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Eur J Cardiothorac Surg 1999;16:499-505
© 1999 Elsevier Science NL

Total arterial coronary revascularization and factors influencing in-hospital mortality

Alistair G. Roysea, Colin F. Royseb, James Tatoulisa

a Department of Cardiothoracic Surgery, The Royal Melbourne Hospital, Parkville, Victoria, Australia
b Department of Anaesthesia, The Royal Melbourne Hospital, Parkville, Victoria, Australia

Corresponding author. Suite 3, Private Medical Centre, P.O. Box 2135, Royal Melbourne Hospital, Parkville, Victoria 3050, Australia. Tel.: +61-3-9342-8908; fax: +61-3-9342-8908
e-mail: alistair.royse{at}nwhcn.org.au


   Abstract
Top
 Abstract
1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 5. Conclusion
 Appendix A
 References
 
Objective: To determine if arterial conduit selection or more efficient arterial revascularization techniques influence in-hospital mortality. Methods: Data from patients undergoing coronary artery bypass surgery at Royal Melbourne Hospital, Australia, between 1 January 1996 and 30 June 1998 (n = 1681) was collected prospectively. Logistic regression analysis was performed. Results: Independent preoperative predictors of increased in-hospital mortality included renal failure, redo coronary artery surgery and intra-aortic balloon pump use. In-hospital mortality for total arterial revascularization 0.7%, radial artery use 0.9%, pedicled arterial revascularization 0.2%, composite arterial conduit 0.4%, and the exclusive Y graft operation 0.3%. These were all associated with reduced in-hospital mortality. Mortality when vein graft was used was 2.9%. Most patients received total arterial revascularization, which was considered the primary surgical strategy. Conclusion: Total arterial revascularization, radial artery use and complex arterial reconstructions were associated with reduced in-hospital mortality. Preoperative renal failure, intra-aortic balloon pump use and redo coronary surgery predicted greater in-hospital mortality.

Key Words: Radial artery • Total arterial • Pedicled arterial • Y graft • Composite arterial


   1. Introduction
Top
 Abstract
 1. Introduction
2. Materials and methods
 3. Results
 4. Discussion
 5. Conclusion
 Appendix A
 References
 
Numerous reports have documented the relatively high late failure rate of saphenous vein grafts in coronary bypass surgery [1–5] which can result in angina, infarction or death. Treatment of this failure carries a greater risk than primary surgery [6–9] or primary coronary angioplasty [10]. The pedicled left internal mammary artery to the left anterior descending artery has excellent late patency [11]. Use of bilateral internal mammary arteries results in two arterial grafts, but most patients still receive saphenous vein graft since most patients receive more than two grafts. The goal of total arterial revascularization can be achieved by using more arterial conduit and/or more efficient reconstruction techniques.

The radial artery provides additional arterial conduit with very low harvest related morbidity [12]. Even if both internal mammary arteries and both radial arteries are used, only four coronary anastomoses can be performed using conventional reconstruction methods. Other arteries such as the gastroepiploic or inferior epigastric may be considered, but usually saphenous vein is used.

More efficient use of arterial conduits can be achieved by sequential grafting (more than one coronary anastomosis per conduit) and composite Y graft techniques (point of conduit inflow being closer to the coronary anastomosis) (Fig. 1). The radial artery is of sufficient length to reach from the left internal mammary artery to all circumflex and right coronary artery branches in most patients [13].



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  		Fig. 1. Postoperative angiogram of conduits. LIMA, left internal mammary artery. Composite conduit involves joining of arteries together as a ‘Y’ graft. In-situ internal mammary arteries are not free grafts and are therefore called pedicled since they do not originate from the aorta. Other arterial conduit such as radial artery which are joined to the pedicled LIMA also do not originate from the aorta and therefore these composite arterial conduit are also referred to as pedicled arterial conduit. Where composite arterial conduit is used without any additional aorta-coronary conduit (i.e. exclusive reliance on this technique) then this is referred to as exclusive Y graft.

