Conduit Choice and Volume-Outcome Relationships in Multiarterial Coronary Artery Bypass Grafting of Medicare Beneficiaries in the United States - PubMed (original) (raw)

Multicenter Study

Conduit Choice and Volume-Outcome Relationships in Multiarterial Coronary Artery Bypass Grafting of Medicare Beneficiaries in the United States

Derrick Y Tam et al. Ann Thorac Surg. 2026 May.

Abstract

Background: Multiarterial grafting is underused. We evaluated the association between surgeon experience and conduit use outcomes after multiarterial grafting.

Methods: Using US Centers for Medicare & Medicaid data, we identified 29,268 patients ≥65 years undergoing isolated, primary, nonemergency multiarterial grafting, of whom 15,682 met the inclusion criteria. Propensity score matching was performed on 26 baseline patient characteristics. Individual surgeons were grouped into tertiles on the basis of conduit use: low volume, <3 radial arteries or 2 bilateral internal thoracic artery (BITA) grafts annually; high volume, >10 radial arteries or 4 BITA grafts annually. The primary outcome was major adverse cardiac events (MACE): death, myocardial infarction, or repeated revascularization at 4 years. Outcomes were compared in a multivariable Cox proportional hazards model adjusting for the individual surgeon's case volume of each conduit.

Results: Among recipients of multiarterial grafting, 5784 (20%) received radial artery grafts and 9898 (34%) received BITA grafts. Radial artery recipients were younger (70.6 vs 71.2 years) and more likely to be diabetic (46.9% vs 43.2%) than BITA recipients. Of 5778 matched pairs, at 4 years, the incidence of MACE was numerically lower in the radial artery group (14.7% vs 15.7%; P = .05), but there was no difference in all-cause mortality (10.8% radial artery vs 11.5% BITA; P = .06). For BITA graft recipients, surgeon experience was associated with MACE only in the lowest vs the highest volume tertile (adjusted hazard ratio, 1.15; 95% CI, 1.01-1.33; P = .046). There was no association between MACE and surgeon volume for radial artery graft recipients.

Conclusions: Radial artery and BITA grafting demonstrated similar midterm outcomes, whereas there was a surgeon-volume effect for BITA use.

Copyright © 2026. Published by Elsevier Inc.

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Conflict of interest statement

Disclosures Joanna Chikwe serves as Editor-in-Chief for The Annals of Thoracic Surgery. Michael E. Bowdish services as Senior Editor for The Annals of Thoracic Surgery and Chair of The Society of Thoracic Surgeons Workforce on Adult Cardiac Surgery Database. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Figures

Figure 1.

Figure 1.

National trends in utilization of the radial artery as the second arterial graft among Medicare patients undergoing multi-arterial grafting for isolated CABG.

Figure 2.

Figure 2.

Cumulative incidence of MACE at 4 years in patients receiving a radial artery as their second arterial graft vs patients receiving a second ITA after propensity score matching (14.7% vs 15.7%, HR:0.88, 95% CI:0.77–1.00, p=0.050).

Figure 3.

Figure 3.

Cumulative incidence of death at 4 years in patients receiving a radial artery as their second arterial graft vs patients receiving a second ITA after propensity score matching (11.5% vs 10.8%, HR:0.90, 95% CI:0.79–1.02, p=0.061).

Figure 4.

Figure 4.

Freedom from MACE in patients receiving a second ITA graft only at 4 years stratified by surgeon volume. Low volume surgeons were associated with a higher incidence of MACE at 4-years (HR:1.15, 95% CI:1.01–1.33, p=0.046) compared to high volume surgeons.

Figure 5.

Figure 5.

Freedom from MACE among patients receiving a radial artery graft as their second arterial graft only at 4 years stratified by surgeon volume. There was no difference in the incidence of MACE at 4 years when stratified by surgeon volume.

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