title: Survival benefit of multiple arterial grafting in a 25-year single-institutional experience: the importance of the third arterial graft.
abstract: OBJECTIVE
  The long-term advantages of multiple arterial grafts, particularly a third arterial conduit, for coronary artery bypass (CABG) are not clear. This study was designed to test whether multiple arterial grafts would provide better long-term outcomes when compared with approaches using fewer arterial conduits.
  
  
  METHODS
  Between 1985 and 1995, prospective data were collected for 588 patients undergoing isolated CABG at our institution. We examined long-term survival and freedom from cardiac death. The primary analysis compared patients receiving bilateral internal thoracic artery (BITA) vs. single ITA (SITA). In a subgroup analysis, BITA patients receiving a right gastroepiploic artery (RGEA) were compared with those receiving a saphenous vein graft (SVG) as a third conduit. Cox proportional hazard modelling was used to adjust for relevant confounders. The Kaplan-Meier method was used to create survival curves over the follow-up period.
  
  
  RESULTS
  The mean age was 59 ± 9 years and 49% received BITA. Mean follow-up was 16.1 ± 5.4 years. Multivariable analysis revealed that overall survival [hazard ratio (HR): 0.74, P = 0.017] and cardiac survival (HR: 0.61, P = 0.004) was significantly improved in the presence of BITA compared with SITA. The survival at 10 and 20 years was 90.2 ± 3.4 and 56.9 ± 6.4% for the BITA vs. 82 ± 4.4 and 40.9 ± 6% for the SITA, respectively. In the subgroup of BITA patients, those receiving the RGEA as a third conduit had superior overall survival (HR: 0.41, P = 0.0032) and cardiac survival (HR: 0.18, P = 0.004) compared with those receiving an SVG. The survival at 10 and 20 years was 98.9 ± 2 and 68.9 ± 18% for the BITA/RGEA vs. 87.2 ± 4.6 and 50.3 ± 7% for the BITA/SVG, respectively.
  
  
  CONCLUSIONS
  In a single-institution experience, the use of multiple arterial grafting is independently associated with superior outcomes. Furthermore, the use of a third arterial conduit (RGEA) targeted to the right coronary artery should be considered to improve long-term survival.
authors.affiliation: Department of Cardiovascular Medicine and Surgery, Cliniques Universitaire St Luc, Université Catholique de Louvain, Brussels, Belgium. david.glineur@uclouvain.be
authors.forename: David
authors.initials: D
authors.lastname: Glineur
authors.forename: William
authors.initials: W
authors.lastname: D'hoore
authors.forename: Joel
authors.initials: J
authors.lastname: Price
authors.forename: Sarah
authors.initials: S
authors.lastname: Dorméus
authors.forename: Laurent
authors.initials: L
authors.lastname: de Kerchove
authors.forename: Robert
authors.initials: R
authors.lastname: Dion
authors.forename: Philippe
authors.initials: P
authors.lastname: Noirhomme
authors.forename: Gebrine
authors.initials: G
authors.lastname: El Khoury
mesh_terms: D019917:Blood Vessel Prosthesis Implantation / Q000379:methods* / Q000401:mortality; D001026:Coronary Artery Bypass / Q000379:methods* / Q000401:mortality; D023921:Coronary Stenosis / Q000150:complications / Q000401:mortality / Q000601:surgery*; D004812:Epidemiologic Methods; D005260:Female; D024405:Gastroepiploic Artery / Q000637:transplantation*; D006801:Humans; D008297:Male; D008323:Mammary Arteries / Q000637:transplantation*; D008875:Middle Aged; D016491:Peripheral Vascular Diseases / Q000150:complications / Q000401:mortality; D012501:Saphenous Vein / Q000637:transplantation*; D018487:Ventricular Dysfunction, Left / Q000150:complications / Q000401:mortality