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Lawton et al 2021 ACC/AHA/SCAI Coronary Revascularization Guideline

January 18, 2022 Circulation. 2022;145:e18–e114. DOI: 10.1161/CIR.0000000000001038 e64

CLINICAL STATEMENTS AND GUIDELINES

can be used to graft the LAD if the LIMA is unusable, or the right IMA can be used in conjunction with the LIMA (BIMA grafting). Several randomized trials and metaanalyses have demonstrated better mid- and long-term patency rates for the radial artery than for the saphenous vein. A pooled analysis of 6 randomized trials has shown improved clinical outcomes at 10 years’ follow-up.13 The right IMA is biologically equivalent to the LIMA, and BIMA grafting has shown a survival advantage compared with CABG with a single IMA in observational studies. The extensive use of arterial conduits (>2) instead of SVGs for multivessel CABG may provide an additional late mortality benefit compared with CABG with 2 arterial grafts.

Recommendation-Specific Supportive Text

1.	 Several randomized trials and meta-analyses have reported better mid- and long-term patency rates for the radial artery than for the saphenous vein,2,14 while observational studies and meta-analyses have suggested a survival benefit when the radial artery is used instead of the saphenous vein for CABG.3 A pooled analysis of 6 randomized trials showed improved clinical outcome with regard to adverse cardiac events at 5 and 10 years after surgery when the radial artery was used instead of the saphenous vein to revascularize the most important non-LAD artery coronary target.1,13 Patients <75 years of age, women, and patients with preserved renal function seem to benefit the most from the use of the radial artery. The evidence is based largely on the use of the radial artery constructed as an aortocoronary graft. In observational studies, composite radial artery grafts have been found to be more vulnerable to the effect of chronic native competitive flow, but the evidence is limited.15

2.	 Data supporting the LIMA versus an SVG for grafting of the LAD are derived almost exclusively from observational studies reported 25 to 35 years ago.5-7 In the CASS (Coronary Artery Surgery Study) registry, survival was improved in patients who received the LIMA-LAD compared with the SVG group after multivariable adjustment.7 In another series of nearly 6000 patients undergoing CABG, LIMA grafting reduced deaths, recurrent infarction, rehospitalization for cardiac events, and repeat revascularization.6 In this study, postoperative angiography revealed substantially higher LIMA patency. A single small RCT also found improved cardiac event– free survival at 10 years in the LIMA arm.4,5 3.	 The benefit of BIMA in CABG is supported by observational studies and in several meta-analyses.3,10,11,16 A meta-analysis of 38 studies, including 174 205 patients, noted a decreased mortality rate at 7.25 years with BIMA use.16 However, a single large RCT compared BIMA with single IMA in 3102 patients and reported no difference in 10-year allcause mortality rate or in the composite of death, MI, or stroke.12 However, a high rate of crossover was noted (14% from BIMA to single IMA, and 22% of the patients with a single IMA received a radial artery). An as-treated analysis reported improved survival in patients who received multiple arterial grafts.12 Increasing BIMA volume was associated with protocol adherence, which suggests the importance of surgical expertise.12 Low institutional BIMA volume has also been associated with a higher operative mortality rate with BIMA grafting.17 Observational studies and 2 meta-analyses support the use of ≥3 arterial grafts, including total arterial revascularization.18,19 The increased risk of sternal infection with BIMA grafting should be considered during preoperative planning.17

12.3 CABG in Patients Undergoing Other

Cardiac Surgery Recommendations for CABG in Patients Undergoing Other Cardiac Surgery Referenced studies that support the recommendations are summarized in Online Data Supplement 38.

COR LOE Recommendations

1 C-LD 1.	 In patients undergoing valve surgery, aortic surgery, or other cardiac operations who have significant CAD, CABG is recommended with a goal of reducing ischemic events.1-11

2b C-LD 2.	 In patients undergoing valve surgery, aortic surgery, or other cardiac operations who have intermediate CAD, CABG may be reasonable with a goal of reducing ischemic events.5,7,10,12

Table 12.  Best Practices for the Use of Bypass Conduits in CABG Objectively assess palmar arch completeness and ulnar compensation before harvesting the radial artery. Use the arm with the best ulnar compensation for radial artery harvesting. Use radial artery grafts to target vessels with subocclusive stenoses. Avoid the use of the radial artery after transradial catheterization. Avoid the use of the radial artery in patients with chronic kidney disease and a high likelihood of rapid progression to hemodialysis. Use oral calcium channel blockers for the first postoperative year after radial artery grafting. Avoid bilateral percutaneous or surgical radial artery procedures in patients with coronary artery disease to preserve the artery for future use. Harvest the internal mammary artery using the skeletonization technique to reduce the risk of sternal wound complications. Use an endoscopic saphenous vein harvest technique in patients at risk of wound complications. Use a no-touch saphenous vein harvest technique in patients at low risk of wound complications. Use the skeletonized right gastroepiploic artery to graft right coronary artery target vessels with subocclusive stenosis if the operator is experienced with the use of the artery. CABG indicates coronary artery bypass graft.

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