FEDERAL STATE BUDGETARY INSTITUTION “RESEARCH INSTITUTE FOR COMPLEX ISSUES OF CARDIOVASCULAR DISEASES”

Aim. To estimate long-terms results of incomplete revascularization with the internal thoracic artery to the left anterior descending anastomosis performed during mammary-coronary bypass grafting (MCBG) in 228 patients with stable coronary artery disease using the single-center registry database.

Methods. All patients were enrolled into 2 groups. Group 1 consisted of patients with residual SYNTAX score ≤8 (group SYNTAX ≤8, n = 75), Group 2 with residual SYNTAX score >8 (group SYNTAX ≥9, n = 153).

Results. The reasons for the incomplete revascularization were: (1) small diameter of the distal segment of the coronary arteries in 52 (23%) patients, (2) calcification and transmural scar of the myocardium in 18 (8%) patients, (3) severe concomitant pathology in 33 (14%) patients, (4) danger and / or inability to place proximal anastomosis on the ascending aorta in 35 (16%) cases, (5) coronary artery hypoplasia in 11 (5%) patients, (6) unfit grafts for shunting in 6 (2%) patients, (7) technical difficulties in visualization of coronary arteries on the posterior and lateral walls due to Dressler's syndrome in 9 (4%) patients. (8) Incomplete revascularization was considered reasonable in 64 (28%) cases due to the number of causes. The three-year all-cause mortality was 4% in the group of SYNTAX ≤8 versus 3.9% in the SYNTAX group ≥9, P = 0.7, similarly to the cardiac death – 2.7% in the group of SYNTAX ≤8 versus 3.3% in the group SYNTAX ≥9, P = 0.9. The need for repeat coronary revascularization was the same in both groups (P = 0.4). The groups did not differ in the number of the combined endpoint (8% in the group of SYNTAX ≤8 versus 6.5% in the group SYNTAX ≥9, (P = 0.9).

Conclusion. The study demonstrated that the results of incomplete revascularization with LIMA to LAD do not depend on the residual SYNTAX score. 

1. Serruys P.W., Farooq V., Vranckx P., Girasis C., Brugaletta S., Garcia-Garcia H.M. et al. A global risk approach to identify patients with left main or 3-vessel disease who could safely and effi caciously be treated with percutaneous coronary intervention: the SYNTAX trial at 3 years. JACC Cardiovasc Interv. 2012. Vol. 5. P. 606–617. doi: 10.1016/j.jcin.2012.03.016

2. Kleisli T., Cheng W., Jacobs M.J., Mirocha J., Derobertis M.A., Kass R.M. et al. In the current era, complete revascularization improves survival after coronary artery bypass surgery. J. Thorac Cardiovasc Surg. 2005. Vol. 129. P. 1283-1291. DOI: 10.1016/j.jtcvs.2004.12.034

3. Kozower B.D., Moon M.R., Barner H.B., Moazami N., Lawton J.S., Pasque M.K., Damiano R.J. Jr. Impact of complete revascularization on long-term survival after coronary artery bypass grafting in octogenarians. Ann Thorac Surg. 2005. Vol. 80. P. 112-116. DOI: 10.1016/j.athoracsur.2005.02.017

4. Osswald B.R., Blackstone E.H., Tochtermann U., Schweiger P., Thomas G., Vahl C.F., Hagl S. Does the completeness of revascularization affect early survival after coronary artery bypass grafting in elderly patients? Eur J Cardiothorac Surg. 2001. Vol. 20. P. 120-125.

5. Cameron A., Davis K.B., Green G., Schaff H.V.Coronary Bypass Surgery with Internal-Thoracic-Artery Grafts — Effects on Survival over a 15-Year Period. NEJM. 1996. Vol. 334. P. 216-220. DOI: 10.1056/NEJM199601253340402

6. Windecker S., Kolh P., Alfonso F., Collet J.P., Cremer J., Falk V. et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur. Heart J. 2014; Oct 1;35(37):2541-619. doi: 10.1093/eurheartj/ehu278.

7. Patel M.R., Dehmer G.J., Hirshfeld J.W., Smith P.K., Spertus J.A. ACC/SCAI/STS/AATS/AHA/ASNC 2009 Appropriateness Criteria for Coronary Revascularization. J. Am. Coll. Cardiol. 2009. Vol. 53. P. 530-553. doi: 10.1161/CIRCULATIONAHA.108.191768

8. Ганюков В.И., Тарасов Р.С., Шилов А.А., Кочергин Н.А., Барбараш Л.С. Мини -инвазивная гибридная реваскуляризация миокарда при многососудистом поражении коронарного русла. Современное состояние вопроса. Комплексные проблемы сердечно-сосудистых заболеваний. 2016; (2):46-50.https://doi.org/10.17802/2306-1278-2016-2-46-50

9. De Innocentiis C., Zimarino M., De Caterina R. Is complete revascularisation mandated for all patients with multivessel coronary artery disease? Interv Cardiol. 2018 Jan;13(1):45-50. doi: 10.15420/icr.2017:23:1.

