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Association of Radial Artery Graft vs Saphenous Vein Graft With Long-term Cardiovascular Outcomes Among Patients Undergoing Coronary Artery Bypass GraftingA Systematic Review and Meta-analysis

Educational Objective
To understand differences in clinical outcomes associated with surgical techniques for coronary artery bypass grafting.
1 Credit CME
Key Points

Question  Is the use of the radial artery instead of the saphenous vein for coronary artery bypass surgery associated with a lower risk of adverse cardiac events in the long term?

Findings  In this individual participant data meta-analysis from 5 randomized clinical trials that included 1036 patients undergoing coronary artery bypass grafting, randomization to receive radial artery compared with saphenous vein graft was associated with an incidence of a composite of death, myocardial infarction, or repeat revascularization of 41 vs 47 events per 1000 person-years after a median follow-up of 10 years, a difference that was statistically significant.

Meaning  Over 10 years of follow-up, radial artery graft compared with saphenous vein graft was associated with a lower risk of a composite of cardiovascular outcomes.

Abstract

Importance  Observational studies have suggested that the use of radial artery grafts for coronary artery bypass grafting may improve clinical outcomes compared with the use of saphenous vein grafts, but this has not been confirmed in randomized trials.

Objective  To compare clinical outcomes between patients receiving radial artery vs saphenous vein grafts for coronary artery bypass grafting after long-term follow-up.

Design, Setting, and Participants  Patient-level pooled analysis comparing radial artery vs saphenous vein graft in adult patients undergoing isolated coronary artery bypass grafting from 5 countries (Australia, Italy, Serbia, South Korea, and the United Kingdom), with enrollment from 1997 to 2009 and follow-up completed in 2019.

Interventions  Patients were randomized to undergo either radial artery (n = 534) or saphenous vein (n = 502) grafts for coronary artery bypass grafting.

Main Outcomes and Measures  The primary outcome was a composite of death, myocardial infarction, or repeat revascularization and the secondary outcome was a composite of death or myocardial infarction.

Results  A total of 1036 patients were randomized (mean age, 66.6 years in the radial artery group vs 67.1 years in the saphenous vein group; 376 [70.4%] men in the radial artery group vs 351 [69.9%] in the saphenous vein group); 942 (90.9%) of the originally randomized patients completed 10 years of follow-up (510 in the radial artery group). At a median (interquartile range) follow-up of 10 (10-11) years, the use of the radial artery, compared with the saphenous vein, in coronary artery bypass grafting was associated with a statistically significant reduction in the incidence of the composite outcome of death, myocardial infarction, or repeat revascularization (220 vs 237 total events; 41 vs 47 events per 1000 patient-years; hazard ratio, 0.73 [95% CI, 0.61-0.88]; P < .001) and of the composite of death or myocardial infarction (188 vs 193 total events; 35 vs 38 events per 1000 patient-years; hazard ratio, 0.77 [95% CI, 0.63-0.94]; P = .01).

Conclusions and Relevance  In this individual participant data meta-analysis with a median follow-up of 10 years, among patients undergoing coronary artery bypass grafting, the use of the radial artery compared with the saphenous vein was associated with a lower risk of a composite of cardiovascular outcomes.

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Article Information

Corresponding Author: Mario Gaudino, MD, Department of Cardiothoracic Surgery, Weill Cornell Medicine, 525 E 68th St, New York, NY 10065 (mfg9004@med.cornell.edu).

Accepted for Publication: May 1, 2020.

Author Contributions: Drs Gaudino and Benedetto had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Gaudino and Benedetto contributed equally.

Concept and design: Gaudino, Benedetto, Biondi-Zoccai, Nasso, Raman, Peric, Petrovic, Speziale, Puskas, Girardi, Hare, Taggart.

Acquisition, analysis, or interpretation of data: Gaudino, Fremes, Ballman, Biondi-Zoccai, Sedrakyan, Raman, Buxton, Hayward, Moat, Collins, Webb, Petrovic, Yoo, Hameed, Di Franco, Moscarelli, Puskas, Hare, Taggart.

Drafting of the manuscript: Gaudino, Benedetto, Biondi-Zoccai, Nasso, Buxton, Petrovic, Hameed, Di Franco, Taggart.

Critical revision of the manuscript for important intellectual content: Gaudino, Fremes, Ballman, Biondi-Zoccai, Sedrakyan, Raman, Buxton, Hayward, Moat, Collins, Webb, Peric, Petrovic, Yoo, Hameed, Di Franco, Moscarelli, Speziale, Puskas, Girardi, Hare, Taggart.

Statistical analysis: Gaudino, Benedetto, Ballman, Biondi-Zoccai, Sedrakyan, Petrovic, Hameed, Moscarelli.

