Radial Artery Versus Right Internal Thoracic Artery Versus Saphenous Vein as the Second Conduit for Coronary Artery Bypass Surgery: A Network Meta‐Analysis of Clinical Outcomes

Abstract

Background There remains uncertainty regarding the second‐best conduit after the internal thoracic artery in coronary artery bypass grafting. Few studies directly compared the clinical results of the radial artery ( RA ), right internal thoracic artery ( RITA ), and saphenous vein ( SV ). No network meta‐analysis has compared these 3 strategies. Methods and Results MEDLINE and EMBASE were searched for adjusted observational studies and randomized controlled trials comparing the RA , SV , and/or RITA as the second conduit for coronary artery bypass grafting. The primary end point was all‐cause long‐term mortality. Secondary end points were operative mortality, perioperative stroke, perioperative myocardial infarction, and deep sternal wound infection ( DSWI ). Pairwise and network meta‐analyses were performed. A total of 149 902 patients (4 randomized, 31 observational studies) were included ( RA , 16 201, SV , 112 018, RITA, 21 683). At NMA , the use of SV was associated with higher long‐term mortality compared with the RA (incidence rate ratio, 1.23; 95% CI , 1.12–1.34) and RITA (incidence rate ratio, 1.26; 95% CI , 1.17–1.35). The risk of DSWI for SV was similar to RA but lower than RITA (odds ratio, 0.71; 95% CI , 0.55–0.91). There were no differences for any outcome between RITA and RA , although DSWI trended higher with RITA (odds ratio, 1.39; 95% CI , 0.92–2.1). The risk of DSWI in bilateral internal thoracic artery studies was higher when the skeletonization technique was not used. Conclusions The use of the RA or the RITA is associated with a similar and statistically significant long‐term clinical benefit compared with the SV . There are no differences in operative risk or complications between the 2 arterial conduits, but DSWI remains a concern with bilateral ITA when skeletonization is not used.

Twenty-Five Years of No-Touch Saphenous Vein Harvesting for Coronary Artery Bypass Grafting: Structural Observations and Impact on Graft Performance

“…In addition, much of the vein's outermost layer, the adventitia, is also removed or damaged. In C artery (RA) [8][9][10] . Apart from the structural differences between arteries and veins, it is noteworthy that, in general, LITA and RA are harvested in such a way that the pedicle of the surrounding tissue remains intact.…”

Why and how to achieve total arterial revascularisation in coronary surgery

“…The theoretical framework is that, if one arterial graft is better than SVG, then two or even three arterial grafts should have incrementally greater survival, and this contention is supported by multiple publications [38][39][40] . In our own national database analysis, we conducted a series of large-scale propensity score matches using 17 variables.…”

“…Reproduced with permission, JACC 2018 [37] . LIMA-RA-Y: left internal mammary artery radial artery Y graft; TAR: total arterial revascularisation survival outcomes compared to SVG [37,40,[42][43][44] . Therefore, the study design of one versus two IMA, rather than one versus two arterial grafts was confounded by RA being used.…”

“…The relationship between graft failure and reduced survival has a plausible mechanism and therefore it is suggested that the conduit of most interest is the SVG rather than the arterial conduits [37,38,40,45,46] . It would be logical, therefore, that the number of SVG grafts has greater effect on survival than the number of arterial grafts.…”

Differential myocardial strain in the early postoperative period in patients receiving arterial vs venous bypass grafts: A hypothesis‐generating study

“…CABG‐based revascularization is most commonly performed via either single arterial graft (SAG) or multiple arterial grafting (MAG) strategies. Whereas arterial grafts (AGs) have better long‐term patency than do saphenous vein grafts (SVGs), recent data indicate that patients receiving MAGs experience higher perioperative risk 8,9 . One explanation is that due to their smaller lumen and higher resistance, AGs provide lower flow in the immediate postoperative period, resulting in delayed improvement in LV perfusion and function.…”