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Letters to the Editor |
"Dedinje" Cardiovascular Institute, Belgrade, Serbia
Received 22 April 2009; accepted 20 May 2009.
* Corresponding author. Address: Department of Cardiac Surgery I, Dedinje Cardiovascular Institute, Milana Tepi
a 1, 11000 Belgrade, Serbia. Tel.: +381 11 3601631/3601724; fax: +381 11 2666392. (Email: nezic{at}EUnet.rs; nezic{at}ikvbd.com).
Key Words: Angiographic graft patency • String sign
We read with great interest the manuscript by Buxton and colleagues [1] that has recently been published. In addition to an excellent review of the role and the fate of currently used conduits for coronary artery bypass grafting, the authors have pointed out the question of radial artery (RA) patency that have been presented so far in prospective, randomised trials (PRTs). We strongly support their observation that the radial artery patency study (RAPS) did not confirm better angiographic RA graft patency compared with saphenous vein (SV) graft patency. The basic results from the RAPS study have been reported few years ago by Desai and associates [2]. Although that study has demonstrated significantly better angiographic patency of RA conduits compared to SV grafts (occlusion rate of 8.2% for RA conduit vs 13.6% for SV conduits), the existence of ‘string sign’ were assigned to 7% of RA grafts and only to 0.9% of SV grafts. Subsequent analysis of those data [3] showed that 48.4% (15 out of 31) of the RA conduits with string sign presented with the Thrombolysis in Myocardial Infarction Study (TIMI) 1 flow. Significantly higher rate of postoperative angina has been registered in patients whose RA conduits were found to have string sign and TIMI 1 flow [3]. In our opinion, if we are discussing study grafts failure/occlusion, RA grafts with angiographic string sign should be included in the category of failed conduits (at least those with TIMI 1 flow, as TIMI 1 flow has been defined as some penetration of contrast material beyond the point of obstruction but without perfusion of the distal coronary bed [4]).
When we compare a total of 11.6% (51/440) of RA conduits that have failed (36 occluded, plus, at least, those 15 with string sign and TIMI flow 1) vs total of 14.1% (62/440) of SV conduits that have failed [(60 grafts occluded, plus 2 with TIMI 1 flow (but without string sign)], p-value is not significant any more (p = 0.38). Although the statistical significance of the difference in angiographic patency rate between compared conduits has gone, this has led us to conclude that the final result of the basic study by Desai and associates [2] did not confirm significantly better angiographic patency for RA conduits compared with SV grafts patency at 1 year after surgery. Collins and co-authors [5] have recently presented the third PRT, which compared angiographic RA conduit patency vs SV conduit patency. They reported an excellent 5-year angiographic patency rate of RA graft – 98.3% (58 out of 59 re-assessed conduits) that has reached significant difference (p = 0.04) compared with 86.4% patency rate of SV graft (38 out of 44 reassessed conduits). However, when we include one RA graft that was reported to have a string sign, the statistical significance (p = 0.16) of the difference in angiographic patency between compared conduits has gone (although there is still an absolute difference of 10% in angiographic patency – 57 out of 59 or 96.6% for RA conduit vs 86.4% for SV conduit).
References
This article has been cited by other articles:
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  B. F. Buxton and P. A.R. Hayward Reply to Nezic et al. Interpretation of string sign in radial artery patency bypass grafts Eur. J. Cardiothorac. Surg., September 1, 2009; 36(3): 606 - 607. [Full Text] [PDF]
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