Ann Thorac Surg 2005;79:1232-1239
© 2005 The Society of Thoracic Surgeons
Original articles: Cardiovascular
Revascularization of the Right Coronary Artery: Grafting or Percutaneous Coronary Intervention?
Pierre-Emmanuel Falcoz, MDa,*,
Sidney Chocron, MD, PhDa,
Christine Binquet, MD, PhDb,
Lucian Stoica, MDa,
Djamel Kaili, MDa,
Catherine Quantin, MD, PhDb,
Joseph-Philippe Etievent, MDa
a Department of Thoracic and Cardiovascular Surgery, Jean-Minjoz Hospital, Besançon, France
b Department of Biostatistics, University Hospital, Dijon, France
Accepted for publication September 24, 2004.
* Address reprint requests to Dr Falcoz, Department of Thoracic and Cardiovascular Surgery, Hôpital Jean-Minjoz, Boulevard Fleming, 25000 Besançon, France (E-mail: pierre-emmanuel.falcoz{at}wanadoo.fr).
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Abstract
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BACKGROUND: The choice of myocardial revascularization strategy for the right coronary artery (RCA) in patients with multivessel disease and chronic stable angina remains controversial. Our aim was to determine the better strategy—hybrid, combining bypass of the left coronary network and percutaneous coronary intervention of the RCA, or exclusively surgical—and if the latter, the best conduit.
METHODS: We used decision analysis, a modeling technique, to compare two RCA revascularization strategies: surgical grafting and percutaneous coronary intervention. A review of the English language literature determined the variables for each strategy. All possible outcomes of each strategy were analyzed to determine the baseline strategy yielding the highest expected effectiveness. Sensitivity analysis determined the most relevant elements in the model and indicated threshold values.
RESULTS: Arterial grafting of the RCA led to the highest expected effectiveness, respectively 6% and 7% higher than that of percutaneous coronary intervention and the saphenous graft procedure. Of the arteries available—the radial, right gastroepiploic, and right internal thoracic artery—the most effective was the right internal thoracic artery, pedicled for the proximal part of the RCA and free connected as a Y or a T to the pedicled left internal thoracic artery for the distal part of the RCA. Sensitivity analysis showed surgery to be the appropriate strategy when the expected 1-year patency rate of the arterial graft exceeded 80%.
CONCLUSIONS: This analysis shows arterial grafting of the RCA to have better outcomes than percutaneous coronary intervention, and the right internal thoracic artery to be the best conduit.
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Introduction
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Coronary revascularization can be performed by either bypass surgery or percutaneous coronary intervention (PCI). Surgery, with the use of left internal thoracic artery (LITA) and additional saphenous veins grafts, has long been the generally accepted treatment for myocardial revascularization [1, 2]. More recently, studies have shown the routine use of arterial grafts in multivessel disease to improve surgical results [3, 4]. However, with advances in PCI—particularly balloon expandable stent implantation—treatment strategy has evolved progressively since the early 1990s, and PCI has set a new standard for myocardial revascularization [5, 6].
Most patients referred to surgery have three-vessel disease with a right coronary artery (RCA) that is stenosed but not occluded. For these patients, a PCI on the RCA with a left coronary network bypass (hybrid procedure) represents an alternative to complete surgical revascularization (surgical procedure). Moreover, in patients who undergo multivessel arterial grafting, most surgeons prefer to use both internal thoracic arteries to bypass the left coronary network. In this case, the choice of the conduit for the diseased RCA is restricted to the radial or gastroepiploic arteries.
A lack of controlled clinical trials specifically comparing hybrid and surgical procedures explains the current controversy over the appropriate choice. The authors propose a decision analytic model to examine this clinically important issue.
The aim of this study was to compare the outcomes of the two procedures—hybrid and surgical—to determine whether PCI or grafting is better adapted for the revascularization of the RCA, and if the latter, the best conduit.
