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The Impact of Excessive Grafting on Long-term Survival in Coronary Artery Bypass Operations
D. Chu1, F. G. Bakaeen1, X. Wang2, J. S. Coselli2, S. A. LeMaire2, J. Huh1. 1Michael E. DeBakey Veterans Affairs Medical Center, Baylor College of Medicine, Houston, TX, 2Texas Heart Institute at St. Luke's Episcopal Hospital, Baylor College of Medicine, Houston, TX,
BACKGROUND:
Complete revascularization in coronary surgery is traditionally defined as revascularization with 1 graft to each major diseased arterial/anatomic territory: anterior, lateral, and inferior. Although incomplete coronary revascularization has been shown to decrease survival in patients undergoing coronary artery bypass grafting (CABG), little is known about the effects of excessive grafting (more than 1 graft to each major diseased arterial/anatomic territory) in CABG patients. The objective of this study was to determine the impact of excessive grafting on long-term survival in CABG patients.
METHODS:
We reviewed prospectively gathered data from 1129 consecutive patients who underwent primary isolated CABG at our institution between October 1997 and March 2007. We compared outcomes of patients who received more than 1 graft to each major diseased arterial/anatomic territory (n=549) and patients who received only 1 graft to each major diseased arterial/anatomic territory (n=580). For each patient, we collected information on 23 variables: 14 preoperative patient characteristics, 2 intraoperative variables, and 7 postoperative outcome measures including all-cause mortality. Based on a mean follow-up time of 4.2 ± 2.8 years, we assessed long-term survival by using Kaplan-Meier curves generated by log-rank tests and adjusted for confounding factors with Cox logistic regression analysis.
RESULTS:
The 2 groups of patients did not differ significantly in terms of age, current tobacco use, history of cerebral vascular disease, history of diabetes, functional angina class, functional heart failure class, body mass index, prior percutaneous coronary intervention, prior myocardial infarction, preoperative albumin level, or preoperative creatinine level. The patients who received more than 1 bypass grafts to each major diseased arterial/anatomic territory had longer cardiopulmonary bypass times (124 ± 36 vs 102 ± 27 minutes; p<0.0001), longer aortic cross-clamp times (70 ± 20 vs 57 ± 17 minutes; p<0.0001), lower incidence of peripheral vascular disease (28% vs 35%; p=0.03), slightly lower incidence of chronic obstructive pulmonary disease (32% vs 38%; p=0.02) than patients who received only 1 graft to each major diseased arterial/anatomic territory. The 2 groups of patients had similar 30-day rates of mortality (1.3% vs 1.4%; p=1.0) and major adverse cardiac events (2.9% vs 2.2%; p=0.57). Cox regression survival curves were also similar between the 2 groups of patients (adjusted hazard ratio, 0.94; 95% CI: 0.67-1.34; p=0.74). 
CONCLUSIONS:
Patients who received more than 1 bypass graft to each major diseased arterial/anatomic territory have 30-day mortality rates and early outcomes similar to those who received only 1 graft. Furthermore, the construction of more than 1 graft to each major diseased arterial/anatomic territory significantly increases operative time and does not improve long-term survival.
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