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Radial artery grafts reduce risk of revascularization compared with saphenous vein graft in CABG
Clinical Question
Which is more effective: saphenous vein graft or radial artery graft in patients underoing coronary artery bypass graft surgery?
Bottom line
This individual patient–level meta-analysis found that radial artery graft results in a lower likelihood of revascularization, and possibly fewer myocardial infarctions, than saphenous vein graft. 1a
Reference
Study design: Meta-analysis (randomized controlled trials)
Funding: Other
Setting: Various (meta-analysis)
Synopsis
Although most patients receive saphenous vein grafts when they undergo coronary artery bypass surgery, several small underpowered trials and some observational data suggest a possible benefit to using radial artery grafts. These authors identified 6 trials that randomized between 60 and 409 patients to receive either saphenous vein graft or radial artery graft to supplement left internal thoracic artery graft. This was an individual patient–level meta-analysis that combined the raw data from all 6 trials, which is more powerful than a traditional meta-analysis that combines summary data from each study. The primary outcome was a combination of death, myocardial infarction, or revascularization. This lumps apples (death) with oranges (revascularization), so it is important to look at each outcome separately. Analysis was by intention to treat using the most recent available data for each trial. Overall, 534 patients were assigned to radial artery graft and 502 to saphenous vein graft. The participants' mean age was 67 years, 30% were women, 31% had a previous myocardial infarction, and the mean number of grafts was 3.1 in each group. Patients were followed up for 3.3 years to 8.4 years in the 6 included studies. The patients randomized to receive radial artery graft had a lower rate of the primary combined outcome (12.5% vs 18.7%; P = .01; number needed to treat [NNT] = 16), primarily because of a lower rate of revascularization (4.3% vs 8.6%; P < .001, NNT = 9). There was a small reduction in myocardial infarctions, as well (3.0% vs 4.2%; P = .04), but no mortality difference between groups. Graft occlusion, a disease-oriented outcome, also occurred less often in the radial artery group (8.1% vs 19.9%; P < .001). Prespecified subgroup analyses found that the benefit of radial artery graft as measured by the combined outcome was greater for patients younger than 75 years, women, and those with normal renal function.
Reviewer
Mark H. Ebell, MD, MS
Professor
University of Georgia
Athens, GA
Comments
Very interesting new information though as I am a family doctor it does not directly impact my clinical decision making.
This article makes it sound as though "revascularization" is a bad thing. Very poorly written. If I'm wrong, and it turns out that the term means something different in this context, then that should be explained.
I am a little confused, but interested to know any complication at radial artery site.
Poorly written. The outcome measured was not revascularization, which is in fact the desired result of the intervention. Rather the measured outcome was the need for repeat revascularization, indicating failure of the initial intervention. Omitting the word ‘repeat’ in this POEM is a critical mistake and the review should be rewritten.
Repeat revascularization
I would like to echo previous posts --- This POEM has what is presumed to be a typographical error: the omission of the word "repeat" in the measured outcome " repeat revascularization." This completely changes the meaning of the outcome. It implies that the restoration of blood blow is an negative outcome, as opposed to the phasing in the article which describes the need for an additional procedure.
The results of this netaanalysis bod well for those who already have 1 or more internal thoracic deployed for CABG. Thanks for bringing this forward
Repeat revascularization
I would like to echo previous posts --- This POEM has what is presumed to be a typographical error: the omission of the word "repeat" in the measured outcome " repeat revascularization." This completely changes the meaning of the outcome. It implies that the restoration of blood blow is an negative outcome, as opposed to the phasing in the article which describes the need for an additional procedure.
Good poem
This is very interesting and not totally unexpected, once one reads the results. It also points out how unconventional methods of analysing studies can lead to very valuable clinical insights.