CLINICAL STUDY: BYPASS SURGERY
What constitutes optimal surgical revascularization?
Answers from the bypass angioplasty revascularization investigation (BARI)
Thomas J. Vander Salm, MD, FACC*,*,
Kevin E. Kip, PhD ,
Robert H. Jones, MD, FACC ,
Hartzell V. Schaff, MD, FACC ,
Richard J. Shemin, MD, FACC||,
Gabriel S. Aldea, MD, FACC¶ and
Katherine M. Detre, MD, DrPH, FACC
* Division of Thoracic and Cardiac Surgery, University of Massachusetts Medical School, Worcester, Massachusetts, USA
Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
Duke University Medical Center, Durham, North Carolina, USA
Mayo Clinic, Rochester, Minnesota, USA
|| Division of Cardiothoracic Surgery, Boston University Medical Center, Boston, Massachusetts, USA
¶ Division of Cardiothoracic Surgery, University of Washington, Seattle, Washington, USA
Manuscript received July 17, 2001;
revised manuscript received November 7, 2001,
accepted November 28, 2001.
* Reprint requests and correspondence: Dr. Thomas J. Vander Salm, Division of Cardiothoracic Surgery, University of Massachusetts Medical School, 55 Lake Avenue, North, Worcester, Massachusetts 01655-3304, USA.
vanderst{at}ummhc.org
OBJECTIVES: The study was done to derive the optimum definition of complete revascularization in coronary artery bypass surgery.
BACKGROUND: "Complete revascularization" has been considered the goal of coronary artery bypass operations, but various definitions of completeness exist.
METHODS: We evaluated the Bypass Angioplasty Revascularization Investigation (BARI) surgical results in the seven years after operation. Different definitions of completeness of revascularization were retrospectively applied to the 1,507 patients in the combined randomized/registry group to derive the definition of complete operative revascularization with the best discrimination in long-term results between those with and without complete revascularization as defined. Four definitions were evaluated: 1) traditional complete revascularization with one graft to each major diseased artery system; 2) functional complete revascularization with one graft to all diseased major or primary segmental vessels; 3) number of distal anastomoses greater than, equal to or less than the number of diseased coronary segments; and 4) number of distal anastomoses to the major coronary systems equal to 1 or greater than 1.
RESULTS: No independent survival advantage existed for traditional or functional complete revascularization as compared with incomplete revascularization. No survival advantage existed for any of the three arms of definition 3. For definition 4, seven-year death/myocardial infarction was highest (32.9%) when more than one anastomosis was constructed to any non-left anterior descending coronary artery (LAD) system (relative risk 1.37, p = 0.03). No increased risk was associated with constructing more than one anastomosis into the LAD system.
CONCLUSIONS: The construction of more than one graft to any system other than the LAD appears to confer no long-term advantage, and may actually be deleterious.
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Abbreviations and Acronyms
| | CABG | | BARI | | Bypass Angioplasty Revascularization Investigation | | CABG | | coronary artery bypass graft | | CASS | | Coronary Artery Surgery Study | | CHF | | congestive heart failure | | ECG | | electrocardiogram | | IMA | | internal mammary artery | | LAD | | left anterior descending coronary artery | | LCx | | left circumflex coronary artery | | MI | | myocardial infarction | | PTCA | | percutaneous transluminal coronary angioplasty | | Ramus | | ramus intermedius artery | | RCA | | right coronary artery | | RR | | relative risk |
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