 
This study aims to report the results of coronary artery bypass surgery during a period of change from traditional aorta-coronary surgery with few arterial conduits to total arterial revascularization in the majority, with frequent reliance on operative techniques that make more efficient use of arterial conduit or which allow an entirely pedicled arterial conduit. The effect of this change on in-hospital mortality has been examined.


   2. Materials and methods
Top
 Abstract
 1. Introduction
 2. Materials and methods
3. Results
 4. Discussion
 5. Conclusion
 Appendix A
 References
 
Data were recorded prospectively on a database written by the authors and colleagues. In-hospital mortality was used as the outcome measure. Death within 30 days of surgery following discharge from hospital was not routinely documented at our institution.

2.1. Definitions of conduit selection and operative technique (Fig. 1)
Total arterial revascularization refers to coronary artery bypass surgery in which no venous conduit is used. Absence of total arterial revascularization was the presence of >=1 venous conduit irrespective of how many arterial conduits were also used for that patient. Radial artery is now harvested in most patients according to our technique [12] and is important in providing a greater supply and longer length of arterial conduit. Composite conduit (Y graft) results from arteries being joined together. Thus one of the arteries provides the blood inflow to the other artery. This technique improves the efficiency of use of arterial conduit since the distance between the point of inflow and outflow of the second conduit is less. Also when the radial artery is joined to the pedicled left internal mammary artery, then the radial artery is sufficiently long enough to reach the right coronary territory. Exclusive Y graft operation refers to exclusive reliance on this technique to revascularize all coronary arteries (for multivessel disease) and there are no supplementary aorta to coronary grafts [14]. Pedicled arterial conduit refers to all coronary grafts being arterial and not originating from the aorta. Thus most of these patients received the exclusive Y graft operation and the remaining patients received single or bilateral pedicled internal mammary artery grafts.

2.2. Hypotheses
Each hypothesis tested examined the presence/absence of the variable for the whole patient sample. Thus patients with total arterial revascularization were compared to those receiving >=1 venous conduit. The same applied to all of the other variables. By using the endpoint of in-hospital mortality, these hypotheses examine the safety of surgery under these conditions.

2.3. Subsets
Pedicled arterial and exclusive Y graft are both complete subsets of total arterial revascularization. Exclusive Y graft represents 76% of pedicled arterial; and 70% of composite conduits. Eighty percent of composite grafts were total arterial and 70% pedicled arterial. Thus arterial conduit and revascularization techniques are the basis upon which total arterial revascularization can be attained and are therefore not independent of total arterial revascularization.

2.4. Preoperative risk factors
Thirty preoperative factors were analysed (Appendix A). Definitions of the Society of Thoracic Surgeons were used [15].

2.5. Conduit and revascularization technique selection
Each of seven surgeons selected conduit and revascularization technique according to their own clinical judgement. No patient was subject to a clinical trial or protocol that limited choice of conduit or revascularization technique. This unit is Australia's second largest and is accredited for training in cardiothoracic surgery by the Royal Australasian College of Surgeons. Trainees would routinely perform part or all of these procedures as supervised by each surgeon not being subject to any protocol, limiting conduit or revascularization technique selection.

Radial artery use and the revascularization techniques analysed in this paper were introduced in the year prior to the study period. Individual surgeon use of these conduits or technique changed greatly during the study period (Table 1) based on the practice of those introducing the radial artery or revascularization techniques and their own experience over time. Radial artery use was very rapidly adopted and previously reported [12]. Thus all surgeons used this conduit widely. Total arterial revascularization rate for the unit was 78% by the end of the study period. Individual surgeons ranged from 43 to 99%. This varied use of conduit and revascularization techniques by different surgeons within a large unit and over time is likely to be a reasonably accurate reflection of surgical practice in other large institutions elsewhere. Preoperative, intraoperative and postoperative management was subject to the same unit protocols and not different between surgeons.


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  		Table 1. Change in practice from 1996 to 1998a

 
2.6. Statistical analysis
In order to identify which preoperative risk factors influenced in-hospital mortality, univariate and multivariate logistic regression analysis was performed using Systat V7.01 (SPSS Inc., Chicago, IL). Reference values within variables was taken as the ‘least’ or ‘best’ (i.e. New York Heart Association reference was ‘Grade I’, and surgical urgency reference was ‘elective’). The forward stepwise method of logistic regression analysis was used, with P=0.05 for entry into the model and P=0.10 for removal.

