Clinical and angiographic outcomes associated with surgical revascularization of angiographically borderline 50-69% coronary artery stenoses

Janek M Senaratne; Colleen M Norris; Michelle M Graham; Diane Galbraith; Jayan Nagendran; Darren H Freed; Jonathan Afilalo; Sean Van Diepen; APPROACH Investigators

doi:10.1093/ejcts/ezw005

Clinical and angiographic outcomes associated with surgical revascularization of angiographically borderline 50-69% coronary artery stenoses

Eur J Cardiothorac Surg. 2016 May;49(5):e112-8. doi: 10.1093/ejcts/ezw005. Epub 2016 Jan 29.

Authors

Janek M Senaratne¹, Colleen M Norris², Michelle M Graham¹, Diane Galbraith³, Jayan Nagendran⁴, Darren H Freed⁴, Jonathan Afilalo⁵, Sean Van Diepen⁶; APPROACH Investigators

Affiliations

¹ Division of Cardiology, University of Alberta Hospital, Edmonton, AB, Canada.
² Division of Cardiology, University of Alberta Hospital, Edmonton, AB, Canada Division of Cardiac Surgery, Mazankowski Alberta Heart Institute, Edmonton, AB, Canada Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease, Calgary, AB, Canada Cardiovascular Health and Stroke, Strategic Clinical Network, AB, Canada Faculty of Nursing, University of Alberta, Edmonton, AB, Canada.
³ Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease, Calgary, AB, Canada.
⁴ Division of Cardiac Surgery, Mazankowski Alberta Heart Institute, Edmonton, AB, Canada.
⁵ Division of Cardiology, Jewish General Hospital, McGill University, Montreal, QC, Canada.
⁶ Division of Cardiology, University of Alberta Hospital, Edmonton, AB, Canada Division of Critical Care, University of Alberta Hospital, Edmonton, AB, Canada sv9@ualberta.ca.

PMID: 26825107
DOI: 10.1093/ejcts/ezw005

Abstract

Objectives: Coronary artery bypass grafting (CABG) improves outcomes in patients with multivessel coronary artery disease. Bypass of angiographically significant lesions ≥70% is recommended, yet little is known about the incidence/outcomes with bypasses of 50-69% angiographically borderline lesions (ABLs) without fractional flow reserve testing. The objective of this study was to investigate the incidence and outcomes of bypass of 50-69% ABLs.

Methods: Between 2007 and 2013, 3195 patients underwent isolated first multivessel CABG. Patients with an isolated ABL of a major epicardial vessel were included. Outcomes of interest included time to all-cause mortality, and 30-day and 1-year mortality.

Results: Among 350 patients with an ABL, 268 (76.6%) had the vessel containing the ABL bypassed, while 82 (23.4%) did not. The mean follow-up was 4.2 years. Patients with a bypassed ABL were older (66.1 vs 62.5 mean years, P = 0.006) but otherwise similar in sex, comorbidities, diabetes, ejection fraction and number of coronary stenoses. Cardiopulmonary bypass time was longer in patients with bypassed ABLs (104.2 vs 90.4 min, mean, P < 0.001). Unadjusted overall mortality until the end of follow-up was higher among patients with bypassed ABLs (11.6 vs 3.7%, P = 0.034). After multivariable adjustment, the association between ABL bypass and mortality was attenuated (hazard ratio 2.84, 95% confidence interval: 0.87-9.23, P = 0.080). No differences were observed in unadjusted 30-day (1.1 vs 0.0%, P = 0.336) or 1-year mortality (4.1 vs 0.0%, P = 0.062). Repeat revascularization rate of patients with bypassed ABLs was numerically higher (4.1 vs 0.0%, P = 0.107).

Conclusions: In an unselected cohort of patients with ABLs, bypass of borderline 50-69% lesions is frequently performed and not associated with improved long-term survival. Our findings suggest that the routine surgical revascularization of 50-69% ABLs may not be warranted.

Keywords: Angiography; Coronary artery bypass grafting; Coronary artery disease.

MeSH terms

Aged
Coronary Angiography
Coronary Artery Bypass / mortality*
Coronary Artery Bypass / statistics & numerical data
Coronary Stenosis / diagnostic imaging*
Coronary Stenosis / surgery*
Female
Humans
Male
Middle Aged
Myocardial Revascularization / mortality*
Myocardial Revascularization / statistics & numerical data
Prospective Studies