Effect of Total Arterial Grafting in the Arterial Revascularization Trial

Abstract Objectives The Arterial Revascularization Trial (ART) was designed to compare 10-year survival in bilateral (BITA) vs. single internal thoracic artery (SITA) grafts. The intention-to-treat analysis has showed comparable outcomes between the two groups but an explanatory analysis suggested that those receiving 2 or more arterial grafts had better survival. Whether the exclusive use of arterial grafts provide further benefit is unclear. Methods We performed an exploratory analysis of the ART based on conduits actually received (as-treated principle). From ART cohort, only patients receiving at least 3 grafts were included. The final population consisted of 1084, 1010 and 390 patients in the single arteria graft (SAG) group, in the multiple arterial graft (MAG) group (2 or more arterial grafts with additional saphenous veins) and total arterial graft (TAG) group (3 or more arterial grafts only) respectively. Inverse probability of treatment weighting (IPTW) was used for comparison. Results When compared to the SAG group, there was a significant trend toward a reduction of 10-year mortality in the MAG and TAG group (test for trend P=0.02). TAG group was associated with the lowest risk of late mortality (HR 0.68; 95%CI 0.48-0.96; P=0.03) and with a significant risk reduction of the composite of death/MI/stroke and repeat revascularization (HR 0.71; 95%CI 0.53-0.94; P=0.02). Conclusions When compared to SAG, both MAG and TAG represent valuable strategies to improve clinical outcomes following CABG but TAG can potentially provide further benefit.