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May - 2018

   

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Radial-Artery or Saphenous-Vein Grafts in Coronary-Artery Bypass Surgery

Mario Gaudino, Umberto Benedetto, Stephen Fremes, et al for the RADIAL Investigators New Eng J Med, 2018, online first April 2018

Comment

The debate about the benefit and risk of radial vs SV grafts, in addition to internal-thoracic graft to LAD, has been ongoing. Although angiographic studies have reported higher rates of radial graft patency, these have been underpowered to detect differences in clinical events. Although guidelines support the use of multiple arterial grafts, the great majority of patients in North America and Europe receive SVGs + ITA.

This study utilised the Radial Artery Database International Alliance (RADIAL), and performed a patient level combined analysis comparing 6 randomized, controlled trials in which long-term outcomes were assessed, and reported outcomes in radial-artery grafts and saphenous-vein grafts for CABG. 

They report;

  • 1036 patients from 6-trials, mean follow-up 60 months
  • Incidence of primary outcome (composite of death, myocardial infarction, or repeat revascularization) was significantly lower for radial group HR 0.67; 95% CI, 0.49 to 0.90; P=0.01
  • Incidence of secondary outcome graft patency on follow-up angiography was significantly lower for radial HR 0.44; 95% CI, 0.28 to 0.70; P<0.001
  • Radial was also associated with lower incidence of myocardial infarction (HR, 0.72; 95% CI, 0.53 to 0.99; P=0.04) and  repeat revascularization (HR, 0.50; 95% CI, 0.40 to 0.63; P<0.001) but not a lower incidence of death from any cause (HR, 0.90; 95% CI, 0.59 to 1.41; P=0.68).
  • Subgroup analysis showed benefit for radial with under 75 years age, women, absence of DM, absence of renal insufficiency, LVEF >35%, and Lcx as target. 

Overall radial vs saphenous graft was associated with lower rate of cardiac adverse events, particularly AMI and need for revascularisation, and lower rate of graft occlusion at 5-years. There was no difference in survival, and sub-group analysis suggests certain populations are likely to benefit more from radial grafts.

 

Abstract

BACKGROUND

The use of radial-artery grafts for coronary-artery bypass grafting (CABG) may result in better postoperative outcomes than the use of saphenous-vein grafts. However, randomized, controlled trials comparing radial-artery grafts and saphenous-vein grafts have been individually underpowered to detect differences in clinical outcomes. We performed a patient-level combined analysis of randomized, controlled trials to compare radial-artery grafts and saphenous-vein grafts for CABG.

METHODS

Six trials were identified. The primary outcome was a composite of death, myocardial infarction, or repeat revascularization. The secondary outcome was graft patency on follow-up angiography. Mixed-effects Cox regression models were used to estimate the treatment effect on the outcomes.

RESULTS

A total of 1036 patients were included in the analysis (534 patients with radial-artery grafts and 502 patients with saphenous-vein grafts). After a mean (±SD) follow-up time of 60±30 months, the incidence of adverse cardiac events was significantly lower in association with radial-artery grafts than with saphenous-vein grafts (hazard ratio, 0.67; 95% confidence interval [CI], 0.49 to 0.90; P=0.01). At follow-up angiography (mean follow-up, 50±30 months), the use of radial-artery grafts was also associated with a significantly lower risk of occlusion (hazard ratio, 0.44; 95% CI, 0.28 to 0.70; P<0.001). As compared with the use of saphenous-vein grafts, the use of radial-artery grafts was associated with a nominally lower incidence of myocardial infarction (hazard ratio, 0.72; 95% CI, 0.53 to 0.99; P=0.04) and a lower incidence of repeat revascularization (hazard ratio, 0.50; 95% CI, 0.40 to 0.63; P<0.001) but not a lower incidence of death from any cause (hazard ratio, 0.90; 95% CI, 0.59 to 1.41; P=0.68).

CONCLUSIONS

As compared with the use of saphenous-vein grafts, the use of radial-artery grafts for CABG resulted in a lower rate of adverse cardiac events and a higher rate of patency at 5 years of follow-up.

May


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