Arterial Revascularization Trial (ART)

Around 25,000 coronary artery bypass grafting (CABG) operations are performed annually in the UK. Most patients need three bypass grafts and the standard CABG uses a single internal mammary artery (single IMA) from either side of the breastbone and supplemental vein grafts from the leg or a radial artery from the arm as necessary. This gives good results in the short-term but over ten years failure of vein grafts is higher than failure of the arteries. This can lead to reduced survival, recurrent angina and the need for further treatment including the possibility of a second operation. There is some evidence that using both arteries on either side of the breastbone (bilateral IMA grafts) may improve survival and reduce the need for redo surgery. However this operation takes longer to do and slightly increases the chance that the breastbone will not heal. To try and determine which is the better operation we propose to randomize (ie as if by the toss of a coin) patients to single or bilateral IMA grafts, along with other vein or artery as necessary. We will then follow up patients annually for at least 10 years after their operation.

Coronary artery bypass grafting (CABG) is the most commonly performed major operation in the industrialised world and the National Service Framework recommends an increase in the UK from around 500 to 750 operations per million of population per annum(ie from around 30,000 to 45,0000). Most patients need three bypass grafts and the standard CABG uses a single internal mammary artery (SIMA) and supplemental vein grafts (or radial artery). Over the long-term vein graft failure leads to reduced survival, recurrent angina and the need for redo surgery. Evidence from observational studies suggest that bilateral IMA (BIMA) grafts improve survival and reduce the need for redo surgery, over that observed with a SIMA graft. However, few patients receive BIMA grafts because of no proven definitive benefit (there have been no randomized trials) and the perception of increased perioperative risk. To determine the role of BIMA grafts we propose a UK, multi-centre, open trial of BIMA versus SIMA on survival, need for further intervention and quality of life over a 10 year period in 4000 patients. Additionally, a blood sample will be requested from all partcipants for analysis of genetic factors (by DNA extraction) and intermediate phenotypes (ie plasma analytes) that may be related to short and long-term clinical outcomes after CABG.