Total Arterial Revascularization Boosts Long-Term Survival in Elderly CABG Patients: Study Shows
Australia: A new large-scale analysis published in JACC: Advances has shown that using total arterial revascularization (TAR) during coronary artery bypass grafting (CABG) offers a significant long-term survival advantage for both younger and elderly patients.
The research, led by Justin Ren from the Department of Surgery, University of Melbourne, Australia, provides compelling evidence that challenges the long-held belief that older patients do not benefit as much from arterial grafting due to limited life expectancy.
The study analyzed data from the Australia and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) registry, including 59,641 patients who underwent primary isolated CABG with at least two grafts between 2001 and 2020. Participants were divided into two age groups: younger (<70 years) and elderly (≥70 years).
Within each group, outcomes were compared between patients who underwent TAR—using only arterial grafts—and those who received conventional non-TAR procedures involving at least one saphenous vein graft (SVG).
The key findings of the study were as follows:
- Total arterial revascularization significantly improved long-term survival in both elderly and younger patients.
- In elderly patients (≥70 years), TAR was associated with a hazard ratio (HR) of 0.87 for survival.
- In younger patients (<70 years), TAR showed a hazard ratio (HR) of 0.80 for survival.
- Patients receiving TAR had the highest survival, followed by those with multiple arterial grafts.
- The lowest survival was observed in patients undergoing single arterial grafting with saphenous vein conduits.
The findings reaffirm the durability and long-term benefits of arterial conduits, which are less prone to atherosclerosis compared to vein grafts. Despite this, TAR remains underutilized in older adults due to concerns about technical difficulty and shorter anticipated lifespans. The study’s authors argue that these assumptions are outdated, emphasizing that many elderly patients live long enough to gain meaningful benefit from the enhanced patency and durability of arterial grafts.
While acknowledging the study’s retrospective nature and limitations—such as lack of data on frailty, surgeon experience, and postoperative events—the researchers highlighted that the analysis drew on a large, high-quality, prospectively maintained registry, lending credibility to its conclusions.
Importantly, the results suggest that avoiding vein grafts altogether could be a key factor in improving long-term survival, regardless of patient age. Dr. Ren and colleagues called for greater adoption of TAR in appropriate elderly patients and urged further randomized clinical trials to validate these observational findings.
The authors concluded that these results should encourage a broader shift in surgical practice, where conduit selection is guided by evidence-based outcomes rather than chronological age. The ongoing Total Arterial (TA) trial in Australia aims to provide further clarity on the angiographic and clinical benefits of this approach.
"The study provides strong evidence that total arterial revascularization significantly enhances long-term survival after CABG, even in elderly patients, emphasizing the need for a more proactive approach to incorporating arterial grafting strategies in modern cardiac surgery," the authors wrote.
Reference:
Ren J, Reid CM, Smith JA, et al. Long-term survival advantage of total arterial revascularization in elderly patients following coronary artery bypass grafting. JACC Adv. 2025;Epub ahead of print.
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