Surgeon proclivity for coronary endarterectomy during isolated coronary artery bypass grafting in Medicare beneficiaries†.

Objectives: Coronary endarterectomy (CE) is an adjunct to coronary artery bypass grafting (CABG) in patients with one or more diffusely diseased coronary arteries. Although associated with increased perioperative morbidity and mortality, it remains a therapeutic strategy to potentially improve late outcomes by facilitating the revascularization of an otherwise ungraftable target.

Methods: Medicare beneficiaries undergoing CABG from 2001 to 2019 were identified. Surgeon proclivity for endarterectomy was determined; surgeons were stratified by quintile of endarterectomy frequency. Overlap propensity score weighting risk-adjusted measured confounding variables. Risk-adjusted survival was compared between surgeons.

Results: 1 500 710 Medicare beneficiaries underwent isolated CABG, of whom 32 302 (2.2%) underwent concomitant CE. Surgeons were divided into never-endarterectomizers (0% frequency, 267 245 surgeries by 1839 surgeons), occasional-endarterectomizers (0-4% frequency, 1 001 310 surgeries by 2207 surgeons) and frequent-endarterectomizers (≥4% frequency, 232 155 surgeries by 756 surgeons). Beneficiaries undergoing surgery by a never-endarterectomizer had a risk-adjusted median survival of 10.05 [95% CI: 10.00, 10.09] versus 9.90 [9.86, 9.95] years in those undergoing surgery by a frequent-endarterectomizer, a difference of 1.71 [1.08, 2.37] months, P < 0.001 for risk-adjusted survival comparison. Similarly, beneficiaries undergoing surgery by an occasional-endarterectomizer had a risk-adjusted median survival of 9.94 [9.91, 9.96] versus 9.85 [9.80, 9.90] years for those undergoing surgery by a frequent-endarterectomizer, a difference of 1.05 [0.56, 1.74] months, P < 0.001 for risk-adjusted survival comparison.

Conclusions: Medicare beneficiaries undergoing CABG by never- or occasional-endarterectomizers had small early risk-adjusted survival advantages and similar late outcomes compared to those undergoing surgery by frequent-endarterectomizers. CE remains a valuable tool in selected cases; however, it may be reasonable for surgeons to adopt a never- or occasional-endarterectomy approach to CABG.