Reply: The incomplete puzzle of complete revascularization

The authors reported no conflicts of interest.The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. Bianco and colleagues1Bianco V. Kilic A. Aranda-Michel E. Serna-Gallegos D. Ferdinand F. Dunn-Lewis C. et al.Complete revascularization during coronary artery bypass grafting is associated with reduced major adverse events.J Thorac Cardiovasc Surg. June 9, 2021; ([Epub ahead of print])Abstract Full Text Full Text PDF Scopus (11) Google Scholar study on complete revascularization (CR) in coronary artery bypass grafting (CABG) has unsurprisingly generated considerable dialogue. Among these commentaries, Zhou and colleagues2Zhou Z. Liang M. Wu Z. Complete revascularization in coronary artery bypass grafting: how sure are we?.J Thorac Cardiovasc Surg Open. 2022; 9: 116-117Scopus (3) Google Scholar have provided some thought-provoking questions. One of their main questions is whether CR should be recommended for all patients as a blanket recommendation. While we acknowledge the limitations of the study by Bianco and colleagues,1Bianco V. Kilic A. Aranda-Michel E. Serna-Gallegos D. Ferdinand F. Dunn-Lewis C. et al.Complete revascularization during coronary artery bypass grafting is associated with reduced major adverse events.J Thorac Cardiovasc Surg. June 9, 2021; ([Epub ahead of print])Abstract Full Text Full Text PDF Scopus (11) Google Scholar including residual confounding, it also supports a larger body of evidence that suggests that there is significant benefit to CR in CABG.3Garcia S. Sandoval Y. Roukoz H. Adabag S. Canoniero M. Yannopoulos D. et al.Outcomes after complete versus incomplete revascularization of patients with multivessel coronary artery disease: a meta-analysis of 89,883 patients enrolled in randomized clinical trials and observational studies.J Am Coll Cardiol. 2013; 62: 1421-1431Crossref PubMed Scopus (276) Google Scholar,4Leviner D.B. Torregrossa G. Puskas J.D. Incomplete revascularization: what the surgeon needs to know.Ann Cardiothorac Surg. 2018; 7: 463-469Crossref PubMed Scopus (17) Google Scholar It seems appropriate that CR should indeed be one of the core priorities of CABG. How one achieves CR is debatable, and several definitions have been proposed and studied, with varying clinical benefit. The analyses by Bianco and colleagues1Bianco V. Kilic A. Aranda-Michel E. Serna-Gallegos D. Ferdinand F. Dunn-Lewis C. et al.Complete revascularization during coronary artery bypass grafting is associated with reduced major adverse events.J Thorac Cardiovasc Surg. June 9, 2021; ([Epub ahead of print])Abstract Full Text Full Text PDF Scopus (11) Google Scholar suggest that revascularization of non-main-branch vessels is unlikely to provide further benefit over revascularization of only main-branch vessels. As a rule of thumb, keeping the revascularization strategy simple, even in the context of extensive multivessel disease, is a safe bet. Any benefit derived from revascularization of non-main-branch vessels is probably marginal at best. Zhou and colleagues2Zhou Z. Liang M. Wu Z. Complete revascularization in coronary artery bypass grafting: how sure are we?.J Thorac Cardiovasc Surg Open. 2022; 9: 116-117Scopus (3) Google Scholar suggest that populations that may not benefit from CR include patients with diabetes, those with reduced left ventricular ejection fraction, frail patients, and elderly patients. We are not sure these patients really do not benefit from CR. On the contrary, it appears that most patient populations benefit from CR, including those with lower ejection fractions.5Bell M.R. Gersh B.J. Schaff H.V. Holmes Jr., D.R. Fisher L.D. Alderman E.L. et al.Effect of completeness of revascularization on long-term outcome of patients with three-vessel disease undergoing coronary artery bypass surgery: a report from the Coronary Artery Surgery Study (CASS) registry.Circulation. 1992; 86: 446-457Crossref PubMed Google Scholar Furthermore, “benefit” may not necessarily mean improved survival but freedom from angina and freedom from myocardial infarction and revascularization events, which is quite significant from a patient perspective. The aforementioned patient population, instead, is more likely to undergo incomplete revascularization (IR) and have worse outcomes irrespective of CR or IR, indicative of a worse disease and comorbidity profile.6Mocanu V. Buth K.J. Kelly R. Légaré J.F. Incomplete revascularization after coronary artery bypass graft operations is independently associated with worse long-term survival.Ann Thorac Surg. 2014; 98: 549-555Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar Perhaps we should reframe our question to “how can we better and safely achieve CR in these populations?” That question is more challenging to answer and may be answered one day with a hybrid approach. Finally, Zhou and colleagues2Zhou Z. Liang M. Wu Z. Complete revascularization in coronary artery bypass grafting: how sure are we?.J Thorac Cardiovasc Surg Open. 2022; 9: 116-117Scopus (3) Google Scholar also bring up the role of multiple arterial grafting in the setting of IR. As they noted, previous studies have demonstrated that multiple arterial grafts may offset the poor outcomes associated with IR.7Kieser T.M. Curran H.J. Rose M.S. Norris C.M. Graham M.M. Arterial grafts balance survival between incomplete and complete revascularization: a series of 1000 consecutive coronary artery bypass graft patients with 98% arterial grafts.J Thorac Cardiovasc Surg. 2014; 147: 75-84Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar More recently, Rosenblum and colleagues8Rosenblum J.M. Binongo J. Wei J. Liu Y. Leshnower B.G. Chen E.P. et al.Priorities in coronary artery bypass grafting: is midterm survival more dependent on completeness of revascularization or multiple arterial grafts?.J Thorac Cardiovasc Surg. 2021; 161: 2070-2078.e6Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar found that multiple arterial grafting led to improved midterm survival in both CR and IR cohorts. More evidence with respect to the interaction between IR and multiple arterial grafting will hopefully be obtained with the ROMA trial.9Gaudino M. Alexander J.H. Bakaeen F.G. Ballman K. Barili F. Calafiore A.M. et al.Randomized comparison of the clinical outcome of single versus multiple arterial grafts: the ROMA trial-rationale and study protocol.Eur J Cardiothorac Surg. 2017; 52: 1031-1040Crossref PubMed Google Scholar We thank Zhou and colleagues2Zhou Z. Liang M. Wu Z. Complete revascularization in coronary artery bypass grafting: how sure are we?.J Thorac Cardiovasc Surg Open. 2022; 9: 116-117Scopus (3) Google Scholar for their insights and encouraging the continued investigation of CR in the setting of CABG. The questions of CR in CABG are more relevant than ever in today's everchanging landscape of revascularization, and it would be a great service to our profession and patients to gain further understanding of such. Complete revascularization in coronary artery bypass grafting: How sure are we?JTCVS OpenVol. 9PreviewThe current European guidelines recommend that the completeness of revascularization should be taken into account when determining the most appropriate strategy in treating ischemic heart diseases.1 In patients who undergo coronary artery bypass grafting (CABG), the benefits of complete revascularization appeared to be shown in previous studies.2 Full-Text PDF Open Access

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