Comparison of Long-term Clinical Outcomes of Skeletonized vs Pedicled Internal Thoracic Artery Harvesting Techniques in the Arterial Revascularization Trial.

Publisher: American Medical Association Country of Publication: United States NLM ID: 101676033 Publication Model: Print Cited Medium: Internet ISSN: 2380-6591 (Electronic) NLM ISO Abbreviation: JAMA Cardiol Subsets: MEDLINE

Original Publication: [Chicago, Illinois] : American Medical Association, [2016]-

Forecasting*; Mammary Arteries/*transplantation ; Myocardial Ischemia/*surgery ; Myocardial Revascularization/*methods ; Tissue and Organ Harvesting/*methods; Aged ; Coronary Artery Bypass/methods ; Female ; Follow-Up Studies ; Humans ; Male ; Middle Aged ; Myocardial Ischemia/mortality ; Survival Rate/trends ; Treatment Outcome ; United Kingdom/epidemiology

Importance: Recent evidence has suggested that skeletonization of the internal thoracic artery (ITA) is associated with worse clinical outcomes in patients undergoing coronary artery bypass surgery (CABG).
Objective: To compare the long-term clinical outcomes of skeletonized and pedicled ITA for CABG.
Design, Setting, and Participants: The Arterial Revascularization Trial (ART) was a 2-group, multicenter trial comparing the use of a bilateral ITA vs a single ITA for CABG at 10 years. Patients in the ART trial were stratified by ITA harvesting technique: skeletonized vs pedicled. Data were collected from June 2004 to December 2017, and data were analyzed from June to July 2021.
Interventions: In this analysis, the 10-year clinical outcomes were compared between patients who received skeletonized vs pedicled ITAs.
Main Outcomes and Measures: The primary outcome was all-cause mortality. The secondary outcomes were a composite of major adverse cardiac events (MACE) including all-cause mortality, myocardial infarction, and repeated revascularization and a composite including MACE and sternal wound complication (SWC). Cox regression and propensity score matching were used.
Results: Of 2161 included patients, 295 (13.7%) were female, and the median (interquartile range) age was 65.0 (58.0-70.0) years. At 10 years, the risk of all-cause mortality was not significantly different between the pedicled and skeletonized groups (hazard ratio [HR], 1.12; 95% CI, 0.92-1.36; P = .27). However, the long-term risks of the secondary outcomes were significantly higher in the skeletonized group compared with the pedicled group (MACE: HR, 1.25; 95% CI, 1.06-1.47; P = .01; MACE and SWC: HR, 1.22; 95% CI, 1.05-1.43; P = .01). The difference was not seen when considering only patients operated on by surgeons who enrolled 51 patients or more in the trial (MACE: HR, 1.07; 95% CI, 0.82-1.39; P = .62; MACE and SWC: HR, 1.04; 95% CI, 0.80-1.34; P = .78).
Conclusions and Relevance: While the long-term survival of patients was not different between groups, the rate of adverse cardiovascular events was consistently higher in the skeletonized group and the difference was associated with surgeon-related factors. Further evidence on the outcome of skeletonized ITA is needed.

Comment in: JAMA Cardiol. 2021 Dec 1;6(12):1362-1363. (PMID: 34586360)

G0200390 United Kingdom MRC_ Medical Research Council; R01 HL152021 United States HL NHLBI NIH HHS

Investigator: D Taggart; S Wos; M Jasinski; M Deja; V Zamvar; B Buxton; S Seevanayagam; P O'Keefe; TLA Forsyth; U Trivedi; S Clark; A Bochenek; R Hasan; J Desai; A Ritchie; C Choong; S Nair; C Sudarshan; A Cale; T Spyt; TLA Gershlick; J Gaer; J Sadowksi; B Kapelak; J Pacholewicz; F Moraes; J Pepper; V Chandrasekaran; R Pawlaczyk; G Mannam; L Rao Sajja; N Briffa; R Casabona; G Actis Dato; W Dihmis; M Kuduvali; L Anisimowicz; B Podesser; N Trehan; ZS Meharwal; M Zembala; K Widenka

Date Created: 20210929 Date Completed: 20220112 Latest Revision: 20220930

20231215

PMC8482293

10.1001/jamacardio.2021.3866

34586338