Coronary artery bypass grafting using total arterial revascularization. Graft patency, clinical outcome and health-related quality of life, insights from a randomized controlled trial

Background Use of arterial grafts for coronary artery bypass grafting (CABG) has been argued to improve the angiographic graft patency, and thereby, the patient outcome by fewer cardiac events such as reoccurrence of angina pectoris, repeat revascularization, myocardial infarction (MI) and even death. There is only limited and unclear evidence from randomized trials, but in large-scale retrospective studies it is clear that use of the internal thoracic artery (ITA) as a bypass graft to especially the left anterior descending (LAD) coronary artery leads to improved graft patency and survival and fewer cardiac events compared with use of the greater saphenous vein as a graft (SVG). Bilateral ITA (BITA) grafts seem to increase this benefit further. Because of sternal wound complications related to BITA harvest, the radial artery (RA) has been proposed and widely used in addition to the left ITA (LITA), but also together with BITAs when more grafts are necessesary. The question whether the RA has superior patency than the SVG is therefore central, but in the long term unanswered. Also, the safety and efficacy of a strategy of total arterial revascularization (TAR) using one or both ITA grafts together with the RA is poorly documented. Finally, health-related quality of life (HRQoL) seems to improve after CABG, but whether TAR has an influence is unclear. Methods In this trial including 161 patients randomized to TAR (LITA or BITA and RA) versus 170 patients randomized to conventional revascularization (CR) (LITA and SVGs) and operated with use of heart-lung machine, the primary outcome measures are overall graft patency (graft stenoses below 50%) defined as the patency index (number of patent grafts divided by the number of constructed grafts) and cardiac event-free survival (readmission for suspected or verified MI, unstable angina pectoris, arrhythmia, congestive heart failure, angiography or percutaneous or surgical revascularization) after 1 and 5 y