Twenty-year outcomes of coronary artery bypass grafting utilizing 3 in situ arterial grafts

Objective: The added value of total arterial revascularization in coronary artery bypass grafting becomes particularly apparent when evaluating long-term results. We previously reported on our 10-year outcomes of total arterial revascularization using bilateral internal thoracic and gastroepiploic arteries as in situ grafts in patients with 3-vessel disease. This study aimed to increase the follow-up period to 20 years. Methods: We updated clinical outcomes of 201 patients operated on between 1992 and 2002. At that time, the technique was primarily performed in patients with a longer life expectancy. Primary end points were overall survival and freedom from the composite of major adverse cardiac events. Secondary end points were the separate cardiac events. Results: Extended follow-up included all patients. The median follow-up time was 19.2 years (interquartile range, 16.2-20.0). The respective 15- and 20-year Kaplan-Meier estimated survival probabilities were 73.9 degrees A (95 degrees A confidence interval [CI], 67.2%-79.5 %) and 63.5% (95% CI, 55.7 %-70.4 %) for overall survival and 57.9% (95% CI, 50.7%-64.5%) and 47.9% (95% CI, 40.1%-55.3%) for freedom from major adverse cardiac events. The respective estimated cumulative incidences at 15 and 20 years were 7.0% (95% CI, 3.5 %-10.6 %) and 7.8% (95% CI, 4.0%-11.6%) for myocardial infarction, 8.6% (95% CI, 4.7%-12.5%) and 9.3% (95% CI, 5.2%-13.3%) for percutaneous reintervention, 7.0% (95% CI, 3.5%-10.5%) and 7.0% (95% CI, 3.5%-10.5%) for reoperation, 8.6% (95% CI, 4.7%-12.6%) and 12.9% (95% CI, 7.6 %-18.2%) for cardiac death, and 10.8% (95% CI, 6.5%-15.2%) and 15.2% (95% CI, 9.8 %-20.6 %) for death from other causes. Conclusions: The use of in situ bilateral internal thoracic and gastroepiploic arteries provides outstanding 15- and 20-year survival and cardiac event-free survival probabilities. Further studies are needed in older patients with more severe comorbidities. Nevertheless, the results from this and scarce other studies on 15- to 20-year outcomes of total arterial revascularization suggest that cardiac surgeons should embrace the application of total arterial grafting to further reduce the risks of long-term cardiac events, especially during the second decade after surgery.