Multi-Arterial versus Single-Arterial Coronary Surgery: Ten Year Follow-up of One Million Patients

BACKGROUND:While many options exist for multivessel coronary revascularization, controversy persists over whether multi-arterial grafting (MAG) confers a survival advantage over single arterial grafting (SAG) and saphenous vein in coronary artery bypass grafting (CABG). We sought to compare longitudinal survival between patients undergoing MAG vs. SAG. METHODS:All patients undergoing isolated CABG with >2 bypass grafts in the Society of Thoracic Surgeons Adult Cardiac Surgery Database (2008-2019) were linked to the National Death Index. Risk-adjustment was performed using inverse probability weighting and multivariable modeling. The primary endpoint was longitudinal survival. Subpopulation analyses and volume thresholds were analyzed to determine optimal benefit. RESULTS:A total of 1,021,632 patients underwent isolated CABG at 1108 programs [100,419 MAG (9.83%); 920,943 SAG (90.17%)]. Median follow-up was 5.30 years (range 0-12). After risk-adjustment, all characteristics were well balanced. At 10 years, MAG was associated with improved unadjusted (HR 0.59, 95% CI 0.58-0.61) and adjusted (HR 0.86, 95% CI 0.85-0.88) 10-year survival. Center volume ≥10 MAG cases/year was associated with benefit. MAG was associated with an overall survival advantage over SAG in all subgroups including stable coronary disease, acute coronary syndrome, and acute infarction. Survival was equivalent to SAG for patients age ≥80 years, and those with severe heart failure, renal failure, peripheral vascular disease or obesity. Only patients with BMI ≥40 had superior survival with SAG. CONCLUSIONS:Multi-arterial CABG is associated with superior long-term survival and should be the surgical multivessel revascularization strategy of choice for patients with a BMI of less than 40.