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Material and Methods
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The Model
This study was designed on a decision analysis model. Decision analysis is a quantitative method for synthesizing data from numerous sources to evaluate treatment alternatives. All decision analyses involve the following basic components: the alternative strategies and potential outcomes associated with each strategy are specified in the decision model, the probabilities for each of these outcomes are estimated from the most appropriate available data and assigned to each decision point in the model, and an analysis is performed to calculate the expected value of each treatment alternative. By calculating the expected value, a favored strategy is identified. All analyses were performed with Data version 3.5 (TreeAge Software, Williamstown, MA), a decision analysis software program. The model was constructed using a dichotomous choice between hybrid and surgical procedures for patients suffering from chronic stable angina for which myocardial revascularization was indicated due to lesions of the left coronary network and of the RCA (Fig 1). The outcomes of each strategy were examined in terms of overall effectiveness. Thus, the model was analyzed to determine the baseline strategy that leads to the highest expected effectiveness.
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Fig 1. Decision tree representing the choice of management strategies for the revascularization of the right coronary artery. The two clinical strategies to be chosen from are represented at the square decision node of the tree. The probabilities and estimates of their values are listed in Tables 1 and 2. Based on values at terminal nodes and the chance of reaching each terminal node, calculations are performed right to left to yield overall values for each option at the decision node. Circles = occurrence of chance events (chance node); squares = choice between strategies (decision node); triangles = logic check in the simulation (terminal node). (PP = postprocedural; y = year.)
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Assumptions
In designing the decision tree, several assumptions were made to simplify the analysis. (1) For a given patient, the left coronary network was systematically bypassed, and revascularization of the RCA could be either surgical or instrumental. (2) Series dealing with unstable angina or acute myocardial infarction were excluded. (3) Studies predating 1994, such as those dealing with coronary angioplasty without stents, were excluded to avoid a bias due to medical progress. (4) Angiography was considered successful when stent placement was associated with a residual stenosis of less than 30% and Thrombolysis in Myocardial Infarction (TIMI) flow grade 2 or more [10]. Patency was present when the grafted coronary artery filled with angiographic contrast from the conduit. (5) One-year patency (from 6 to 12 months) was defined as any flow through both the graft and the native vessel; the graft was said to be nonpatent if a stump was seen or if there was no flow on the aortogram; a conduit showing extensive narrowing or "string sign" was considered functionally occluded and recorded as nonpatent. (6) Restenosis after stent placement was expressed in terms of patency (1 – restenosis); thus, 1-year patency for the hybrid procedure was defined as a stenosis diameter of 50% or less at follow-up angiography. (7) Thirty-day complications were defined as nonfatal myocardial infarction, cerebrovascular accident (stroke, transient ischemic attack, and reversible ischemic neurologic deficit), arrhythmia, and vascular complications.
Utility
The concept of utility measures a decision maker's relative preference for an outcome state. The states of health at the terminal nodes of the decision tree represent the final outcomes. Each one is assigned a utility value—between 0 and 1—that quantifies the preference for this state. In this study, the decision tree includes four final outcomes, each of which represents a clinically relevant endpoint. Two early outcomes were defined in the postoperative (30-day) period: postprocedural death and angiographic success. And two were defined as late outcome (6 to 12 months): 1-year death and 1-year patency of the RCA. One-year patency of the RCA and angiographic success, both optimal outcomes, were assigned a utility value of 1. A utility value of 0.5 was assigned to the absence of 1-year patency and angiographic failure, both intermediate outcomes. Postprocedural and 1-year death were assigned a utility value of 0.
Literature Review and Probabilities of Chance Events
Tables 1 and 2 summarize the main data probabilities and estimates of their values used in the decision analysis. These values are based on a critical review of the available literature regarding the RCA. A Medline search for English language articles dating from 1994 and falling under the headings "right coronary artery," "angioplasty," "percutaneous coronary," "coronary artery bypass graft," "transluminal," and "stents," both alone and in combination with the terms "randomized controlled trials," "cohort study," and "meta-analysis" yielded 145 articles. All abstracts were reviewed and the corresponding articles retrieved when appropriate. Additional articles were identified from the bibliographies of retrieved articles. Articles that satisfied predetermined critical appraisal criteria—methodologic quality, largest number of cases reported, most recent information, and relevance to our study population—were selected by a consensus of two reviewers. Discrepancies in data extraction from texts or tables were arbitrated by a third party. Analyses of the resultant data were done to obtain a baseline value (average of the values found in the studies) and a range (lowest and highest estimates) for all variables of interest.
