the median (interquartile range) age was 65.0 (58.0-70.0) years. At 10 years, the risk of all-cause mortality was not significantly different between the pedicled and skeletonized groups (hazard ratio [HR], 1.12; 95% CI, 0.92-1.36; P = .27). However, the long-term risks of the secondary outcomes were significantly higher in the skeletonized group compared with the pedicled group (MACE: HR, 1.25; 95% CI, 1.06-1.47; P = .01; MACE and SWC: HR, 1.22; 95% CI, 1.05-1.43; P = .01). The difference was not seen when considering only patients operated on by surgeons who enrolled 51 patients or more in the trial (MACE: HR, 1.07; 95% CI, 0.82-1.39; P = .62; MACE and SWC: HR, 1.04; 95% CI, 0.80-1.34; P = .78). Conclusions and Relevance: While the long-term survival of patients was not different between groups, the rate of adverse cardiovascular events was consistently higher in the skeletonized group and the difference was associated with surgeon-related factors. Further evidence on the outcome of skeletonized ITA is needed.
Authors: Matto Pettinari; Monica Gianoli; Meindert Palmen; Stepan Cerny; Burak Onan; Sandeep Singh; Patrique Segers; Cengiz Bolcal; Cem Alhan; Emiliano Navarra; Herbert De Praetere; Jan Vojacek; Theodor Cebotaru; Paul Modi; Fabien Doguet; Ulrich Franke; Ahmed Ouda; Ludovic Melly; Ghislain Malapert; Louis Labrousse; Alfonso Agnino; Tine Philipsen; Jean-Luc Jansens; Thierry Folliguet; Daniel Pereda; Francesco Musumeci; Piotr Suwalski; Koen Cathenis; Frank Van Praet; Johannes Bonatti; Wouter Oosterlinck Journal: Interact Cardiovasc Thorac Surg Date: 2022-09-09