title: Total arterial revascularization with internal thoracic and radial artery grafts in triple-vessel coronary artery disease is associated with improved survival.
abstract: OBJECTIVE
  We sought to evaluate our experience with total arterial revascularization and compare it with the traditional approach of a single internal thoracic artery supplemented by saphenous veins.
  
  
  METHODS
  From 1995 to 2010, 6059 patients with triple-vessel coronary artery disease underwent primary isolated coronary artery bypass grafting at 8 centers. A study cohort of 3774 patients was formed, with 2988 (79%) undergoing total arterial revascularization and 786 (21%) receiving only saphenous veins to supplement a single in situ internal thoracic artery. In the total arterial revascularization group, bilateral internal thoracic arteries were used in 1079 patients (36%) and at least 1 radial artery was used in 2916 patients (97%). Propensity score matching was used for risk adjustment.
  
  
  RESULTS
  Patients undergoing total arterial revascularization were younger (65.0±10.4 years vs 71.3±7.9 years, P<.001) and less likely to have diabetes, cerebrovascular disease, recent myocardial infarction, and severe left ventricular impairment. At 15 years, patients who underwent total arterial revascularization experienced superior unadjusted survival (62%±1.1% vs 35%±1.9%, P<.001). Multivariable Cox regression in the entire study cohort showed the total arterial group had improved survival with a hazard ratio of 0.79 (95% confidence interval, 0.70-0.90; P<.001). After propensity score matching yielded 384 patient pairs, patients who underwent total arterial revascularization showed improved survival at 15 years than patients who underwent single arterial revascularization (54%±3.3% vs 41%±3.0%, P=.0004).
  
  
  CONCLUSIONS
  This large multicenter study suggests that a strategy of total arterial revascularization is associated with improved long-term survival compared with the use of only a single arterial and saphenous vein grafts. Total arterial revascularization should be encouraged in patients with a reasonable life expectancy.
authors.affiliation: Victorian Heart Centre, Epworth Hospital, University of Melbourne, Melbourne, Australia; Department of Cardiac Surgery, Austin Hospital, University of Melbourne, Melbourne, Australia. Electronic address: brianbuxton40@gmail.com.
authors.forename: Brian F
authors.initials: BF
authors.lastname: Buxton
authors.affiliation: Department of Cardiac Surgery, Austin Hospital, University of Melbourne, Melbourne, Australia.
authors.forename: William Y
authors.initials: WY
authors.lastname: Shi
authors.affiliation: Victorian Heart Centre, Epworth Hospital, University of Melbourne, Melbourne, Australia; Department of Cardiothoracic Surgery, Royal Melbourne Hospital, Melbourne, Australia.
authors.forename: James
authors.initials: J
authors.lastname: Tatoulis
authors.affiliation: Victorian Heart Centre, Epworth Hospital, University of Melbourne, Melbourne, Australia.
authors.forename: John A
authors.initials: JA
authors.lastname: Fuller
authors.affiliation: Victorian Heart Centre, Epworth Hospital, University of Melbourne, Melbourne, Australia; Department of Cardiac Surgery, Austin Hospital, University of Melbourne, Melbourne, Australia.
authors.forename: Alexander
authors.initials: A
authors.lastname: Rosalion
authors.affiliation: Victorian Heart Centre, Epworth Hospital, University of Melbourne, Melbourne, Australia; Department of Cardiac Surgery, Austin Hospital, University of Melbourne, Melbourne, Australia.
authors.forename: Philip A
authors.initials: PA
authors.lastname: Hayward
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001315:Australia / Q000453:epidemiology; D001026:Coronary Artery Bypass; D003324:Coronary Artery Disease / Q000401:mortality / Q000601:surgery*; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007387:Internal Mammary-Coronary Artery Anastomosis / Q000379:methods* / Q000401:mortality; D008297:Male; D008323:Mammary Arteries / Q000637:transplantation*; D008875:Middle Aged; D009204:Myocardial Revascularization / Q000379:methods* / Q000401:mortality; D057216:Propensity Score; D017534:Radial Artery / Q000637:transplantation*; D012307:Risk Factors; D056346:Sternotomy