Sensitivity Analysis
The stability of the results obtained from the model for mean probabilities was assessed through sensitivity analysis. Sensitivity analysis can be performed on individual probabilities (one-way sensitivity analysis) or by varying two probabilities at the same time (two-way sensitivity analysis). One-way sensitivity analysis was performed for each probability in the decision tree by varying it over its entire plausible range while holding all other probabilities constant. For a particular probability to be relevant in a one-way sensitivity analysis, a variation of its value would result in a threshold at which the original optimal strategy and an alternative strategy would have equal expected effectiveness. For values beyond the threshold, the alternative strategy would become optimal. Two-way sensitivity analysis was performed for all probabilities found to be relevant in one-way sensitivity analysis.
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Results
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Baseline Analysis
Twenty-five articles met the defined criteria and were used for data abstraction (see Table 3). The baseline analysis was based on the assumptions described above and used the probabilities described (Tables 1 and 2) and formalized utility scores. The surgical procedure using an arterial graft had the highest expected effectiveness, and thus is the preferred approach: 87% versus 81% for PCI and 80% for saphenous vein graft.
Sensitivity Analysis
Because the probabilities for the various outcomes used in this analysis could conceivably vary, sensitivity testing was performed to assess the validity of the conclusions over a wide range of probabilities.
On the whole, in terms of death (postprocedural or 1-year), angiographic success, and postprocedural complications, one-way sensitivity analysis showed consistent results and advocated surgical procedure as the better of the two strategies. Within the ranges tested, the different variables in the model influenced the weight of the surgical procedure, but did not change the preferred strategy. In no case, did one-way sensitivity analysis reveal a threshold. When focusing on the 1-year patency rate, one-way sensitivity analysis for the patency of the arterial graft revealed that the threshold value at which the two better strategies were equivalent was a patency rate of 80% (Fig 2a). The expected effectiveness at this threshold was 81.3%. Figure 2a graphs a one-way sensitivity analysis, illustrating that as long as the patency rate of arterial graft exceeds 80%, surgery remains the appropriate strategy. Figure 2b shows the one-way sensitivity analysis for the patency of the hybrid procedure: above 86%, the hybrid procedure becomes the favored strategy.
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Fig 2. One-way sensitivity analysis showing the effect of 1-year patency in terms of overall effectiveness. The graph illustrates the effect of 1-year patency after (A) arterial grafting and (B) the hybrid procedure on expected effectiveness for the right coronary artery. Vertical dashed lines represent the 1-year patency at the threshold value. Circles = hybrid procedure; diamonds = arterial graft; triangles = venous graft. (T = threshold value.)
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Two-way sensitivity analysis depicted how the optimal strategy changed as the patency rate related to each strategy varied (Fig 3). A combination of the patency rates corresponds to a point on the graph. For any combination, if the point lies in the black area, the surgical procedure is the optimal choice and in the white area, it is the hybrid procedure. The boundary line between the two areas represents a series of threshold values at which the two strategies yield an equivalent outcome.
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Fig 3. Two-way sensitivity analysis of the relation between the 1-year patency for surgical and hybrid procedures in revascularization of the right coronary artery. Two-way sensitivity analysis shows how the optimal strategy changes according to 1-year patency when all other probabilities are maintained at the baseline. The black area represents favored strategy for the surgical procedure, and the white area is favored strategy for the hybrid procedure. The preponderance of the black area within the figure indicates that surgical procedure is favored by the model. The base-case scenario, indicated by a star, represents a 1-year patency of 88.7% for the surgical procedure and 77.3% for the hybrid procedure. The dashed lines represent the change in the boundary between the two areas when the baseline value of 1-year patency with the hybrid procedure varies around its 95% confidence interval (77.3% ± 3.9%).
