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Ann Thorac Surg 1998;66:1055-1059
© 1998 The Society of Thoracic Surgeons

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Supplement

Arterial graft patency in coronary artery bypass grafting: what do we really know?

^a Medical City Dallas Hospital, Dallas, Texas, USA

Address reprint requests to Dr Mack, 7777 Forest Ln, B-206, Dallas, TX 75230
e-mail: (mmack{at}crsti.org)

Presented at "Facts and Myths of Minimally Invasive Cardiac Surgery: Current Trends in Thoracic Surgery IV," New Orleans, LA, Jan 24, 1998.

Abstract

Background. With increasing use of beating heart techniques for bypass of the left anterior descending coronary artery with the left internal mammary artery (LIMA), appropriate concerns have been raised of whether graft patency by these techniques compares favorably with conventional, arrested heart techniques.

Methods. All published articles that examine outcome efficacy of the LIMA graft to the left anterior descending coronary artery were reviewed. Because angiography has been considered the "gold standard," only those studies that included angiographic follow-up were analyzed.

Results. From 1972 through 1998, there have been 37 peer-reviewed publications that examined outcomes of LIMA grafting in conventional coronary bypass grafting, of which 27 contained angiographic follow-up data. The completeness of angiographic follow-up was variable, but early graft patency (1 month) in studied patients ranged between 94% and 99%. Late graft patency (up to 15 years) ranged from 51% to 98%. Five recent series of minimally invasive direct coronary artery bypass grafting that contained LIMA graft patency data show early graft patency rates between 91% and 99%.

Conclusions. Meaningful comparison of LIMA graft patency between arrested heart, conventional coronary artery bypass grafting, and minimally invasive direct coronary artery bypass grafting is difficult; however, early graft patency by both techniques can confidently be stated as being 90% or greater.

Minimally invasive coronary artery bypass grafting (MIDCABG) is becoming a frequently employed technique for revascularization of the left anterior descending artery (LAD) with a left internal mammary artery (LIMA) [1, 2]. Appropriately, concerns have been raised regarding the ability to perform an accurate anastomosis on a beating heart through a limited-access incision [3]. If graft patency is compromised by this beating heart approach, the validity of the use of this technique for LAD revascularization would appropriately be questioned. Because a number of published series of MIDCABG contain results of early angiography, we reviewed all published series of conventional coronary artery bypass grafting (CABG) performed by a median sternotomy approach on an arrested heart in an attempt to determine what is the LIMA graft patency "benchmark" or "gold standard" against which to compare the efficacy of MIDCABG.

Material and methods

A literature review was undertaken to determine the published results regarding the efficacy of the use of the LIMA for revascularization of the LAD. All articles from the first published article by Green in 1972 to the most recently published series of MIDCABG in 1998 were analyzed [4–40]. Determination of the end points used to demonstrate benefit was made for all published articles. Specifically, the end points for all series were either graft patency or intervention or symptom-free survival. If graft patency was examined in these series, determination was made of the percentage of patients operated on who underwent postoperative angiography, the interval at which patients were studied, the graft patency, and specific exclusions from the studies.

All published series of MIDCABG were then examined for the same criteria and an attempt was made to see if meaningful comparisons could be made between conventional and MIDCABG LIMA graft patency. Published series containing information regarding vein graft patency after coronary artery bypass grafting were not included in this review.

Results

Conventional coronary artery bypass grafting
From 1972 through 1998, there have been a total of 37 peer-reviewed publications that address the efficacy of the LIMA for revascularization of the LAD. These include two editorials, which themselves contain no results [4, 5]. The remaining 35 publications present the results of LIMA grafting from 18 institutions. Institutions with multiple publications include St. Luke’s-Roosevelt (6), Cleveland Clinic (5), St. Louis University (4), and Ottawa (3), with two publications each from the groups in Milwaukee, New Orleans, and Tucson. Of these publications, survival or symptom-free survival was the determining factor of benefit in eight series with no angiographic follow-up data reported [6–13]. These series were, therefore, eliminated from further analysis. Angiographic data from the remaining 27 series are contained in Tables 1 through 4.

