Cor Vasa 2005, 46(12):463-469

Complete myocardial arterial revascularization vs. conventional coronary artery bypass graft surgery-interim results of the CARACCASS study.

Vilém Rohn^1,*, Paul Simon², Elena Devyatko², Jana Vodičková¹, Jan Pirk¹, Ivo Skalský¹

¹ Klinika kardiovaskulární chirurgie, Institut klinické a experimentální medicíny, Praha, Česká republika

² Department of Cardiac and Thoracic Surgery, University of Vienna, Vídeň, Rakousko

Aim:
The aim of the study is to furnish evidence-based medicine" data for the decision making about the type of surgical treatment of coronary heart disease.

Method:
CARACCASS, a prospective, multicentric, randomized study compares the outcome of complete myocardial arterial revascularization (MAR) and conventional coronary artery bypass grafting (CABG) (i. e., LIMA /left internal mammary artery/ to the LAD /left anterior descending artery/ and venous bypass) in patients with three-vessel disease. The study included a total of 763 patients aged 38-65 years. Primary endpoints include total mortality and postoperative myocardial infarction. Secondary endpoints are a combination of absence of cardiac death and documented myocardial infarction or the need for re-revascularization (percutaneous coronary intervention or coronary artery bypass grafting).

Results:
The study included 763 patients, with 756 on follow-up (706 males, 50 females), mean age 56 ± 6.7 (33-65) years; 383 patients are in Group 1 ( conventional bypass) while 374 comprise Group 2 (MAR). Preoperative data were comparable except for age (56.8 ± 6.48 in Group 1 vs. 54.25 ± 6.83 in Group 2; p = 0.0016) and the number of hypertensive patients (67% in Group 1 vs. 56% in Group 2). Group 2 patients had fewer CABG procedures (2.96 ± 0.296 vs. 2.75 ± 0.45; p = 0.0017), but there was no difference in the number of peripheral anastomoses (3.39 ± 0.62; 3.2 ± 0.52; p = 0.145). MAP patients had longer aortic cross-clamping (44.11 ± 16.41 vs. 49.69 ± 15.52; p ≤ 0.0001) and on-pump times (74.73 ± 21.92 vs.
78.42 ± 23.59; p = 0,026).
Perioperative mortality was 0.79%, without a significant difference between the groups (0.79% vs. 0.80%). There was no difference in hospitalization time (mean 8.27 ± 3.91 vs. 9.37 ± 8.70 days; median 7 in either group). Group 2 patients stayed longer at the intensive care unit (2.10 ± 5.1 vs. 1.8 ± 2.0; p = 0.053). There was no difference in the number of periopera-tive myocardial infarctions (1.31% vs. 2.67%; p = 0.1801). Group 2 included more patients with blood losses within the first 12 hours > 1,000 ml (10.43% vs. 3.94%; p = 0.0005); however, the number of revisions for bleeding was identical
(p = 0.0882). Postoperative arrhythmias were more frequent in Group 2 (17.11% vs. 11.55%; p = 0.029) as were infectious complications (8.56% vs. 4.45%; p = 0.022). Mediastinitis rates did not differ between the groups (p = 0.1206).
Early coronary angiography procedures (total 458 anastomoses, 3.6/patient) showed patency of 97.12% of arterial and 93.15% of venous grafts (p = 0.037); also significant was the difference between LIMA vs. vena saphena magna /VSM/ anastomosis patency; 99.33 vs. 93.15%, respectively (p = 0.04).
A total of 147 patients have currently been on follow-up for 5 years, showing no significant differences in mortality, recurrent angina, incidence of myocardial infarction or other complications. There were three deaths (2%), two Group 1 patients and one Group 2 patient. Group 2 includes more patients (p = 0.018) returning to their jobs. There was likewise no differ-ence in the numbers of re-revascularization procedures.
The patency of venous and arterial graft anastomoses at 5 years was 83.78% vs. 93.75%, respectively (p = 0.063).

Conclusion:
MAR did not have an adverse effect on perioperative mortality or morbidity. It did not result in higher rates of perioperative myocardial infarctions and ischemia or serious postoperative complications. The body of available data is still limited to draw any authoritative postoperative conclusions.
The early angiographic bypass patency when using LIMA is significantly superior to VSM. There is a clear tendency to an increasing difference between the patency of arterial grafts and VSM.

Keywords: Coronary artery bypass grafting surgery; Complete arterial revascularization

Published: December 1, 2005  Show citation