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Comment
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In the field of myocardial revascularization, PCI and coronary artery bypass graft surgery have been compared in numerous controlled clinical trials [5, 6, 11, 28, 29] and meta-analyses [30, 31] of patients suitable for either procedure. The American College of Cardiology/American Heart Association recently published practice guidelines for percutaneous coronary intervention [9] with the aim of summarizing the indications for PCI by class and level of evidence.
Evidence is still lacking in the literature, however, as to whether the RCA would best benefit from a surgical or a hybrid procedure. The usefulness of the surgical procedure as opposed to the hybrid one for the revascularization of the RCA has given rise to great controversy.
The RCA is frequently heavily calcified with a higher incidence of coronary wall disease. Because it is a large-size vessel with potential for competitive flow, in the case of moderate stenosis in large dominant RCA systems, it is a priori more suitable for PCI than for surgery. Moreover, for several reasons, there may not be an arterial conduit available to bypass the RCA: the two mammary arteries are often used for the left network, the initial results with the radial artery are not always favorable, and finally, surgeons hesitate to open the abdominal cavity to harvest the gastroepiploic artery. Opponents of surgical revascularization point out that the expected rate of restenosis of the RCA should be low after PCI; the Benestent study [32] and the Multicenter Ultrasound Stenting in Coronaries (MUSIC) study [13] both showed the rate of restenosis to be linked to the diameter of the coronary artery—the greater the diameter, the lower the rate of restenosis. Elezi and colleagues [14] showed that 80% of patients had a RCA diameter greater than 2.8 mm. On the other hand, advocates of surgical revascularization say that it is more logical to perform complete surgical revascularization of the entire coronary network during the same intervention in order to avoid the risk of restenosis. Repeat procedures are more often necessary after PCI than after coronary artery bypass graft surgery [30], thus requiring redo surgery.
As no clear consensus has emerged from the basic recommendations of the guidelines, and in view of the lack of controlled clinical trials focusing on this topic, the authors decided to address this controversial question using formal decision analysis. This method does have its own limitations, some of which are inherent to the assumptions and tree structure and deserve mention. First, cardiovascular risk factors and patients' previous comorbid conditions were not directly included in the tree structure. Table 3 summarizes the preoperative characteristics of patients from reports included in the analysis. Nevertheless, relevant mean values could not be calculated for all characteristics, either because sufficient data were not available (family history, obesity, chronic obstructive pulmonary disease, cerebral and peripheral vascular disease, and chronic renal failure), or because data were presented in such a way that values could not be standardized (ejection fraction). Second, the figure for 1-year patency of the RITA (90.9%) was lowered because the data from the free and pedicled RITA were averaged together.
Despite the above limitations, from the standpoint of baseline probabilities, our analysis favors the surgical procedure in terms of overall effectiveness. This finding is in accordance with recent publications [5, 30], which state that surgery is the most effective method of revascularization of multivessel disease. It is especially noteworthy that except for the rates of 1-year patency, sensitivity analysis did not have a significant impact on the baseline results. Hence, the interpretation of results can be considered reliable and robust. Our analysis emphasized that 1-year patency was the most relevant outcome to consider. Figure 3 illustrates the correlation between the two procedures for 1-year patency, and although it does indicate a preference for the surgical procedure in this model, 1-year patency of the RCA deserves further discussion. Indeed, our analysis indicates a mean 1-year arterial graft patency rate of 88.7% (ranging from 75.0% to 97.1%). Figure 2a suggests that any arterial graft could