View this table: [in this window] [in a new window]   Table 1. Results of Early Angiography (1 Month) After Conventional Coronary Artery Bypass Grafting

View this table: [in this window] [in a new window]   Table 2. Results of Intermediate-Term Angiography (>1 Month to 1 Year) After Conventional Coronary Artery Bypass Grafting

There are four published studies addressing LIMA graft patency by the Cleveland Clinic [15–18]. In Lytle and associates’ first article [15], in a series of 100 consecutive patients, 46 LIMA grafts were studied. Forty-two (91%) were patent at a mean interval of 20 months.

Lytle and associates’ second series [16] examined 140 patients with LIMA grafts who received postoperative catheterization for any reason in their institution. This included patients operated on elsewhere, so of course the denominator is unknown. Graft patency was 97% at less than 5 years and 96% at greater than 5 years.

Loop and coworkers [17] reported on angiographic results of 37% of 2,306 patients undergoing LIMA grafting at a mean interval of 8.7 years, with a graft patency of 90%. Patients excluded were those with left main coronary disease, those undergoing redo and emergency operations, and nonsurvivors.

Boylan and colleagues [18] in 1994 presented a retrospective review. Fifty-seven of 100 consecutive patients were studied, with graft patency of 93% at less than 10 years and 90% in those studied greater than 10 years.

The group from St. Louis University has published four articles between 1976 and 1990 [19–22]. The percentage of patients undergoing angiography ranged from 45% to 91% at intervals between 20 days and 13 years. Graft patency ranged from 95% early (1 month) to 82% at 10 years. However, in Barner and associates’ early series [19], survivors only were included, 8% refused angiography, and only 45% returned for late (13 months) study. In Tyras and coworkers’ analysis [21], 69%, 65%, and 63% of the patients who were operated on were studied at 1 month, 1 year, and 5 years, with LIMA graft patencies of 95%, 93%, and 90%, respectively. Nonsurvivors (1.4%) and patients lost to follow-up (2%) were not included.

Barner and associates [20] in 1982 studied 285 patients who had a patent graft at 1 year from a population of 472 patients who underwent operation (60%) and had subsequent angiography at greater than 1 year. The LIMA patency was 89.2%.

Fiore and associates’ report [22] analyzed 200 consecutive patients undergoing LIMA grafting in a study of double internal mammary artery grafts. Thirteen-year actuarial graft patency was 82% in the 91% of patients studied. Nonsurvivors (n = 11) were, of course, excluded.

FitzGibbon and colleagues from Ottawa have reported extensive, very complete angiographic follow-up of both saphenous vein and internal mammary artery grafts [23–25]. Their recent report of 476 consecutive survivors receiving LIMA grafts examined 96% of grafts at less than 6 months, 67% at 1 year, and 26% at 5 years [25]. Graft patency was 95%, 91%, and 80% respectively. FitzGibbon and colleagues also included a grading system for grafts of "A" for widely patent grafts, "B" for grafts that were patent, but with a stenosis of greater than 50%, and "O" for occluded grafts. "Perfect" patency (grade A) was 85%, 83%, and 77% at 6 months, 1 year, and 5 years, respectively.

Two other series included longitudinal follow-up on a series of patients. In 1984, Grondin and colleagues [26] followed up a group of 40 patients for 10 years. Although LIMA graft patency was 97% at 1 month, 88% at 1 year, and 84% at 10 years, a significant number of patients were not studied because they did not survive (n = 5) or declined (n = 4) by 10 years.

Ivert and coworkers [27] followed up 99 patients up to 11 years. The percentage of patients studied was 92% at 2 weeks, 85% at 1 year, 67% at 5 years, and 37% at 11 years. Nonsurvivors (2%) were not studied. The LIMA graft patency in studied patients was 94%, 90%, 89%, and 87% at the respective intervals.

