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Radial-Artery grafts lead to improved outcomes of CABG


Radial-Artery grafts lead to improved outcomes of CABG

The use of radial-artery grafts for multivessel coronary artery bypass grafting (CABG) improved post-operative outcomes as compared to saphenous-vein grafts, according to a new study published in New England Journal of Medicine.

The study was conducted by John Puskas, MD, of Icahn School of Medicine at Mount Sinai in New York City, and colleagues wherein they performed a patient-level combined analysis of randomized, controlled trials to compare radial-artery grafts and saphenous-vein grafts for CABG.

For carrying out the study, the researchers performed Radial Artery Database International Alliance (RADIAL) meta-analysis of patient-level trial data. Six trials were identified. The primary outcome was a composite of death, myocardial infarction, or repeat revascularization. The secondary outcome was graft patency on follow-up angiography. Mixed-effects Cox regression models were used to estimate the treatment effect on the outcomes.

RADIAL looked at outcomes from 1,036 patients across six trials (534 received radial-artery grafts and 502 received saphenous-vein grafts).

On the basis of the trials, following inferences were made:

  • the incidence of adverse cardiac events was significantly lower in association with radial-artery grafts than with saphenous-vein grafts
  • the use of radial-artery grafts was associated with a significantly lower risk of occlusion
  • the composite outcome of death, myocardial infarction or repeat revascularization was reduced by the multi-artery strategy instead of vein conduit
  •  the use of radial-artery grafts was associated with a nominally lower incidence of myocardial infarction and  repeat revascularization, as compared with the use of the saphenous vein graft
  • Death from any cause numerically went in the same direction but with a wide confidence interval (15 versus 17 per 1,000 patient-years, HR 0.90, P=0.68), Mario Gaudino, MD, of New York-Presbyterian and Weill Cornell Medicine in New York City, reported at the American Association for Thoracic Surgery (AATS) meeting in San Diego.

The findings “should guide a genuine change” in how CABG is done, argued Dr. Puskas. “Surgeons in North America and Europe presently use the radial artery in less than 8% of all coronary bypass procedures.”

Puskas called RADIAL a landmark study — and not only for being the first late-breaking study in AATS’s more than 100-year history.

“While retrospective observational studies have suggested that this [benefit of radial conduit] might be the case, several randomized controlled trials of radial artery versus saphenous vein grafts as the second conduit in coronary bypass operations have failed to prove a statistically significant improvement in clinical outcomes with the radial artery, because these individual trials have had too few patients enrolled to reach statistical significance,” he told MedPage Today.

The authors concluded that as compared with the use of saphenous-vein grafts, the use of radial-artery grafts for CABG resulted in a lower rate of adverse cardiac events and a higher rate of patency at 5 years of follow-up.

For further information, click on the link:  10.1056/NEJMoa1716026

 

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Medha Baranwal

Medha Baranwal

Medha Baranwal joined Medical Dialogues as a Desk Editor in 2018 for Speciality Medical Dialogues. She covers several medical specialties including Cardiac Sciences, Dentistry, Diabetes and Endo, Diagnostics, ENT, Gastroenterology, Neurosciences, and Radiology. She has completed her Bachelors in Biomedical Sciences from DU and then pursued Masters in Biotechnology from Amity University. She can be contacted at medha@medicaldialogues.in. Contact no. 011-43720751
Source: With inputs from NEJM

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    Dr Harinder Singh Bedi May 8, 2018, 5:03 pm

    The RADIAL trial is indeed a landmark one . It proves once and for all that the RA is far superior to the SVG. We have been using the RA since 1995 and are extremely happy with the results . There are however some very important contraindications to its use :
    Exclusion criteria for RA use:
    1. Positive Allen test ie inadequate ulnar collateral flow
    2. RA stenosis
    3. RA plaque or calcification as seen by Doppler ultrasonography
    4. h/o vasculitis or Raynaud’s disease/ phenomenon
    5. Chronic renal failure on hemodialysis (as RA may be needed for an AV fistula)
    6. Diffuse calcification noted during harvesting
    7. Diameter < 2 mm
    8. Use of the trans-radial route for a coronary angiogram for at least 3 months prior to CABG
    It behoves the surgeon to be fully conversant with the anatomy of the RA and to use utmost care during its harvest – no touch, non-cautery technique, safeguarding the lateral cutaneous and superficial radial nerve, use of anti-spastic measures pre intra and post operatively, and grafting to vessels with at least 80% stenosis .
    We have now started using bilateral RA wherever appropriate – in approx. 30 % cases ( 90% unilateral) . Postoperative angiograms showing excellent patency have boosted our confidence .

    The evidence of improved clinical outcome as shown in the RADIAL trial is of great importance to our patients . On the basis of current evidence we strongly advocate the use of the RA wherever indicated .

    Dr.Harinder Singh Bedi MCh,FIACS (Gold Medallist)
    Chairman , Cardio Vascular Endovascular & Thoracic Sciences,
    Ludhiana Mediways Hospital, Ferozpur Road
    Ludhiana- 142027
    Punjab, India
    Mobile- 9814060480
    e-mail- cardiaccarecentre1@gmail.com , drhsbedicmc@gmail.com, drhsbedi12@yahoo.com,
    website: http://www.drhsbedi.com

    Secretary – Venous Association of India (VAI)
    Founder President and Patron – Association of North Zone Cardio Thoracic & Vascular Surgeons (ANZCTVS)

    \"Excellence is to do an ordinary thing in an extraordinary way.\"
    — Booker T. Washington