10. Moon M.R., Sundt T.M. III, Pasque M.K., Barner H.B., Gay W.A. Jr, Damiano R.J. Jr. Influence of internal mammary artery grafting and completeness of revascularization on longterm outcome in octogenarians. Ann Thorac Surg. 2001. Vol. 72. P. 2003–2007.

11. Rastan A.J., Walther T., Falk V., Kempfert J., Merk D., Lehmann S., Holzhey D., Mohr F.W. Does reasonable incomplete surgical revascularization affect early or long-term survival in patients with multivessel coronary artery disease receiving left internal mammary artery bypass to left anterior descending artery? Circulation. 2009. 120(11 Suppl):S70-7. doi: 10.1161/CIRCULATIONAHA.108.842005

12. Farooq V., Serruys P.W., Bourantas C.V., Zhang Y., Muramatsu T., Feldman T. et al. Quantification of incomplete revascularization and its association with five-year mortality in the synergy between percutaneous coronary intervention with taxus and cardiac surgery (SYNTAX) trial validation of the residual SYNTAX score. Circulation. 2013. Vol. 128(2). P. 141-51. doi: 10.1161/CIRCULATIONAHA.113.001803.

13. Melina G., Angeloni E., Refice S., Monti F., Serdoz R., Rosato S. et al. Clinical SYNTAX score predicts outcomes of patients undergoing coronary artery bypass grafting. Am Heart J. 2017 Jun;188:118-126. doi: 10.1016/j.ahj.2017.03.016.

14. Généreux S.P., Palmerini T., Caixeta A., Rosner G., Green P., Dressler O. et al. Quantification and Impact of Untreated Coronary Artery Disease After Percutaneous Coronary Intervention The Residual SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery). J Am Coll Cardiol. 2012. Vol. 59. P. 2165–2174. doi: 10.1016/j.jacc.2012.03.010

15. Bell M.R., Gersh B.J., Schaff H.V., Holmes D.R. Jr, Fisher L.D., Alderman E.L. et al. Effect of completeness of revascularization on long-term outcome of patients with threevessel disease undergoing coronary artery bypass surgery. A reportfrom the Coronary Artery Surgery Study (CASS) Registry. Circulation. 1992. 86(2):446-57.

16. Jones E.L., Weintraub W.S. The importance of completeness of revascularization during long-term follow-up after coronary artery operations. J Thorac Cardiovasc Surg. 1996; 112: 227-237.

17. Girerd N., Magne J., Rabilloud M., Charbonneau E., Mohamadi S., Pibarot P. et al. The impact of complete revascularization on long-term survival is strongly dependent on age. Ann Thorac Surg. 2012; 94(4):1166-72. doi: 10.1016/j.athoracsur.2012.05.023 Mohammadi S., Kalavrouziotis D., Dagenais F., et al. Completeness of revascularization and survival among octogenarians with triple-vessel disease. Ann Thorac Surg. 2012. Vol. 93. P. 1432-1437.

18. Kim K.B., Kim J.S., Kang H.J., Koo B.K., Kim H.S., Oh B.H., Park Y.B. Ten-year experience with off-pump coronary artery bypass grafting: lessons learned from early postoperative angiography. J. Thorac. Cardiovasc. Surg. 2010 ;139(2):256- 62. doi: 10.1016/j.jtcvs.2009.08.040.

19. Sarno G., Garg S., Onuma Y., Gutiérrez-Chico J.L., van den Brand M.J., Rensing B.J., Morel M.A., Serruys P.W.; ARTSII Investigators. Impact of completeness of revascularization on the five-year outcome in percutaneous coronary intervention and coronary artery bypass graft patients (from the ARTS-II study). Am J Cardiol. 2010; 106(10):1369-75. doi: 10.1016/j.amjcard.2010.06.069.

20. Danny Ch., Faisal G., Xing L.W., Coselli J. S., LeMaire S. A., J. Huh The impact of placing multiple grafts to each myocardial territory on long-term survival after coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2009; 137(1): 60- 64. doi: 10.1016/j.jtcvs.2008.09.018.

21. Kieser T.M., Curran H.J, Rose M.S., Norris C.M., Graham M.M. Arterial grafts balance survival between incomplete and complete revascularization: A series of 1000 consecutive patients with coronary artery bypass graft with 98% arterial grafts. J Thorac Cardiovasc Surg. 2014 ;147(1):75-83. doi: 10.1016/j.jtcvs.2013.08.003

22. Malkin С.J., George V., Ghobrial M.S., Krishnan A., Siotia A., Raina T., Morton A.C., Gunn J. Residual SYNTAX score after PCI for triple vessel coronary artery disease: quantifying the adverse effect of incomplete revascularization. EuroIntervention. 2013; 8(11):1286-95. doi: 10.4244/EIJV8I11A197.