Commentary: Complete or incomplete? Just use more arteries

Central MessageMultiple arterial grafting and completeness of revascularization are 2 main pillars improved outcomes in coronary artery bypass grafting.See Article page 2070. Multiple grafting. See One the unique advantages surgery (CABG) is potential to decrease future myocardial infarction, not only by bypassing flow-limiting lesions identified angiography, but also protecting a distal territory that could become ischemic an eventual rupture thrombosis non–flow-limiting from proximal third bypassed vessel.1Doenst T. Haverich A. Serruys P. Bonow R.O. Kappetein Falk V. et al.PCI CABG for treating stable disease: JACC review topic week.J Am Coll Cardiol. 2019; 73: 964-976Crossref PubMed Scopus (136) Google Scholar Hence, as Jones Weintraub Emory earlier mentioned their landmark study evaluating revascularization: “in absence compelling technical limitation complete or nearly should be attempted with operation.”2Jones E.L. W.S. The importance during long-term follow-up after operations.J Thorac Cardiovasc Surg. 1996; 112: 227-237Abstract Full Text PDF (175) Besides revascularization, another strategy has been associated CABG: use multiple grafts (MAGs) instead single (SAGs).3Rocha R.V. Tam D.Y. Karkhanis R. Nedadur Fang J. Tu J.V. al.Multiple better patients.Circulation. 2018; 138: 2081-2090Crossref (46) In current study, Rosenblum colleagues4Rosenblum J.M. Binongo Wei Liu Y. Leshnower B.G. Chen E.P. al.Priorities grafting: midterm survival more dependent on grafts?.J 2021; 161: 2070-2078.e6Abstract (8) investigated which 4 strategies would (MAG SAG without revascularization) using inverse probability treatment weighting (IPTW) address baseline imbalances. At median 1366 days, MAG was mid-term compared SAG, regardless revascularization. authors need congratulated unanswered question: “What patients: revascularization? Or both?” Nonetheless, this question easy answer. Completeness parameter simple measure. There have attempts define what constitutes procedure: ratio between number diseased vessels bypasses, territories divided revascularized (complete numeric areas myocardium, no viable myocardium functional revascularization).2Jones Scholar,5Bangalore S. Guo Samadashvili Z. Blecker Hannan Revascularization patients multivessel disease severe left ventricular systolic dysfunction: everolimus-eluting stents versus graft surgery.Circulation. 2016; 133: 2132-2140Crossref (88) Scholar, 6Bell M.R. Gersh B.J. Schaff H.V. Holmes Jr., D.R. Fisher L.D. Alderman al.Effect outcome three-vessel undergoing surgery. A report (CASS) registry.Circulation. 1992; 86: 446-457Crossref 7Ong A.T. P.W. Complete percutaneous intervention.Circulation. 2006; 114: 249-255Crossref (94) Despite proposed definitions, there clearly accepted criteria determine addition, reasons incomplete any individual patient multifactorial (patients' instability, small targets, calcified coronaries, intramyocardial vessels, lack conduits) generally well described, even single-institutional reports otherwise high-level data granularity. advantage IPTW characteristics adjustment ability calculate average effect entire (unlike propensity score matching). To estimate IPTW, it imperative population analyzed undergo types therapy. However, likely important reason who had did get Furthermore, surgical bilateral internal thoracic at institution excludes greater risk sternal infection. Also, different group comparisons performed. Perhaps method adjust multiplicity (Bonferroni false-discovery rate correction) employed minimize chances false-positive result. regards comparison overwhelming majority observational outcomes.8Yi G. Shine B. Rehman S.M. Altman D.G. Taggart D.P. Effect mammary survival: meta-analysis approach.Circulation. 2014; 130: 539-545Crossref (207) retrospective studies will never able fully unmeasured confounders influence surgeon's subjective decision perform one technique over another.9Gaudino M. Di Franco Rahouma Iannaccone Deb al.Unmeasured comparing meta-analysis.J Heart Assoc. 7: e008010Crossref (86) When analyzing hospital results post-IPTW adjustment, incidence death similar cohorts. postoperative intra-aortic balloon pump rates were lower SAG. Likewise, intensive care unit time statistically shorter early benefits unlikely related biological superiority approach rather suggest residual imbalance might persisted despite statistical adjustments confound clinical comparison. Finally, investigators observed difference (hazard ratio, 1.04; 95% confidence interval, 0.77-1.40, P = .80). Perhaps, if extended up 5 10 years, we observe difference. like emphasize always pursued performing does exempt surgeon attempt revascularize all possible vessels/territories. relevant message impact care, conservative “non-MAG” believes cannot accomplished case, they least specific population. can determined very granular operative angiographic such colleagues' provocative well-designed study. contrast, questions role probably answered randomized ART (Arterial Trial) ongoing ROMA (Randomized Comparison Clinical Outcome Single Versus Arterial grafts) trial appropriately evaluate question.10Gaudino Alexander J.H. Bakaeen F.G. Ballman K. Barili F. Calafiore A.M. al.Randomized grafts: trial-rationale protocol.Eur J Cardiothorac 2017; 52: 1031-1040Crossref Scholar,11Taggart Benedetto U. Gerry Gray Lees al.Bilateral internal-thoracic-artery years.N Engl Med. 380: 437-446Crossref (230) Priorities Is grafts?The Journal Thoracic Cardiovascular SurgeryVol. 161Issue 6PreviewBoth (multiple grafting) increased purpose relative Full-Text