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Saphenous Vein Graft Vs. Radial Artery Searching for the Second-Best Coronary Artery Bypass Graft

(Long Term Outcome) Hilal Alsabti, MD,MSc, FRCSc Deputy Director General, and Head Of Cardiothoracic Surgery Sultan Qaboos University Hospital

• • • • • •

Introduction. Historical Prospective. Harvesting Technique. Early and mid-term Outcome. Long term outcome. Conclusion.

• Over 800,000 patients undergo CABG every year. • The long term outcome after CABG depends on graft patency. • Many Grafts Options are available: – – – – –

Internal thoracic Artery. Saphenous vein graft. Radial artery. Right gastroepipolic artery. Inferior Epigastric artery.

LITA to LAD ( Best): – Best graft patency. – Better survival. – Less re-intervention rate.

Advantages and Disadvantages of different conduits as a second graft to LIMA Advantages: • SVG: good handling, enough length, less transfusion and harvest time compared to BITA. • RA: Long, good handling, Luminal diameter close to Coronary, less transfusion and time then BITA. • RITA: excellent long term results, less spastic graft any territory as a composite graft. • GEA: Graft to any territory as in situ, available in redo.

Disadvantages: • Poor short and long term patency, varix pt. , post op leg oedema, poor wound healing. • Very spasmodic, not always available, arm wound. • More bleeding , more sternal infection, thin arterial wall not good for aorto-coronary bypass. • More spasmodic, same as SV patency, different sizes .

Historical Perspective: • RA was first used by Carpentier in 1971. • Stopped two years later because of 35% incidence of narrowing and occlusion due to: – Spasm. – Intimal hyperplasia after endothelial denuation. – Due to trauma of skeletonization.

• It was revived on 1989 by Acar and his group after modifying the harvesting techniques the solution used.

Preoperative Evaluation: • Preoperative Evaluation: – Allen Test( to check the ulnar collateral circulation) – Pulse oximetry. – Duplex scan.

• Preoperative contraindications: – Forearm ischemia. – Calcification. – Dissection from prior cannulation.

Harvesting Technique: • Harvesting: open or endoscopic. • With or without ultrasonic scalpel. • Pharmacological preparation: – Nitroglycrin. – Ca Channel blocker ( Diltiazem). – Phosphodiasterase Inhibitor (papaverine). – Verapamil and nitroglycerin (VG solution).

• Common Complication: sensory abnormality and numbness.

Radial Artery

• I guess only Cleaveland clinic reported worse graft patency of RA compared to SV.

Kaplan-Meier curves of cumulative patency rates according to type of . bypass graft

Khot U N et al. Circulation 2004;109:2086-2091

Early Results: • Early Results always depend on Many factors: • • • • • • • •

Quality of coronary anastomosis. Endothelial integrity. Intra-operative handling. Preservation of conduit before usage. Pharmacological treatment to prevent spasm. Low cardiac output, high inotropic support. Degree of the native graft stenosis. Distal beds.

Early and Mid-term Results showed excellent graft patency rate

T. Athanasiou et al EJCTS 40 2011

T. Athanasiou et al EJCTS 40 2011

Many Observational Retrospective studies:

Sajja et al, ATS ,2005

Sajja et al, ATS ,2005

Clinical Trials: RAPS • 561 pts in 13 centers. • Pts underwent CABG with SVG and RA in opposite territory. • 1 year angiography. • 440 pts.

Results: • 8.2%RA and 13.6% SVG graft failure. • Diffuse narrowing of the graft present in 7% RA and 0.9% SV. • Absence of sever native vessel stenosis is a risk factor for RA occlusion. • Patency of RA in both Cx and RCA is the same.

Clinical Trials: RAPS Multivariate Predictor of graft failure:

• RA occlusion is similar between males and females. While it is more in Females in SV. • RA occlusion is less in diabetic then the SV. • PVD is associated with higher risk of RA graft failure.

The Radial Artery Vs SVG patency (RSVP) • Single center trial. • Prospective Randomized. • 5 years patency rate. • 142 enrolled, 105 had Angio.

• Graft patency , 98.3% of RA compared to 86.4% SV. • Graft narrowing is 10% in RA compared to 23% in SV.

Collins et al, Circulation.2008; 117: 2859-2864

Graft patency at 5 years

Collins P et al. Circulation 2008;117:2859-2864

Mid and long term studies :

Acar et al: 5-20 years experience: At 7 years: patency rate • LIMA 83%. • RIMA 87%. • RA 83%. • SVG 81%.

RA patency is : • Diagonal 93%. • Cx 82.5%. • RCA 77.6%

Acar et al. Eur J Cardiothorac Surg. 2012 January; 41(1): 87–92


Kaplan—Meier survival following coronary bypass with the radial artery. Overall survival and freedom form cardiovascular death were 70% and 89% at 15 years respectively

Hoffman et al,

• • • • • •

Circulation. 2012 Sep 11;126(11 Suppl 1):S170-5

16 years experience. RA patency 82% SV 47% . LITA 85% RITA 80% . Overall freedom from catheterization, percutaneous coronary intervention, and CABG was 85%, 97%, and 99%, respectively.

RA patency was not different from LITA patency (P=0.3).

Radial Artery Conduits Improve LongTerm Survival After CABG

Hoffman et al,

Circulation. 2012 Sep 11;126(11 Suppl 1):S170-5

Kaplan-Meier–estimated disease progression rates in all territories with patent conduits

Ann Thorac Surg 2012;94:475-481

Kaplan-Meier–estimated disease progression rates with patent conduits in the lateral territory.

Ann Thorac Surg 2012;94:475-481

Kaplan-Meier–estimated overall freedom of disease progression and graft failure.

Ann Thorac Surg 2012;94:475-481

Kaplan–Meier curve for late survival for multiple arterial grafting (MultArt) subgroups vs left internal mammary artery (LIMA)/saphenous vein (SV) unmatched groups: bilateral internal ... mammary artery (BIMA)/SV (dashed dotted line) vs LIMA/SV (solid line); ha

Locker C et al. Circulation 2012;126:1023-1030 Copyright Š American Heart Association

Kaplan–Meier curve for late survival for multiple arterial grafting (MultArt) vs left internal mammary artery (LIMA)/saphenous vein (SV), propensity score–matched groups: MultArt ... (dashed line) vs LIMA/SV (solid line); hazard ratio, 0.73; 95% confidence inte

Locker C et al. Circulation 2012;126:1023-1030

Copyright © American Heart Association

Possati et al, Circulation.2003; 108: 1350-1354

Long-term RA graft status in relation to target-vessel . stenosis

Possati G et al. Circulation 2003;108:1350-1354 Copyright Š American Heart Association

In Conclusion: • Radial Artery is an excellent graft that should be used. • RA is superior in many single centers with long term results. • There is a high incidence of Occlusion of the RCA no matter what you put in it. • More evidence from large scale multi-centric trials needed.

Thank You



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