All-artery multigraft coronary artery bypass grafting with only internal thoracic arteries possible and safe: A randomized trial

Myers, Wayne L.; Berg, Richard; Ray, Jefferson F.; Douglas-Jones, John W.E.; Maki, Hope S.; Ulmer, Richard H.; Chaitman, Bernard R.; Reinhart, Richard A.

doi:10.1067/msy.2000.108113

Cited by 33 publications

(20 citation statements)

References 17 publications

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“…In a recent large study published in 2013 by Parsa and colleagues, 9 which enrolled 17,609 patients (more than the 15,962 patients included in the meta-analysis 1 ), adjusted mortality was similar (HR, 0.95; 95% CI, 0.83 to 1.08) between the BITA and SITA groups. To the best of our knowledge, only 2 randomized controlled trials 10,11 Updating the meta-analysis by Taggart and colleagues 1 to determine whether BITA grafting reduces long-term mortality relative to SITA grafting in CABG, we exclusively abstracted, then combined in a meta-analysis, adjusted (not unadjusted [crude]) risk estimates for long-term mortality from 20 observational studies (more than 70,000 patients were enrolled, which was more than quadruple the number of patients included in the previous metaanalysis 1 ). Moreover, meta-regression analyses were performed to determine whether the effects of BITA grafting were modulated by prespecified factors.…”

Section: Discussionmentioning

confidence: 99%

A meta-analysis of adjusted hazard ratios from 20 observational studies of bilateral versus single internal thoracic artery coronary artery bypass grafting

Takagi

Goto

Watanabe

et al. 2014

The Journal of Thoracic and Cardiovascular Surgery

106

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Section: Discussionmentioning

confidence: 99%

A meta-analysis of adjusted hazard ratios from 20 observational studies of bilateral versus single internal thoracic artery coronary artery bypass grafting

Takagi

Goto

Watanabe

et al. 2014

The Journal of Thoracic and Cardiovascular Surgery

106

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“…It must, however, be noted that the results of the observational studies have not been confirmed in the randomized comparisons. The 4 RCTs that have compared BITA and SITA to date have all failed to show a survival difference between the 2 revascularization strategies . Two of the RCTs were small, with less than 100 patients in each arm, and had limited follow‐up, so that they were probably underpowered to detect moderate differences .…”

Section: Discussionmentioning

confidence: 99%

“…The 4 RCTs that have compared BITA and SITA to date have all failed to show a survival difference between the 2 revascularization strategies . Two of the RCTs were small, with less than 100 patients in each arm, and had limited follow‐up, so that they were probably underpowered to detect moderate differences . Another study was moderate in size (Stand‐in‐Y, 800 patients) and the most recent, the ART trial, included more than 3000 patients.…”

Section: Discussionmentioning

confidence: 99%

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Unmeasured Confounders in Observational Studies Comparing Bilateral Versus Single Internal Thoracic Artery for Coronary Artery Bypass Grafting: A Meta‐Analysis

Gaudino

Franco

Rahouma

et al. 2018

JAHA

100

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BackgroundObservational studies suggest a survival advantage with bilateral single internal thoracic artery (BITA) versus single internal thoracic artery grafting for coronary surgery, whereas this conclusion is not supported by randomized trials. We hypothesized that this inconsistency is attributed to unmeasured confounders intrinsic to observational studies. To test our hypothesis, we performed a meta‐analysis of the observational literature comparing BITA and single internal thoracic artery, deriving incident rate ratio for mortality at end of follow‐up and at 1 year. We postulated that BITA would not affect 1‐year survival based on the natural history of coronary artery bypass occlusion, so that a difference between groups at 1 year could not be attributed to the intervention.Methods and ResultsWe searched MEDLINE and Pubmed to identify all observational studies comparing the outcome of BITA versus single internal thoracic artery. One‐year and long‐term mortality for BITA and single internal thoracic artery were compared in the propensity‐score–matched (PSM) series, that is, the form of observational evidence less prone to confounders. Thirty‐eight observational studies (174 205 total patients) were selected for final comparison. In the 12 propensity‐score–matched series (34 019 patients), the mortality reduction for BITA was similar at 1 year and at the end of follow‐up (incident rate ratio, 0.70; 95% confidence interval, 0.60–0.82 versus 0.77; 95% confidence interval, 0.70–0.85; P for subgroup difference=0.43).ConclusionsUnmeasured confounders, rather than biological superiority, may explain the survival advantage of BITA in observational series.

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“…Results from four RCTs comparing BIMA with SIMA (summarized in Table 2) have been published. 14) Some studies 17,18) had a very limited sample size (<100 patients). An Italian study randomized 850 patients to four different strategies.…”

Section: Clinical Evidencementioning

confidence: 99%

Is the Use of BIMA in CABG Sub-Optimal? A Review of the Current Clinical and Economic Evidence Including Innovative Approaches to the Management of Mediastinitis

Bayer

Hart²,

Arulampalam³

et al. 2020

ATCS

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worldwide 1,2) with annual volumes of approximately 160000 isolated cases in the US. 3) There is a significant inter-country variation with recent incidence rates ranging from 17 to 73 per 100000 inhabitants in western European countries. 4) The absolute number of CABG has fallen during the last decade due to an increase in percutaneous coronary intervention (PCI) procedures. For example, in Germany, between 2008 and 2018, isolated CABG surgery decreased from 47337 to 33999 cases (-28%). According to current international guidelines, in single-vessel disease, low-risk multi-vessel coronary artery disease or isolated left main disease PCI is generally preferred; on the other hand, CABG is usually recommended in patients with complex two-vessel disease, three-vessel disease, and/or non-isolated left main disease. 5) Bilateral internal mammary artery (BIMA) in coronary artery bypass grafting (CABG) has traditionally been limited. This review looks at the recent outcome data on BIMA in CABG focusing on the management of risk factors for mediastinitis, one of the potential barriers for more extensive BIMA utilization. A combination of pre-, intra-and postoperative strategies are essential to reduce mediastinitis. Limited data indicate that the incidence of mediastinitis can be reduced using closed incision negative-pressure wound therapy as a part of these strategies with the possibility of offering patients best treatment options by extending BIMA to those with a higher risk of mediastinitis. Recent economic data imply that the technology may challenge the current low uptake of BIMA by reducing the short-term cost differentials between single internal mammary artery and BIMA. Given that most published randomized controlled trials and meta-analyses of observational long-term outcome data favor BIMA, if short-term complications of BIMA including mediastinitis can be controlled adequately, there may be opportunities for more extensive use of BIMA leading to improved long-term outcomes. An ongoing study looking at BIMA in high-risk patients may provide evidence to support the hypothesis that mediastinitis should not be a factor in limiting the use of BIMA in CABG.

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All-artery multigraft coronary artery bypass grafting with only internal thoracic arteries possible and safe: A randomized trial

Cited by 33 publications

References 17 publications

A meta-analysis of adjusted hazard ratios from 20 observational studies of bilateral versus single internal thoracic artery coronary artery bypass grafting

A meta-analysis of adjusted hazard ratios from 20 observational studies of bilateral versus single internal thoracic artery coronary artery bypass grafting

Unmeasured Confounders in Observational Studies Comparing Bilateral Versus Single Internal Thoracic Artery for Coronary Artery Bypass Grafting: A Meta‐Analysis

Is the Use of BIMA in CABG Sub-Optimal? A Review of the Current Clinical and Economic Evidence Including Innovative Approaches to the Management of Mediastinitis

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