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Original Articles: Adult Cardiac

Invited Commentary

Department of Surgery, Duke University Medical Center, Box 3851, Durham, NC 27710

(Email: glowe001{at}mc.duke.edu).

I read with interest the article by Schwann and colleagues [1].

Now, some 45 years after the first reported coronary artery bypass graft, the debate still remains unsettled regarding selection of conduit in coronary artery bypass grafting. The surgeon has the choice of single grafting, sequential grafting, and Y-grafting or T-grafting techniques. Realistic conduit choices include internal mammary artery, radial artery, and autologous saphenous vein. Few adequately powered randomized trials have been done, primarily due to issues of trial cost and safety of graft imaging techniques [2]. Therefore, the choices nowadays in coronary graft conduits must be largely based on nonrandomized studies.

Schwann and colleagues [1] report one such nonrandomized study with a 12-year result of sequential radial artery (RA) grafts in 532 consecutive patients relative to 4,131 patients of conventional mammary artery with saphenous veins. Survival was significantly better in the RA group, and graft patency was not significantly different for single versus sequential RA grafts.

This is a large, retrospective study with high-quality survival data and typical retrospective catheterization data available in 23% of patients. Although caution is needed in interpreting retrospective studies subject to uncontrolled selection bias, the study of Schwann and colleagues [1] does suggest that good results can be obtained from sequential radial artery grafting instead of saphenous vein for nonmammary conduits. This result is not surprising. The major question remaining is which patients are appropriate for sequential radial artery grafting? Other studies have suggested that radial grafts may have patencies superior to saphenous veins but that patencies depend on native vessel size and stenosis [3]. Unlike this study, others have suggested lower distal patencies in some sequential grafts [4–6]. Even for our very best conduit, the mammary artery, showing survival benefit of mammary versus saphenous grafting has been difficult after 30 years of study. Clearly, further investigation is needed to confirm suggestions from Schwann and colleagues [1] that radial grafting confers survival value in women or in general. Until graft imaging becomes cheap and safe, better data may await large retrospective, controlled studies using large databases such as The Society of Thoracic Surgeons' database for surgical details and the Medicare database for clinical follow-up.

	References

Top References

 

1. Schwann TA, Zacharias A, Riordan CJ, Durham SJ, Shah AS, Habib RH. Sequential radial artery grafts for multivessel coronary artery bypass graft surgery: 10-year survival and angiography results Ann Thorac Surg 2009;88:31-39.[Abstract/Free Full Text]
2. Desai ND, Cohen EA, Naylor CD, Fremes SE, Radial Artery Patency Study Investigators A randomized comparison of radial-artery and saphenous-vein coronary bypass grafts N Engl J Med 2004;351:2302-2309.[Medline]
3. Desai ND, Naylor CD, Kiss A, et al. Radial Artery Patency Study Investigators Impact of patient and target-vessel characteristics on arterial and venous bypass graft patency: insight from a randomized trial Circ 2007;115:684-691.[Abstract/Free Full Text]
4. Farsak B, Tokmakoglu H, Kandemir O, et al. Angiographic assessment of sequential and individual coronary artery bypass grafting J Card Surg 2003;18:524-529.[Medline]
5. van Brussel BL, Plokker HW, Voors AA, et al. Different clinical outcome in coronary artery bypass with single and sequential vein grafts: a fifteen-year follow-up study J Thorac Cardiovasc Surg 1996;112:69-78.[Abstract/Free Full Text]
6. Vural KM, Sener E, Tasdemir O. Long-term patency of sequential and individual saphenous vein coronary bypass grafts Eur J Cardio-Thorac Surg 2001;19:140-144.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Donald D. Glower Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Glower, D. D. Search for Related Content PubMed PubMed Citation Articles by Glower, D. D. Related Collections Coronary disease Related Article