Multiarterial grafting survival exceeds conventional CABG, PCI

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The case for more MAG

One might wonder about the validity of another retrospective, single-center study comparing revascularization techniques, but the study by Dr. Locker and his colleagues is “compelling” for two reasons, Paul Kurlansky, MD, of Columbia University, New York, pointed out in his invited commentary (J Thorac Cardiovasc Surg. 2016;152:380-1).

Dr. Paul Kurlansky

Dr. Kurlansky noted the finding of equivalent survival at up to 8 years among propensity-matched patients who had left coronary artery bypass grafting with the use of a single internal thoracic artery with supplemental vein grafts (left ITA/SV) and those who received drug-eluting stents was “a bit more provocative” than some of the expected study results; and the reversal of the survival benefit of left ITA/SV, compared with both balloon angioplasty and bare-metal stents after 7 to 10 years was “more perturbing for the surgical community.”

This study underscores that increased use of multiple arterial grafting is essential to give patients the best revascularization option, even in the age of growing percutaneous interventions, Dr. Kurlansky said.

“Limitations notwithstanding, the message for the surgical community is clear – if we wish to have the opportunity to treat patients with advanced, multivessel coronary artery disease, we will need to more fully embrace a strategy of MAG,” he said.

Dr. Kurlansky had no financial relationships to disclose.



A large, 16-year single-center study of patients with multivessel disease has determined that multivessel coronary artery bypass grafting achieved longer survival than not only percutaneous coronary interventions, but also conventional coronary artery bypass grafting, researchers from the Mayo Clinic reported in the August issue of the Journal of Thoracic and Cardiovascular Surgery (J Thorac Cardiovasc Surg. 2016;152:369-79).

Lead author Chaim Locker, MD, and his colleagues said the use of what they called MultiArt, for multivessel arterial grafting, also known as MAG, “must increase.”

The evolution of bare-metal and then drug-eluting stents may have favored percutaneous coronary interventions (PCI) over coronary artery bypass grafting (CABG), but, Dr. Locker and his coauthors said, “Evidence is accumulating that late outcome of surgical revascularization is improved when at least two arterial grafts are used.”

The study analyzed results of 12,615 patients who had either isolated primary CABG (6,667) or PCI (5,948) from 1993 to 2009. Among the CABG patients, 5,712 had the more conventional approach involving arterial grafts into the left internal thoracic artery/saphenous vein (ITA/SV) and 955 had MAG. Patients in the PCI group had three different procedures: balloon angioplasty (1,020), drug-eluting stent (1,686), or bare-metal stent (3,242). The study excluded patients who had revascularization procedures after a heart attack.

While the overall 15-year survival for patients with CABG was lower than it was for those who had PCI (36% vs. 46%), the survival for those who had MAG was significantly higher: 65% vs. 31% for those who had left ITA/SV revascularization. 8-year survival for the MAG subgroup was also significantly higher than all other subgroups: 87% vs. 69% for left ITA/SV, 75% for bare-metal stent, 73% for balloon angioplasty, and 70% for drug-eluting stent.

Propensity matching found similar survivability for balloon angioplasty and left ITA/SV when compared with MAG: 66% for MAG vs. 57% for the former; and 64% for MAG vs. 56% for the latter. The researchers also estimated the hazard ratio during the first 5 years of follow-up and found that those who had bare-metal stents had “significantly worse” survival, compared with MAG, but that survival evened out after that. Survival in the bare-metal stent group was similar to that of the left ITA/SV group, but “significantly worse” during the first 5 years for those who had balloon angioplasty.

Dr. Locker and his colleagues acknowledged that multiple randomized studies have compared CABG and PCI over the years, but they said that in most of those studies “the enrolled patients were highly selected and likely did not represent the broader population of patients with MVD [multivessel disease] undergoing revascularization.” With the exception of the SYNTAX trial (Synergy Between PCI With Taxus and Cardiac Surgery) (N Engl J Med. 2009;360:961-72; Lancet. 2013;381:629-38), those studies did not report on the frequency of MAG within the study population. The Mayo study, on the other hand, included all treated patients, excluding those who had a previous heart attack.

However, MAG is used infrequently, Dr. Locker and his colleagues said. The average annual rate of MAG in their Mayo practice was 15.2%, higher than the 5% annual rate the Society of Thoracic Surgeons National Cardiac Surgery Database (J Thorac Cardiovasc Surg. 2012;143:273-81) reported, and higher than the 12% rate in Europe (Eur J Cardiothorac Surg. 2006;29: 486-91). The SYNTAX trial reported an annual MAG rate of 27.6% for all CABG cases.

“It seems clear that use of MultiArt should be more frequent in patients with MVD undergoing CABG,” Dr. Locker and his coauthors said. “MultiArt can be used in most patients with MVD, including diabetic patients and elderly patients, and this strategy will improve outcomes of surgical revascularization.”

Dr. Locker and his coauthors had no financial relationships to disclose.

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