Total Arterial Revascularization for Coronary Artery

JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY

VOL. 72, NO. 12, 2018

ª 2018 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION PUBLISHED BY ELSEVIER

EDITORIAL COMMENT

Total Arterial Revascularization for Coronary Artery Bypass A Gold Standard Searching for Evidence and Application* Anelechi C. Anyanwu, MD, David H. Adams, MD

I

n this issue of the Journal, Royse et al. (1) report

IF LONGEVITY IS PART OF SELECTION

long-term survival in patients who had coronary

CRITERIA, LONG-TERM SURVIVAL WILL BE BETTER

artery bypass graft surgery (CABG) with total

arterial revascularization, noting superior survival after 7 years compared with CABG with single inter-

Surgeons will typically only perform multiple arterial

nal thoracic artery (ITA) and vein grafts. Lytle et al.

grafts if patients are expected to enjoy long survival

(2)

after CABG. Propensity matching cannot adjust for

had

demonstrated

similar

excellent

arterial

this, as the critical clinical judgment that surgeons

SEE PAGE 1332

often use in decision making (“the eye ball test”) is

conduit outcomes 2 decades ago with bilateral ITA

not considered. For example, a 45-year-old unem-

grafts, concluding that “it has been the position of

ployed male who is an alcoholic, homeless, and a

some coronary artery surgeons that the consider-

heavy smoker would most probably have 1 ITA and

ation of multiple arterial grafting could be ignored

vein grafts. Such a patient has a high probability of

because no clear evidence existed that outcomes

experiencing major adverse events, but propensity

were improved for any patient subsets. That position

matching would pair him with a 45-year-old banking

is no longer tenable.” In the United States, however,

executive receiving 4 arterial grafts, and count dif-

multiarterial CABG is still largely ignored, with only

ferential adverse events as being associated with the

grafts,

treatment (vein grafting); in reality, negative out-

and