Obtained funding: Gaudino, Moat.

Administrative, technical, or material support: Gaudino, Biondi-Zoccai, Raman, Buxton, Collins, Petrovic, Yoo, Di Franco, Moscarelli, Girardi.

Supervision: Gaudino, Biondi-Zoccai, Nasso, Raman, Buxton, Peric, Petrovic, Yoo, Di Franco, Speziale, Taggart.

Other - data curation: Moat.

Other - policy implications: Sedrakyan.

Conflict of Interest Disclosures: Dr Fremes reported receiving grants from the University of Toronto during the conduct of the study and grants from the Canadian Institutes of Health Research outside the submitted work. Dr Biondi-Zoccai reported consulting for Abbott Vascular and Bayer. Dr Moat reported being an employee of Abbott, Santa Clara. Dr Puskas reported receiving royalties from surgical instruments invented by the author from Scanlan Inc and personal fees from Medtronic outside the submitted work and having a patent to surgical instruments issued and licensed, with royalties paid. Dr Hare reported receiving personal fees from the National Health and Medical Research Council of Australia and grants from the National Heart Foundation of Australia during the conduct of the study and personal fees from Amgen, AstraZeneca, Merck, and Pfizer and nonfinancial support from Lundbeck, Servier, and Vifor outside the submitted work. No other disclosures were reported.

Group Information: Complete list of the RADIAL Investigators: Mario Gaudino, MD (Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York); Umberto Benedetto, MD (Bristol Heart Institute, Bristol, United Kingdom); Stephen Fremes, MD (Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada); Karla Ballman, PhD (Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York); Giuseppe Biondi-Zoccai, MD (Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University, Rome, Italy and Mediterranea Cardiocentro, Napoli, Italy); Art Sedrakyan, MD, PhD (Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York); Giuseppe Nasso, MD (Anthea Hospital, Bari, Italy); Jai Raman, MD, PhD (Austin Hospital, Melbourne, Victoria, Australia); Brian Buxton, MD (University of Melbourne, Melbourne, Victoria, Australia); Philip A. Hayward, MD (University of Melbourne, Melbourne, Victoria, Australia); Neil Moat, MD; Peter Collins, MD; Carolyn Webb, PhD (NHLI, Imperial College London, and Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom); Miodrag Peric, PhD; Ivana Petrovic, MD (Dedinje Cardiovascular Institute and Belgrade University School of Medicine, Belgrade, Serbia); Kyung J. Yoo, MD (Yonsei University College of Medicine, Seoul, South Korea); Irbaz Hameed, MD; Antonino Di Franco, MD (Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York); Marco Moscarelli, MD; Giuseppe Speziale, MD (Anthea Hospital, Bari, Italy); Leonard N. Girardi, MD (Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York); David L. Hare, MD (Austin Hospital, Melbourne, Victoria, Australia, and University of Melbourne, Melbourne, Victoria, Australia); David P. Taggart, MD (University of Oxford, Oxford, United Kingdom); John Puskas, MD (Icahn School of Medicine at Mount Sinai, New York City, New York); Mohamed Rahouma, MD (Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York); Michelle Demetres, MLIS (Samuel J. Wood Library & C.V. Starr Biomedical Information Center, Weill Cornell Medicine, New York, New York).

Funding/Support: This project was funded by the Department of Cardiothoracic Surgery of Weill Cornell Medicine in New York. Dr Fremes was supported in part by the Bernard S. Goldman Chair in Cardiovascular Surgery. Dr Benedetto was supported by the Bristol Biomedical Research Centre.

Role of the Funder/Sponsors: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

Data Sharing Statement: The data, analytic methods, and study materials will be made available to other researchers upon reasonable request and approval by the steering committee. Data will be provided by the first author.