Two recent series include early angiographic results. Gill and colleagues [28] studied 25 consecutive patients immediately postoperatively, with a 96% patency rate. Berger and coworkers [29] reported 645 patients (denominator indeterminable) who received LIMA angiography as part of a multicenter aprotonin trial (IMAGE) at an average interval of 10.8 days. Graft patency was 98.8%; however, an additional 7.8% had a graft stenosis of 50% or greater (FitzGibbon grade A patency = 91%).

Goldman and associates [30, 31], in two reports of LIMA graft patency in the multicenter Veterans Affairs aspirin study, reported 1-year and 3-year patency rates of 93% and 90%. The percentage of patients operated on who underwent angiographic follow-up was difficult to determine but appears to range from 16% to 25%.

Three additional series [32–34] contain results of late angiography (>1 year). Kay and associates [32] studied 14% of 628 patients at a mean interval of 19.5 months, with a 98% graft patency. Okies and colleagues [33] studied 6% of 4,183 LIMA grafts, with an 83% patency at 5 years and 70% at 10 years. Zeff and coworkers [34] studied 37 of 39 patients at a mean of 8.9 years, with a 95% graft patency; however, there was a 7.7% late cardiac mortality rate.

Table 4 contains additional results of patients studied at various intervals from 2 weeks to 15 years, including the first publication of the subject by Green and associates in 1972 [14, 35–40]. The percentage of patients studied ranged from 6% to 49%, with graft patency ranging from 51% to 97%.

Minimally invasive direct coronary artery bypass grafting
Five series contain information regarding angiographic results of LIMA grafting of the LAD by a MIDCABG approach. Schaff and coworkers [41] studied 15 of 16 patients intraoperatively and found all grafts to be patent; however, three grafts were revised because of an abnormal angiographic finding.

Califiore and associates [1] have studied 62% of 434 patients at an interval up to 1 year, with a patency rate of 93.7% and a FitzGibbon grade A rate of 88.9%. They further commented that in their last 190 patients, of whom 70% (n = 134) were studied angiographically, the patency rate was 98.5% with a perfect patency rate (FitzGibbon grade A) of 96.3%.

Subramanian and associates [2] reported on angiographic patency in 89% of 189 patients studied at less than 36 hours. The patency rate was 92%; however, for the purposes of this study stenosis was considered occlusion.

Gill and coworkers [28] reported complete angiographic follow-up on 29 patients; the patency rate was 97%, with an additional 19% having grade B patency. Later follow-up angiography (mean, 10 months) of a larger group of patients that includes these reveals four of seven early angiographic abnormalities have cleared, one graft has occluded, and two remain unchanged (personal communication).

In our own series [42], in which 97% of 103 patients were studied either intraoperatively (38%) or immediately postoperatively (62%), a patency rate of 99% was demonstrated. However, 8 patients had a grade B finding, resulting in intraoperative revision in 3 patients.

Comment

Although an extensive body of literature exists addressing the issue of LIMA graft patency, the ability to answer the question of whether MIDCABG graft patency is comparable with that of conventional coronary artery bypass grafting is difficult to assess because the series are not comparable. Table 1 and Table 5, which illustrate early graft patency results, are most comparable. However, the conventional coronary artery bypass grafting series can be variously criticized for not including nonsurvivors (of necessity) in the angiographic results. Can we assume these patients had patent grafts? Additionally, most series (except the one by Gill and coworkers) did not study all patients. Are the data obtained from the studied patients able to be extrapolated to all patients who underwent operation?

Although meaningful comparison is not possible, it can probably be concluded that early angiographic graft patency by either conventional or MIDCABG technique is generally 90% or greater. Late graft patency of the LIMA graft performed by conventional coronary artery bypass grafting is 80% or greater in most series and greater than 90% in some. The late patency of the grafts performed by MIDCABG remains unknown.

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				M. J. Mack Reply Ann. Thorac. Surg., March 1, 2000; 69(3): 979 - 980. [Full Text] [PDF]

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