be used to bypass the RCA since each resulted in an expected 1-year patency above 80%. Among the available arterial grafts, the RITA has the better 1-year patency. Nevertheless, the use of pedicled RITA should be restricted to the proximal RCA before the acute margin of the heart (patency rate 95% [33] versus 83.3% for distal RCA [26]. For distal RCA, the RITA should be used "free" in a Y or T connection with the pedicled LITA [34, 35]. For the hybrid procedure, our analysis showed a mean 1-year patency of 77.3% (ranging from 62.9% to 90.3%), which is in accordance with figures given in the recent guidelines of the American College of Cardiology [9]. Figure 2b shows that the hybrid procedure is the favored strategy on condition that the expected 1-year patency of PCI is above 86%. Most of the retrieved articles gave a late patency for PCI below this threshold, with 67% [15] for complex lesions (types B2 and C of the ACC/AHA classification). In contrast, De Jaegere and associates [13], in the MUSIC study, presented a 6-month patency of 90.3% (with a poststenting minimal lumen diameter at 2.9 ± 0.36 mm). This was confirmed by Ijsselmuiden and colleagues [8], who recently reported a 1-year patency of 88% for 45 lesions with a poststenting minimal lumen diameter between 3.0 and 3.5 mm. Although follow-up angiography at 6 to 12 months is the most sensitive to detect restenosis [36], we thought it would be of interest to enter a long-term (more than 3 years) patency rates for RCA in our model. For all arterial conduits, there was a steady decline of patency over time: the mean value of long-term patency of arterial graft was 85.5% (ranging from 79.2% to 90.9%) [34, 37, 38]. Although the phenomenon of restenosis culminates during the 3 to 4 months after angioplasty, and may regress in the long term [39], the mean value of long-term patency for PCI was inferior to 72% [12, 36], and was found to be an independent risk factor for late mortality [36]. The subanalysis we did for long-term patency confirmed arterial grafting of the RCA as the better strategy (85% of overall effectiveness versus 73% for PCI).
As for utility estimates, failure (defined as angiographic failure or the absence of 1-year patency) was given an intermediate value between 0 and 1, namely, between death and success (defined as angiographic success and 1-year patency). Because an acceptable utility for failure was likely to range from one third to two thirds, we chose a utility value of 0.5. However, there is no difference in the decision making when the utility of failure values vary within this range.
In conclusion, the results we obtained using decision analysis for the optimal management of the RCA in patients with chronic stable angina and multivessel disease show arterial grafting to have better outcomes than PCI, and the RITA to be the best conduit. If, as is often the case, the RITA is not available for the RCA because it has been used for left-side vessels, the radial artery or the right gastroepiploic artery can be used, as both compare favorably with PCI. The analysis has been performed with noncoated stents. The use of drug-eluting stents may change the decision-making analysis in the future.
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Acknowledgments
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The authors thank Nancy Richardson-Peuteuil for her editorial assistance, and Alice Robbe and Sophie Pigeonnat for their contribution. This study was supported by grants from Programme Hospitalier de la Recherche Clinique (Ministère de la Santé Publique), Paris, France.
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References
|
|---|
- Lytle BW, Blackstone E, Loop FD, et al. Two internal thoracic artery grafts are better than one J Thorac Cardiovasc Surg 1999;117:855-872.[Abstract/Free Full Text]
- Chow MS, Sim E, Orszulak TA, Schaff H. Patency of internal thoracic artery grafts: comparison of right versus left and importance of vessel grafted Circulation 1994;90:129-132.
- Nishida H, Tomizawa Y, Endo M, Koyanagi H, Kasanuki H. Coronary artery bypass with only in situ bilateral internal thoracic arteries and right gastroepiploic artery Circulation 2001;104(Suppl 1):76-80.
- Wendler O, Hennen B, Demertzis S, et al. Complete arterial revascularization in multivessel coronary artery disease with two conduits (skeletonized grafts and T grafts) Circulation 2000;102(Suppl 3):79-83.
