How do surgeons decide? Conduit choice in coronary artery bypass graft surgery in the UK†

Shruti Jayakumar; Marisa Gasparini; Tom Treasure; Clare Burdett; Cardiothoracic Trainees Research Collaborative

doi:10.1093/icvts/ivz047

How do surgeons decide? Conduit choice in coronary artery bypass graft surgery in the UK†

Interact Cardiovasc Thorac Surg. 2019 Aug 1;29(2):179–186. doi: 10.1093/icvts/ivz047. Epub 2019 Mar 15.

Authors

Shruti Jayakumar¹, Marisa Gasparini², Tom Treasure³, Clare Burdett⁴; Cardiothoracic Trainees Research Collaborative

Collaborators

Cardiothoracic Trainees Research Collaborative:
Felix Jozsa, Olivia Padfield, Jonathan Strickland, Nilaani Murugesu, Nathan Samuel, Mohammed Said Noor, Gerald Roseman, Alina Budcan, Omar Dirir, Uday Keshwala, Sara Wasim, Andrew Thomson, Florence Mouy, Sandipika Gupta, Caryl Richards, Emily Bar, Nicholas Pearson, Sahil Nichani, Yong Yong Tew, Gerald Tan, Hey Cong Ying, Omkaar Sivanesan

Affiliations

¹ Department of Academic Medicine, St. George's University Hospital, London, UK.
² Department of General Surgery, Ealing Hospital, London, UK.
³ Clinical Operational Research Unit, University College London, London, UK.
⁴ School of Clinical Medicine, Cambridge University, Cambridge, UK.

PMID: 30879044
DOI: 10.1093/icvts/ivz047

Abstract

Objectives: Conduits used in coronary artery bypass grafting may have significant impact on outcomes, but evidence is mixed and there is large variation in practice. This study provides insights into the opinions of the UK surgeons on conduit use and their decision-making processes.

Methods: A questionnaire was created using the Ottawa Decision Support Framework to elicit the importance that surgeons placed on bilateral internal mammary artery grafting, skeletonization, total arterial revascularization and sequential anastomoses on a scale of 1-10. Scores ≥8 were deemed 'important' and ≤3 'not important'. Surgeons were asked to specify changes to practice in frail patients or emergencies. Additional questions included conduit type used, factors affecting decision-making and vein harvesting methods. Questionnaires were administered in person with data analysed centrally.

Results: Ninety-seven consultant cardiac surgeons from 25 centres responded. Thirty-two percent surgeons routinely used radial arteries and 36% used right internal mammary artery. High-quality evidence contributed most to decision-making receiving a total of 328/960 points, with consultant experience being the second (255/960 points). There was a bimodal distribution of perceived importance of bilateral internal mammary artery use, with 29 (30%) 'important' and 'not important' scores each. 23% of surgeons found total arterial revascularization important. Most surgeons (64%) preferred pedicled mammary arteries. Twenty-six percent of surgeons considered sequential grafting to be important.

Conclusions: Low uptake of total arterial revascularization and bilateral internal mammary artery among the UK consultants may be due to the lack of high-quality evidence demonstrating a significant benefit. It is also possible that reluctance to use certain conduits may stem from low levels of exposure to conduits or inadequate training, particularly given the importance of consultant experience on decision-making.

Keywords: Arterial revascularization; Bilateral internal mammary arteries; Conduits; Coronary artery bypass grafting.