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Does radial use as a second arterial conduit for coronary artery bypass grafting improve long-term outcomes in diabetics?

^a Division of Cardiothoracic Surgery, The Regional Heart and Vascular Center at St. Vincent Mercy Medical Center, Toledo, OH, USA
^b Department of Surgery, University of Toledo – College of Medicine, Toledo, OH, USA

Received 6 September 2007; received in revised form 16 January 2008; accepted 24 January 2008.

^_* Corresponding author. Address: Cardiovascular and Pulmonary Research, Yvonne Viens, SGM, Research Institute, St. Vincent Mercy Medical Center, 2222 Cherry Street, MOB2, Suite 1250, Toledo, OH, 43608, USA. Tel.: +1 419 251 4998; fax: +1 419 251 0320. (Email: Robert_Habib{at}mhsnr.org).

Objectives: The evidence supporting the survival benefit of multiple arterial grafts in the general coronary bypass surgery (CABG) population is compelling. Alternatively, results of studies comparing 2 versus 1 internal thoracic artery (ITA) grafts in diabetics have reported conflicting survival data. The use of radial versus ITA as the second arterial conduit has not been studied. Methods: We obtained complete death follow-up in 1516 consecutive diabetic [64 ± 10 years (mean ± SD). Insulin/no insulin: There were 540 (36%)/976 (64%)] primary isolated CABG patients all with 1 ITA grafts. The series included 626 ITA/radial (41%) and 890 ITA/vein (59%) patients. Using separate radial-use propensity models, we matched one-to-one 475 (76%) ITA/radial to 475 (53%) unique ITA/vein patients; each including 166 insulin and 309 no insulin patients. Results: Unadjusted survival was markedly better for (1) ITA/radial (94.3%, 86.7% and 70.4% at 1, 5 and 10 years, respectively) versus ITA/vein (91.8%, 74.5% and 53.8%; p < 0.0001) and (2) for no insulin (94.2%, 82.8% and 65.5%) versus insulin (90.4%, 73.1% and 49.2%; p < 0.0001). In matched patients, 11-year Kaplan–Meier analysis showed essentially identical ITA/radial and ITA/vein survival for all diabetics combined (p = 0.53; log rank) and for the no insulin (p = 0.76) cohort. Lastly, a trend for better ITA/radial survival in insulin dependent diabetics after the second postoperative year did not reach significance (p = 0.13). Conclusions: Using radial as a second arterial conduit as opposed to vein grafting did not confer a survival benefit in diabetics. This unexpected result is perhaps related to relatively diminished radial graft patency and/or the augmented radial vasoreactivity characteristic of diabetics. These findings indicate that the radial survival advantage demonstrated in the general CABG population lies primarily in non-diabetics in whom this advantage may be underestimated.

Key Words: Coronary artery disease • Arterial grafting • Diabetes mellitus • Insulin • Kaplan–Meier survival • Outcomes

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