- Serruys PW, Unger F, Sousa JE, et al. Comparison of coronary artery bypass surgery and stenting for the treatment of multivessel disease N Engl J Med 2001;344:1117-1124.[Abstract/Free Full Text]
- Rodriguez A, Bernardi V, Navia J, et al. Argentine randomized studyCoronary angioplasty with stenting versus coronary bypass surgery in patients with multiple vessel disease (ERACI II): 30-day and one-year follow-up results. J Am Coll Cardiol 2001;37:51-58.[Abstract/Free Full Text]
- Foley DP, Pieper M, Wijns W, et al. The influence of stent length on clinical and angiographic outcome in patients undergoing elective stenting for native coronary artery lesionsFinal results of the magic 5L study. Eur Heart J 2001;22:1585-1593.[Abstract/Free Full Text]
- Ijsselmuiden AJJ, Serruys PW, Scholte A, et al. Direct coronary stent implantation does not reduce the incidence of in-stent restenosis or major adverse cardiac eventsSix month results of a randomized trial. Eur Heart J 2003;24:421-429.[Abstract/Free Full Text]
- ACC/AHA Guidelines for percutaneous coronary intervention (revision of the 1993 PTCA guidelines)—executive summary: a report of the American College of Cardiology/American Heart Association task force on practice guidelines Circulation 2001;103:3019-3041.[Free Full Text]
- Kornowski R, Mehran R, Satler LF, et al. Procedural results and late clinical outcomes following multivessel coronary stenting J Am Coll Cardiol 1999;33:420-426.[Abstract/Free Full Text]
- Eefting F, Nathoe H, Van Dijk D, et al. Randomized comparison between stenting and off-pump bypass surgery in patients referred for angioplasty Circulation 2003;108:2870-2876.[Abstract/Free Full Text]
- Kimura T, Abe K, Shizuta S, et al. Long-term clinical and angiographic follow-up after coronary stent placement in native coronary arteries Circulation 2002;105:2986-2991.[Abstract/Free Full Text]
- De Jaegere P, Mudra H, Figulla H, et al. Intravascular ultrasound-guided optimized stent deployment immediate and 6 months clinical and angiographic results from the Multicenter Ultrasound Stenting in Coronaries study (MUSIC study) Eur Heart J 1998;19:1214-1223.[Abstract/Free Full Text]
- Elezi S, Kastrati A, Neumann FJ, Hadamitzky M, Dirschinger J, Schömig A. Vessel size and long-term outcome after coronary stent placement Circulation 1998;98:1875-1880.[Abstract/Free Full Text]
- Kastrati A, Schömig A, Elezi S, et al. Prognostic value of the modified American College of Cardiology/American Heart Association stenosis morphology classification for long-term angiographic and clinical outcome after coronary stent placement Circulation 1999;100:1285-1290.[Abstract/Free Full Text]
- Van der Meer J, Hillege HL, Van Gilst WH, et al. Coronary bypass surgeryA comparison of internal mammary artery and saphenous vein grafts after coronary artery bypass surgery: no difference in 1-year occlusion rates and clinical outcomes. Circulation 1994;90:2367-2374.[Abstract/Free Full Text]
- Shroyer ALW, Coombs LP, Peterson ED, et al. The Society of Thoracic surgeons: 30-day operative mortality and morbidity risk models Ann Thorac Surg 2003;75:1856-1865.[Abstract/Free Full Text]
- Bourassa MG. Long-term vein patency graft Curr Opin Cardiol 1994;9:685-691.[Medline]
- Tatoulis J, Royse AG, Buxton BF, et al. The radial artery in coronary surgery: a 5-year experienceClinical and angiographic results. Ann Thorac Surg 2002;73:143-148.[Abstract/Free Full Text]
- Maniar HS, Sundt TM, Barner HB, et al. Effect of target stenosis and location on radial artery graft patency J Thorac Cardiovasc Surg 2002;123:45-52.[Abstract/Free Full Text]
- Royse AG, Royse CF, Tatoulis J, et al. Postoperative radial artery angiography for coronary artery bypass surgery Eur J Cardiothorac Surg 2000;17:294-304.[Abstract/Free Full Text]