In order to test for bias with respect to preoperative risk factors, the presence or absence of significant risk factors (Tables 2 and 3) were tested against the types of arterial conduit selection or revascularization techniques (Table 1), using the Fisher exact test (SPSS V8.0, SPSS Inc., Chicago, IL).


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  		Table 2. Multivariate logistic regression of preoperative variablesa

 

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  		Table 3. Univariate logistic regression analyses of preoperative variablesa

 
The effects of conduit or revascularization technique selection on in-hospital mortality were tested by an exact test for the odds-ratio (OR=1), using StatXact V3.1 (Cytel Software Corporation, Cambridge, MA).

Where indicated (Tables 3, 4 and 6), the two-sided raw P value was adjusted for multiple hypothesis testing (P') according to the Ryan–Holm step-down Bonferroni procedure [16]. Two sided P or P'<=0.05 was considered significant. Continuous variables were expressed as mean±1 standard error.


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  		Table 4. Preoperative selection biasa

 

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  		Table 6. Analysis of conduit selection and operative reconstruction methoda

 

   3. Results
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
4. Discussion
 5. Conclusion
 Appendix A
 References
 
All patients undergoing coronary artery bypass surgery (n=1681) at the Royal Melbourne Hospital, Australia, between 1 January 1996 and 30 June 1998 were included. Concomitant procedures were performed in 161 (9.6%). Mean age was 65±11 years and 76% were male. The majority of patients were in Canadian cardiovascular score III and IV (55%) and New York Heart Association score III and IV (58%).

There were 25 deaths, resulting in an overall mortality rate of 1.5%. If a venous conduit was used (n=623) the mortality was 2.9%. After total arterial revascularization the 7 deaths were due to cardiac failure (n=3), multi-organ failure (n=2) and bleeding complications (n=2). When venous conduit was used, the 18 deaths were due to cardiac (n=12), respiratory (n=3), renal failure (n=1) and bleeding complications (n=2).

The use of radial artery, total arterial revascularization and composite grafting techniques increased greatly during this time. Table 1 compares use of these techniques and conduits in the first 6 months of 1996 and 1998. Radial artery was more widely accepted within the unit during 1996 and its use rose to 83% in 1998. The use of total arterial revascularization rose from 19% in the first half of 1996 to 78% in 1998. This was partly due to an increased use of complex arterial reconstructions, such as composite and sequential grafting methods.

3.1. Preoperative risk factors
Multivariate logistic regression analysis identified only renal failure, redo coronary surgery and preoperative use of intra-aortic balloon pump as independent predictors of increased in-hospital mortality (Table 2). Univariate logistic regression analysis was also performed on all the preoperative variables (Appendix A) and variables that attained a raw P<=0.05 are listed in Table 3. Adjustment of the raw P values according to the Ryan–Holm step-down Bonferroni procedure (P') resulted in the same three preoperative variables identified by the multivariate analysis being identified as significant predictors of mortality. This reinforces the importance of adjustment of P to correct for the testing of multiple hypotheses.

3.2. Preoperative selection bias
Patients were examined for evidence of preoperative selection bias according to conduit selection or revascularization technique (Table 4). Those preoperative variables found to be significant on multivariate logistic regression analysis (Table 2) were examined separately for each of the factors listed in Table 5.


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  		Table 5. Relationship between conduit and operative reconstructive method useda

 
After adjustment of multiple hypothesis testing, few differences were noted. Only intra-aortic balloon pump use was less common in the total arterial revascularization (P'=0.002) and pedicled arterial group (P'=0.014). There were no other significant differences detected (Table 4).

3.3. Relationship between conduit selection and revascularization technique
Table 5 details the relationship between these variables. For those receiving total arterial revascularization, radial artery was used in 87%. Radial artery was used in 98% of those receiving the exclusive Y graft operation, all of which achieved total arterial revascularization.

