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Department of Cardiac Surgery I, Dedinje Cardiovascular Institute, Milana Tepi
a 1, Belgrade, 11000 Serbia
(Email: nezic{at}eunet.rs).
We read the article by Zacharias and colleagues [1] regarding the late results of conventional versus all-arterial revascularization based on internal thoracic and radial artery (RA) grafting with great interest. Although this is an outstanding article, we disagree with the authors' statement that several prospective and retrospective reports [2–4] have shown superior RA patency compared with saphenous vein grafts (SVG).
In the retrospective study, Zacharias and associates [2] used propensity scoring. Matched patients had essentially identical demographics, comorbidities, severity of coronary disease, and operative data. Although the cumulative 6-year survival was better for patients with RA conduits (versus patients with SVG) as a second conduit (925 patients in each group), the angiographic patency of RA conduits (1.8 ± 1.4 years to re-angiogram) was 68.2%, and was not statistically better (p = 0.11) than SVG patency (63.3%).
In the other retrospective study by Schwann and colleagues, [3] the patients were not matched. Although this study demonstrated superior RA graft patency compared with SVGs in patients with coronary artery endarterectomy, patients without radial grafting had significantly different risk profiles (eg, renal failure, cerebrovascular disease, recent myocardial infarction, congestive heart failure, and so forth).
The third study [4] was derived from an excellent, prospective, randomized basic study by Desai and colleagues [5] that compared angiographic patency of RA grafts with that of SVGs 1 year after surgery. In that basic study the RA was randomly assigned to bypass major vessels in either the right coronary or circumflex territory, the SVG was used for the alternate territory (control). Although that study demonstrated significantly better angiographic patency of RA conduits compared with SVGs (occlusion rate 8.2% for RA conduits vs. 13.6% for SVG; p = 0.009), the presence of a "string sign" was found in 7% of RA grafts and 0.9% of SVGs. Subsequent analysis of those data [6] showed that 48.4% (15 of 31) of the RA conduits with "string sign" had Thrombolysis in Myocardial Infarction Study (TIMI) flow 1. Postoperative angina was significantly higher in patients who had RA conduits with a "string sign" and TIMI flow 1 [6]. The RA grafts with a "string sign" were considered failures in Schwann and colleagues' [3] article. When we compare a total of 11.6% (51 of 440) of failed RA conduits (36 occluded, plus, at least, 15 with "string sign" and TIMI flow 1) versus a total of 14.1% (62 of 440) of failed SVG (60 grafts occluded, plus 2 with TIMI flow 1), there is no significant difference between grafts (p = 0.38). This leads us to conclude that the final result of the basic study by Desai and associates [5] does not confirm significantly better angiographic patency for radial artery conduits as compared with SVGs 1 year after surgery.
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  A. Zacharias and R. H. Habib Reply Ann. Thorac. Surg., November 1, 2009; 88(5): 1725 - 1725. [Full Text] [PDF]
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