References
1.
Gaudino  M , Rahouma  M , Abouarab  A ,  et al.  Radial artery versus saphenous vein as the second conduit for coronary artery bypass surgery: a meta-analysis.   J Thorac Cardiovasc Surg. 2019;157(5):1819-1825.e10. doi:10.1016/j.jtcvs.2018.08.123PubMedGoogle ScholarCrossref
2.
Gaudino  M , Di Franco  A , Rahouma  M ,  et al.  Unmeasured confounders in observational studies comparing bilateral versus single internal thoracic artery for coronary artery bypass grafting: a meta-analysis.   J Am Heart Assoc. 2018;7(1):e008010. doi:10.1161/JAHA.117.008010PubMedGoogle Scholar
3.
Gaudino  M , Benedetto  U , Fremes  S ,  et al; RADIAL Investigators.  Radial-artery or saphenous-vein grafts in coronary-artery bypass surgery.   N Engl J Med. 2018;378(22):2069-2077. doi:10.1056/NEJMoa1716026PubMedGoogle ScholarCrossref
4.
Benedetto  U , Raja  SG , Albanese  A , Amrani  M , Biondi-Zoccai  G , Frati  G .  Searching for the second best graft for coronary artery bypass surgery: a network meta-analysis of randomized controlled trials†.   Eur J Cardiothorac Surg. 2015;47(1):59-65. doi:10.1093/ejcts/ezu111PubMedGoogle ScholarCrossref
5.
Gaudino  M , Benedetto  U , Fremes  S ,  et al; RADIAL Investigators.  The RADial artery International ALliance (RADIAL) extended follow-up study: rationale and study protocol.   Eur J Cardiothorac Surg. 2019;56(6):1025-1030. doi:10.1093/ejcts/ezz247PubMedGoogle ScholarCrossref
6.
Stewart  LA , Clarke  M , Rovers  M ,  et al; PRISMA-IPD Development Group.  Preferred reporting items for systematic review and meta-analyses of individual participant data: the PRISMA-IPD statement.   JAMA. 2015;313(16):1657-1665. doi:10.1001/jama.2015.3656PubMedGoogle ScholarCrossref
7.
Nasso  G , Coppola  R , Bonifazi  R , Piancone  F , Bozzetti  G , Speziale  G .  Arterial revascularization in primary coronary artery bypass grafting: direct comparison of 4 strategies—results of the Stand-in-Y Mammary Study.   J Thorac Cardiovasc Surg. 2009;137(5):1093-1100. doi:10.1016/j.jtcvs.2008.10.029PubMedGoogle ScholarCrossref
8.
Buxton  BF , Raman  JS , Ruengsakulrach  P ,  et al.  Radial artery patency and clinical outcomes: five-year interim results of a randomized trial.   J Thorac Cardiovasc Surg. 2003;125(6):1363-1371. doi:10.1016/S0022-5223(02)73241-8PubMedGoogle ScholarCrossref
9.
Petrovic  I , Nezic  D , Peric  M ,  et al.  Radial artery vs saphenous vein graft used as the second conduit for surgical myocardial revascularization: long-term clinical follow-up.   J Cardiothorac Surg. 2015;10:127. doi:10.1186/s13019-015-0331-9PubMedGoogle ScholarCrossref
10.
Collins  P , Webb  CM , Chong  CF , Moat  NE ; Radial Artery Versus Saphenous Vein Patency (RSVP) Trial Investigators.  Radial artery versus saphenous vein patency randomized trial: five-year angiographic follow-up.   Circulation. 2008;117(22):2859-2864. doi:10.1161/CIRCULATIONAHA.107.736215PubMedGoogle ScholarCrossref
11.
Song  S-W , Sul  S-Y , Lee  H-J , Yoo  K-J .  Comparison of the radial artery and saphenous vein as composite grafts in off-pump coronary artery bypass grafting in elderly patients: a randomized controlled trial.   Korean Circ J. 2012;42(2):107-112. doi:10.4070/kcj.2012.42.2.107PubMedGoogle ScholarCrossref
12.
Gowda  S , Desai  PB , Kulkarni  SS , Hull  VV , Math  AAK , Vernekar  SN .  Markers of renal function tests.   N Am J Med Sci. 2010;2(4):170-173.PubMedGoogle Scholar
13.
Taggart  DP , Benedetto  U , Gerry  S ,  et al; Arterial Revascularization Trial Investigators.  Bilateral versus single internal-thoracic-artery grafts at 10 years.   N Engl J Med. 2019;380(5):437-446. doi:10.1056/NEJMoa1808783PubMedGoogle ScholarCrossref
14.
Gaudino  M , Fremes  SE , Ruel  M ,  et al.  Prevalence and impact of treatment crossover in cardiac surgery randomized trials: a meta-epidemiologic study.   J Am Heart Assoc. 2019;8(21):e013711. doi:10.1161/JAHA.119.013711PubMedGoogle Scholar
15.
Schwann  TA , Habib  RH , Wallace  A ,  et al.  Operative outcomes of multiple-arterial versus single-arterial coronary bypass grafting.   Ann Thorac Surg. 2018;105(4):1109-1119. doi:10.1016/j.athoracsur.2017.10.058PubMedGoogle ScholarCrossref
16.
Gaudino  M , Alexander  JH , Bakaeen  FG ,  et al.  Randomized comparison of the clinical outcome of single versus multiple arterial grafts: the ROMA trial-rationale and study protocol.   Eur J Cardiothorac Surg. 2017;52(6):1031-1040. doi:10.1093/ejcts/ezx358PubMedGoogle ScholarCrossref
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