Society of Thoracic Surgeons: Use arteries rather than veins in CABG

Arteries, not veins, should be used when performing CABG, according to a new clinical practice guideline from the Society of Thoracic Surgeons.

The preferred conduit for CABG is the left internal thoracic artery, which has been associated with better survival, graft patency and freedom from CV events compared with saphenous vein grafts, Gabriel S. Aldea, MD, from the division of cardiothoracic surgery at the University of Washington School of Medicine in Seattle, and colleagues wrote.

“Despite this, our review of the [Society of Thoracic Surgeons] National Database showed that less than 10% of patients undergoing CABG surgery in the U.S. received two or more arterial grafts,” Aldea said in a press release. “The goal of our writing group was to review and update all current data to assess how the choice of arterial conduit affects patient outcomes following surgery.”

When bypass of the left anterior descending artery is indicated, the left internal thoracic artery should be used, Aldea and colleagues wrote, deeming that recommendation class I, level of evidence B.

In some patients, it is appropriate for a second arterial graft to be used, which should be the right internal thoracic artery or the radial artery, they wrote, noting that bilateral internal thoracic arteries should be considered in patients without excessive risk for sternal complications.

They wrote that the following measures may be considered to reduce risk for sternal infection from bilateral internal thoracic artery grafting: using a skeletonized graft, having the patient cease smoking, implementing glycemic control and enhanced sternal stabilization.

In patients with inadequate left internal thoracic artery grafts or in need of an adjunct, use of a radial artery graft is reasonable if the coronary target has severe stenosis, Aldea and colleagues wrote. When this is necessary, using pharmacological agents to reduced acute spasm (both intraoperative and perioperative) is reasonable, they added.

The right gastroepiploic artery can be considered when a patient has poor conduit options or if an adjunct to more complete arterial revascularization is needed, according to the authors.

A heart team should be convened to determine the optimal approach to the key issues involving arterial grafts, including specific targets, number and type, they wrote.

“Current data suggest that a right internal thoracic artery or radial artery graft can be used safely in many, if not most, patients and is associated with improved graft patency and survival,” Aldea said in the release. “However, our research shows that there is an increased risk of sternal wound infection in some patients, so we recommend discussing treatment options with the heart team to determine the most effective graft conduit for each individual patient.” – by Erik Swain

Disclosure: The guideline authors report no relevant financial disclosures.