3.4. Effect of conduit selection and revascularization technique on in-hospital mortality
Total arterial revascularization was associated with reduced mortality (Table 6). Radial artery use was considered separately, since 27% of radial artery use was in patients without total arterial revascularization (Table 5). It also, was associated with reduced mortality. Composite revascularization was considered separately from pedicled arterial revascularization since it was neither entirely pedicled (70%), nor total arterial (80%) (Table 5). The entirely pedicled subgroup of composite revascularization, used for multivessel coronary revascularization, was considered separately by the exclusive Y graft operation. After adjustment for multiple hypotheses testing of the univariate analyses, all of these factors were associated with reduced in-hospital mortality (Table 6).


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
5. Conclusion
 Appendix A
 References
 
This prospectively acquired dataset from a single institution represents a moderately large experience over a 2.5-year period. Use of the radial artery was instrumental in achieving total arterial revascularization, and was used in 87% of these patients (Table 5). Both total arterial revascularization and radial artery were associated with reduced mortality (Table 6). The operative techniques of pedicled arterial, composite arterial and exclusive Y graft revascularization were all associated with reduced in-hospital mortality.

Our stimulus to achieve high levels of total arterial revascularization was to try to overcome the late failure rate of saphenous vein grafts [2,4,5]. Very rapid change in our practice occurred long before the late patency of radial arteries was known (Table 1). This was because of a clinical impression that total arterial revascularization was associated with reduced perioperative mortality, which is confirmed by this study. This transition in surgical practice was aided by the ease of radial artery harvest with very low morbidity [12]. Although composite arterial conduit has been used frequently in this series, early in the experience it was mostly used with supplementary aorta-coronary conduit. By the end of the experience, confidence in this technique had grown so that supplementary aorta-coronary grafts were rarely used (Table 1).

There appeared to be little evidence of preoperative selection bias (Table 4). Preoperative intra-aortic balloon pumps were used less often for those receiving total arterial and pedicled arterial revascularization but not for other groups. There was no other evidence of selection bias, but intra-aortic balloon pump was an independent predictor of mortality and this bias may influence mortality.

The greater availability of arterial conduit due to use of the radial artery made total arterial revascularization possible in the majority of patients, using conventional reconstructive techniques. However, in order to achieve near 100% total arterial revascularization, introduction of sequential and composite grafting techniques was necessary. Operative techniques referred to in this paper are not commonly used and are explained in Fig. 1. It is surprising that use of exclusive Y grafts was still associated with reduced mortality, since this group has smaller numbers and also excludes many patients with single or double coronary anastomoses, who might otherwise represent a better operative risk.

We interpret our findings by considering the attainment of total arterial revascularization as the principal surgical strategy. Thus conduit selection, and more efficient use of these conduits by the operative techniques, contribute in different ways toward this goal. It is not possible to state, however, which of these variables is more important. Whilst pedicled arterial revascularization has the lowest odds-ratio, there is some evidence of selection bias.

Only three preoperative factors were predictive of increased mortality (Table 2). Surprisingly, urgency of surgery was not an independent predictor. Improved perioperative management of surgical emergencies, as well as a reduced incidence of emergencies such as emergency transfer from the angiography laboratory, may partly explain this finding. This also highlights how strict observance of a definition may not accurately represent local practice. In our experience, patients may remain in hospital with unstable angina despite intravenous therapy for >24 h while waiting for operating room availability and are therefore classified as ‘elective’ according to the STS definitions [15]. These patients would be considered by us to be clinically urgent.

Our data considers in-hospital mortality and therefore the safety of performing surgery. It does not consider late outcome, which may vary due to differences in the late patency of arterial conduit compared to venous conduit or due to differences in the configuration of the conduit reconstruction. It is generally expected that initial experience with a new operative technique will result in an increased mortality and/or complication rate whilst the surgical team become familiar with the technique – the ‘learning curve’. Although this series includes many new techniques, there has been a reduction in mortality.


   5. Conclusion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 5. Conclusion
Appendix A
 References
 
Total arterial revascularization, use of radial artery, pedicled arterial, composite arterial and exclusive Y graft revascularization are all associated with reduced in-hospital mortality. Renal failure, redo coronary artery surgery and preoperative use of the intra-aortic balloon pump predicted increased in-hospital mortality.


