Original Investigation
Vein Graft Use and Long-Term Survival Following Coronary Bypass Grafting

https://doi.org/10.1016/j.jacc.2022.11.054Get rights and content
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Abstract

Background

Although placement of at least 1 arterial graft during coronary artery bypass grafting (CABG) has a proven survival benefit, it is unknown what degree of revascularization with saphenous vein grafting (SVG) is associated with improved survival.

Objectives

The authors sought to determine whether undergoing surgery performed by a surgeon who is liberal with vein graft utilization is associated with improved survival in patients undergoing single arterial graft CABG (SAG-CABG).

Methods

This was a retrospective, observational study of SAG-CABG performed in Medicare beneficiaries from 2001 to 2015. Surgeons were stratified by number of SVG utilized per SAG-CABG into conservative (≥1 SD below mean), average (within 1 SD of mean), and liberal (≥1 SD above mean). Long-term survival was estimated using Kaplan-Meier analysis and compared among surgeon groups before and after augmented inverse-probability weighting.

Results

There were 1,028,264 Medicare beneficiaries undergoing SAG-CABG from 2001 to 2015 (mean age 72.0 ± 7.9 years, 68.3% male). Over time, 1-vein and 2-vein SAG-CABG utilization increased, whereas 3-vein and ≥4-vein SAG-CABG utilization decreased (P < 0.001). Surgeons who were conservative vein graft users performed a mean 1.7 ± 0.2 vein grafts per SAG-CABG, whereas those who were liberal vein graft users performed a mean 2.9 ± 0.2 vein grafts per SAG-CABG. Weighted analysis demonstrated no difference in median survival among patients undergoing SAG-CABG by liberal vs conservative vein graft users (adjusted median survival difference 27 days).

Conclusions

Among Medicare beneficiaries undergoing SAG-CABG, there is no association between surgeon proclivity for vein graft utilization and long-term survival, suggesting that a conservative approach to vein graft utilization is reasonable.

Key Words

coronary artery bypass grafting
Medicare
single artery graft
vein grafts

Abbreviation and Acronyms

ADI
area deprivation index
AIPW
augmented inverse-probability weighting
ASU
average saphenous vein graft user
CABG
coronary artery bypass grafting
CPT
Current Procedural Terminology
CSU
conservative saphenous vein graft user
ICD
International Classification of Diseases
LSU
liberal saphenous vein graft user
MACE
major adverse cardiac or cerebrovascular events
PCI
percutaneous coronary intervention
SAG-CABG
single arterial grafting coronary artery bypass grafting
SMD
standardized mean difference
SVG
saphenous vein graft

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Listen to this manuscript's audio summary by Editor-in-Chief Dr Valentin Fuster on www.jacc.org/journal/jacc.

Marcus Flather, MD, served as Guest Associate Editor for this paper. Athena Poppas, MD, served as Guest Editor-in-Chief for this paper.

The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.