Long-Term Survival Advantage of Total Arterial Revascularization in Elderly Patients Following Coronary Artery Bypass Grafting.

Abstract

Background: Despite the evidence of clinical benefit, total arterial revascularization (TAR) remains underutilized in elderly patients undergoing coronary artery bypass grafting due to concerns about perceived surgical complexity and limited life expectancy.

Objectives: The objective of the study was to evaluate long-term survival of TAR vs conventional non-TAR grafting strategies in elderly (≥70 years) and younger (<70 years) patients using a binational cardiac surgery registry.

Methods: The study included patients who underwent primary isolated coronary artery bypass grafting with at least 2 grafts between 2001 and 2020. The endpoint was long-term all-cause mortality. Patients were stratified into 2 age groups, <70 years and ≥70 years. Within each cohort, survival outcomes were compared between those who received TAR, and those who received non-TAR involving at least 1 saphenous vein graft. Secondary analyses further divided the non-TAR group into patients receiving multiple arterial grafting or single arterial grafting. Baseline differences were adjusted using inverse probability treatment weighting, followed by Cox proportional hazard modeling.

Results: Among 59,641 patients, TAR was associated with significantly improved survival compared to non-TAR in both elderly (HR: 0.87; 95% CI: 0.81-0.92; P < 0.001) and younger age groups (HR: 0.80; 95% CI: 0.73-0.88; P < 0.001). A clear hierarchy in survival was also demonstrated, with the highest survival observed in patients undergoing TAR, followed by non-TAR-multiple arterial grafting, and the lowest in those receiving non-TAR-single arterial grafting.

Conclusions: TAR improves long-term survival in both elderly and younger patients. These findings challenge the assumption that limited life expectancy precludes arterial grafting and support broader implementation of TAR in appropriately selected older patients. Randomized clinical trials evaluating TAR are warranted to validate these observational findings.