   Acknowledgments
 
The authors wish to acknowledge Dr. John Ludbrook (Biomedical Statistical Consulting Pty Ltd.) for his statistical analysis and manuscript review. We thank Mrs Karen Groves for data collation, Dr Paul Soeding for manuscript review and members of the cardiothoracic surgery unit, Royal Melbourne Hospital. Grant assistance from the Royal Australasian College of Surgeons and the Lew Carty Foundation is gratefully acknowledged.


   Appendix A
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 5. Conclusion
 Appendix A
References
 


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  		Preoperative variables tested, grade within variables and STS definition document page reference [15] a

 

   References
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 5. Conclusion
 Appendix A
 References
 
  1. Zeff R., Kongtahworn C., Iannone L., Gordon D., Brown T., Phillips S., Skinner J., Spector M. Internal mammary artery versus saphenous vein graft to the left anterior descending coronary artery: prospective randomized study with 10-year follow-up. Ann Thorac Surg 1988;45:533-536.[Abstract]
  2. Grondin C., Campeau L., Lesperance J., Enjalbert M., Bourassa M. Comparison of late changes in internal mammary artery and saphenous vein grafts in two consecutive series of patients 10 years after operation. Circulation 1984;70:1208-1212.
  3. Cooper G., Underwood M., Deverall P. Arterial and venous conduits for coronary artery bypass. A current review. Eur J Cardio-thorac Surg 1996;10:129-140.[Abstract]
  4. Mills N., Everson C. Vein graft failure. Curr Opin Cardiol 1995;10:562-568.[Medline]
  5. Campeau L., Enjalbert M., Lesperance J., Vaislic C., Grondin C., Bourassa M. Atherosclerosis and late closure of aortocoronary saphenous vein grafts: sequential angiographic studies at 2 weeks. 1 year, 5 to 7 years, and 10 to 12 years after surgery. Circulation 1983;68:II1-II7.
  6. Christenson J., Schmuziger M., Simonet F. Reoperative coronary artery bypass procedures: risk factors for early mortality and late survival. Eur J Cardio-thorac Surg 1997;11:129-133.[Abstract]
  7. Craver J., Hodakowski G., Shen Y., Weintraub W., Accola K., Guyton R., Jones E. Third-time coronary artery bypass operations: surgical strategy and results. Ann Thorac Surg 1996;62:1801-1807.[Abstract/Free Full Text]
  8. New York state coronary artery bypass surgery 1994–1996 http://www.health.state.ny.us/nysdoh/consumer/heart/cabg96.pdf. 1998.
  9. STS National cardiac surgery database mortality by status 1996 http://www.sts.org/image/5464. 1998.
  10. New York state angioplasty report 1995 http://www.health.state.ny.us/nysdoh/reports/angio95.htm. 1996.
  11. Barner H., Barnett M. Fifteen- to twenty-one-year angiographic assessment of internal thoracic artery as a bypass conduit. Ann Thorac Surg 1994;57:1526-1528.[Abstract]
  12. Royse A., Royse C., Shah P., Williams A., Kaushik S., Tatoulis J. Radial artery harvest technique, use and functional outcome. Eur J Cardio-thorac Surg 1999;15:186-193.[Abstract/Free Full Text]
  13. Royse A Complete arterial grafting using a left ITA and a single radial artery Y graft. In: Buxton B., Westaby S., Frazier O., eds. Ischemic heart disease: surgical management. London: Mosby, 1998:219-221.
  14. Royse A., Royse C., Raman J. Exclusive Y graft operation for multivessel coronary revascularization. Ann Thorac Surg 1999;68:1613-1619.
  15. Society of Thoracic Surgeons data definitions http://www.sts.org/outcomes/sts/defsbook.pdf.
  16. Ludbrook J. Multiple comparison procedures updated. Clin Exp Pharmacol Physiol 1998;25:1032-1037.[Medline]
Received June 28, 1999; received in revised form August 23, 1999; accepted September 1, 1999.




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