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Ann Thorac Surg 2007;84:799-800
© 2007 The Society of Thoracic Surgeons
Policlinico A. Gemelli, Department of Cardiac Surgery, Università Cattolica, L.go A Gemelli 1, Rome, 00168 Italy
(Email: mgaudino{at}tiscali.it; possati{at}tiscali.it).
The Radial Artery Patency and Clinical Outcomes (RAPCO) trial will constitute a landmark in the history of arterial revascularization, and within some years this trial will furnish fundamental answers to the respective role and indications of coronary artery bypass conduits. For these reasons the authors whose dedication and enthusiasm made realization of the RAPCO possible must receive all our gratitude and appreciation.
In the present analysis, Hayward and Buxton [1] review the interim RAPCO angiographic database including data from both trial and nontrial grafts and give us an important state of the art overview of the mid-term angiographic patency of arterial and venous conduits.
The main findings of this study are the almost perfect results of in situ internal thoracic artery grafts, the 89% 5-year patency of both free right internal thoracic arteries and radial arteries (RAs), an outstanding 82% patency rate of saphenous vein grafts, and a trend to higher failure rate of venous versus free arterial conduits. Although with the increase in follow-up time it is possible that the gap between arterial and venous conduits will increase, the results achieved by saphenous grafts are of absolute relevance and clearly superior to those of the classic historical studies [2].
Of outmost importance is the fact that the patency of venous grafts is not so dependent on runoff and quality of target vessels as for the free arterial conduits. In a population with a mean age that is steadily growing and with increasingly complex and diseased coronary anatomy as the one actually referred for coronary artery bypass grafting (CABG), it seems plausible then that the near future will see a reappraisal of saphenous conduits.
Another note of interest is the 90% mid-term patency rate of the RA; this value confirms our own observations [3–5] and dissipates the concerns elicited by others [6]: when this adopted methodology is appropriate, the RA is probably the second arterial graft of choice on both sides of the ocean.
However, Hayward and Buxton [1] do not stratify RA results according to the degree of the target vessel stenosis; it is our experience that the angiographic patency of this artery is crucially influenced by the severity of the coronary lesion, and the patency rate approaches that of the in situ internal thoracic artery when it is used to graft vessels with subocclusive stenosis [7]. In this regard a correct indication is mandatory and is probably the most important determinant of RA outcome.
When all the data of the RAPCO trial will be collected and analyzed we will finally have the fundamental answers regarding arterial grafting that we are all awaiting. Until that moment we must have a cautious attitude in analyzing preliminary reports; however, the results presented by Hayward and Buxton [1] coupled with an analysis of the actual population referred for coronary revascularization suggest a new perspective on arterial CABG. Of the two categories of cases for whom this surgical strategy was initially designed, young patients are becoming rarer and rarer and the oldest patients do not derive real benefits from arterial conduits.
If the data are confirmed, a wonderful and exciting theoretical dream will probably be reduced to an area of academic research reserved to a very limited niche of patients and with little clinical application.
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