- Suma H, Amano A, Horii T, Kigawa I, Fukuda S, Wanibuchi Y. Gastroepiploic artery in 400 patients Eur J Cardiothorac Surg 1996;10:6-11.[Abstract]
- Grandjean JG, Voors AA, Boonstra PW, Den Heyer P, Ebels T. Exclusive use of arterial grafts in coronary artery bypass operations for three-vessel disease: use of both thoracic arteries and the gastroepiploic artery in 256 consecutive patients J Thorac Cardiovasc Surg 1996;112:935-942.[Abstract/Free Full Text]
- Albertini A, Lochegnies A, El Khoury G, et al. Use of the right gastroepiploic artery as a coronary graft in 307 patients Cardiovasc Surg 1998;6:419-423.[Medline]
- Tatoulis J, Buxton BF, Fuller JA. Results of 1,454 free right internal thoracic artery to coronary artery grafts Ann Thorac Surg 1997;64:1263-1269.[Abstract/Free Full Text]
- Verhelst R, Etienne PY, El Khoury G, Noirhomme P, Rubay J, Dion R. Free internal mammary artery graft in myocardial revascularization Cardiovasc Surg 1996;4:212-216.[Medline]
- Dietl CA, Benoit CH, Gilbert CL, et al. Which is the graft of choice for the right coronary and posterior descending arteries? Comparison of the right internal mammary artery and the right gastroepiploic artery Circulation 1995;92(Suppl 2):92-97.[Abstract/Free Full Text]
- The BARI Investigators Influence of diabetes on 5-year mortality and morbidity in a randomized trial comparing CABG and PTCA in patients with multivessel disease: the bypass angioplasty revascularization investigation (BARI) Circulation 1997;96:1761-1769.[Abstract/Free Full Text]
- Van den Brand MJ, Rensing BJ, Morel MA, et al. The effect of completeness revascularization on event-free survival at one year in the ARTS trial J Am Coll Cardiol 2002;39:559-564.[Abstract/Free Full Text]
- Rihal CS, Raco DL, Gersh BJ, Yusuf S. Indications for coronary artery bypass surgery and percutaneous coronary intervention in chronic stable anginaReview of the evidence and methodological considerations. Circulation 2003;108:2439-2445.[Free Full Text]
- Hoffman SN, Tenbrook JA, Wolf MP, Pauker SG, Salem DB, Wong JB. A meta-analysis of randomized controlled trials comparing coronary artery bypass graft with percutaneous transluminal coronary angioplasty: one- to eight-year outcomes J Am Coll Cardiol 2003;41:1293-1304.[Abstract/Free Full Text]
- Serruys PW, De Jaegere P, Kiemeneij F, et al. A comparison of balloon-expandable-stent implantation with balloon angioplasty in patients with coronary artery diseaseBenestent Study Group. N Engl J Med 1994;331:489-495.[Abstract/Free Full Text]
- Dion R, Verhelst R, Rousseau M, et al. Sequential mammary grafting: clinical, functional, and angiographic assessment 6 months postoperatively in 231 consecutive patients J Thorac Cardiovasc Surg 1989;98:80-89.[Abstract]
- Dion R, Glineur D, Derouck D, et al. Long-term clinical and angiographic follow-up of sequential ITA grafting Eur J Cardiothorac Surg 2000;17:407-414.[Abstract/Free Full Text]
- Tector AJ, Amundsen S, Schmahl TM, Kress DC, Peter M. Total revascularization with T grafts Ann Thorac Surg 1994;57:33-39.[Abstract]
- Schühlen H, Kastrati A, Mehilli J, et al. Restenosis detected by routine angiographic follow-up and late mortality after coronary stent placement Am Heart J 2004;147:317-322.[Medline]
- Shah PJ, Durairaj M, Gordon I, et al. Factors affecting patency of internal thoracic artery grafts: clinical and angiographic study in 1434 symptomatic patients operated between 1982 and 2002 Eur J Cardiothorac Surg 2004;26:118-124.[Abstract/Free Full Text]
- Tatoulis J, Buxton BF, Fuller JA. Patencies of 2,127 arterial to coronary conduits over 15 years Ann Thorac Surg 2004;77:93-101.[Abstract/Free Full Text]
- Kimura T, Yokoi H, Nakagawa Y, et al. Three-year follow-up after implantation of metallic coronary artery stents N Engl J Med 1996;334:561-566.[Abstract/Free Full Text]
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Abstract
Introduction
