Surgeons’ preferences for vein graft utilization do not determine long-term survival in Medicare patients undergoing single-arterial graft (SAG) coronary artery bypass grafting (CABG), a new study reveals. This finding suggests that surgeons may be reasonably conservative in vein graft utilization, Emily Shih, MD, of Baylor University Medical Center, Dallas, and colleagues in a manuscript published Monday online and in the Feb. 28 issue of the Journal of the American College of Cardiology. CABG is recommended over medical therapy to improve survival and freedom from major adverse cardiovascular or cerebrovascular events (MACE) in patients with complex multivessel coronary artery disease experience . There is controversy about whether single- or multiarterial grafting provides better long-term outcomes. This study aimed to determine whether liberal vs conservative use of vein graft utilization is associated with increased survival rates in Medicare patients undergoing SAG-CABG. Surgeons’ use of conservative (≥ 1 SD below mean), average (within 1 SD of mean) and liberal (≥ above the mean) SAG-CABG was measured by how many saphenous vein grafts (SVGs) were used in the procedure. The Kaplan-Meier analysis was used to estimate and compare surgeon groups before and after augmented inverse-probability weighting. This observational, retrospective study evaluated 1,028,264 Medicare patients (mean age = 72.0 ± 7.9 years; 68.3% male; 88.9% white, 6.2% Black) who underwent SAG-CABG between 2001 and 2015. Some comorbidities included diabetes (45.3%), hypertension (84.2%) and anemia (41.0%). Throughout the study, one-vein and two-vein SAG-CABG usage increased, and three-vein and ≥4-vein SAG-CABG usage decreased (P < 0.001). Surgeons using vein grafts conservatively performed a mean of 1.7 ± 0.2 vein grafts per SAG-CABG. Surgeons using vein grafts liberally utilized a mean 2.9 ± 0.2 vein grafts per SAG-CABG. There were no differences in median survival in patients undergoing SAG-CABG, regardless of liberal vs conservative vein grafting (adjusted mean survival difference 27 days). The investigators concluded that the results suggest conservative approaches to SVG are reasonable in elderly patients undergoing SAG-CABG. In an accompanying editorial, Marcus Flather, MBBS, MBA, and Suprateeka Talukder, MBBS, MRes, of the University of East Anglia, Norwich, England, briefly described the history of CABG and went on to describe the benefits of this study. The editorialists noted that this study was “carefully constructed” and that the investigators made an effort to minimize the potential limitations that come with retrospective studies. They also said they are unsure why there is great variation in the number of SVGs used by surgeons, but this study should provide insight as to how those decisions are made. Flather and Talukder concluded that future studies should evaluate risk factors for long-term mortality that may further determine which patients should receive fewer SVG. The editorialists concluded, “Although surgeon preference is important to determine the number of vein grafts provided during CABG, there will be many other measured and unmeasured variables influencing vein graft utilization. Their suggestion to use fewer vein grafts is not associated with better outcomes, and therefore, questions about the types of grafts and the number of conduits required for optimal revascularization remain open.” Sources: Shih E, Squiers JJ, Banwait JK, et al. Vein Graft Use and Long-Term Survival Following Coronary Bypass Grafting. J Am Coll Cardiol 2023;81:713-725. Flather M, Talukder S. Saphenous Vein Grafts for Coronary Surgery: More May Be Less. J Am Coll Cardiol 2023;81:726-728. Image Credit: ungvar – stock.adobe.com