title: The impact of sequential grafting on clinical outcomes following coronary artery bypass grafting.
abstract: OBJECTIVE
  Sequential anastomoses in coronary artery bypass grafting (CABG) offer theoretical advantages including increased graft flow and more complete revascularisation. However, published studies concerning the safety and efficacy of this technique are not definitive. The objective of this study was to assess the effect of sequential anastomoses on outcomes following CABG.
  
  
  METHODS
  Perioperative data were prospectively collected on all patients with triple-vessel disease who underwent first-time, isolated, on-pump CABG between 1995 and 2005 at a single centre. Patients with a left internal mammary artery graft to the anterior wall and saphenous vein grafts to the lateral and posterior walls were included.
  
  
  RESULTS
  Compared to patients without sequential anastomoses (n=1108), patients with sequential anastomoses (n=1246) were more likely to have an ejection fraction (EF)<40% (14.9% vs 10.8%, p=0.004), a recent myocardial infarction (19.3% vs 14.3%, p=0.001) and an urgent/emergent operative status (19.6% vs 14.4%, p=0.0008). Median follow-up was 78 months. After adjusting for clinical covariates, sequential grafting was not an independent predictor of in-hospital adverse events (odds ratio (OR) 1.15, 95% confidence interval (CI) 0.88-1.50, p=0.31) or long-term mortality and/or readmission to hospital (hazard ratio (HR) 0.98, 95% CI 0.86-1.12, p=0.74). Sequential grafting was an independent predictor of receiving greater than three distal anastomoses (OR 9.26, 95% CI; 6.27-13.67, p<0.0001).
  
  
  CONCLUSIONS
  Patients undergoing sequential grafting presented with greater acuity and worse systolic function. After adjusting for baseline differences, sequential grafting was not found to be an independent predictor of adverse events. These results support the safety of sequential anastomoses in patients undergoing CABG.
authors.affiliation: The Division of Cardiac Surgery, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.
authors.forename: Maral
authors.initials: M
authors.lastname: Ouzounian
authors.forename: Ansar
authors.initials: A
authors.lastname: Hassan
authors.forename: Alexandra M
authors.initials: AM
authors.lastname: Yip
authors.forename: Karen J
authors.initials: KJ
authors.lastname: Buth
authors.forename: Roger J F
authors.initials: RJ
authors.lastname: Baskett
authors.forename: Imtiaz S
authors.initials: IS
authors.lastname: Ali
authors.forename: Gregory M
authors.initials: GM
authors.lastname: Hirsch
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000714:Anastomosis, Surgical / Q000009:adverse effects / Q000379:methods; D001026:Coronary Artery Bypass / Q000009:adverse effects / Q000379:methods*; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging / Q000601:surgery*; D004812:Epidemiologic Methods; D005260:Female; D006801:Humans; D007387:Internal Mammary-Coronary Artery Anastomosis / Q000009:adverse effects / Q000379:methods; D008297:Male; D008875:Middle Aged; D011859:Radiography; D016896:Treatment Outcome