Coronary artery bypass surgery management algorithm in women and men based on the findings of CROWN-SAGA study

Aim. Optimization of surgical coronary revascularization tactics for women and men, based on a comparative analysis of modern coronary surgery techniques from the CROWN-SAGA (Coronary Revascularization Outcomes Within Necessary Sex And Gender Aspects) study.
Material and methods. Single-center CROWN-SAGA study (NCT06749171) presented a comparative analysis of the impact of preoperative profile and range of surgical techniques in coronary artery bypass grafting (CABG) surgery on short- and long-term outcomes in women and men. The primary endpoint was a composite of all-cause mortality, myocardial infarction (MI), stroke or transient ischemic attack (TIA) and repeat revascularization (major adverse cardiovascular and cerebrovascular events, MACCE) during the long-term follow-up. The secondary endpoint was allcause mortality during the long-term followup.
Results. Among the included sample of 400 patients (200 women and 200 men) in the CROWNSAGA study, women were older than men and had less favorable preoperative profile. Short-term in-hospital outcomes in terms of mortality and MACCE were comparable between women and men. Over long-term follow-up, the incidence of MACCE was 21.2 % in women and 16.2 % in men (hazard ratio (HR) = 1.15 [95 % confidence interval (CI) 0.72; 1.82], p = 0.557) and the incidence of death was 11.1 % in women and 10.2 % in men (HR = 0.94 [95 % CI 0.51; 1.72], p = 0.83), women had higher risks of MI (HR = 6.66 [95 % CI 0.83; 53.28], p = 0,038), repeat revascularization (HR = 4.11 [95 % CI 1.18; 14.32], p = 0.016) and stroke (HR = 1.24 [95 % CI 0.59; 2.6], p = 0.567). ONCAB compared to OPCAB within the men cohort had a significantly lower risk of death (HR = 0.28 [95 % CI 0.09; 0.91], p = 0.03). Women had an increased risk of graft occlusion. All Off-pumps strata (OPCAB, NTA, MICSCAB) compared with ONCAB showed higher risk of adverse long-term outcomes among all patients in regard to MACCE (HR = 1.54 [95 % CI 0.95; 2.49], p = 0.08), death (HR = 2.17 [95 % CI 1.14; 4.14], p = 0.016) and graft occlusion. Predictor of long-term MACCE and death for women was use of composite grafts, while for men — ejection fraction (EF) ≤ 40 %, age > 70 years, and off-pump CABG. Considering the obtained data and identified predictors, CABG approach for both sexes implies complete coronary revascularization with an increased number of distal anastomoses, the use of arterial grafts, use of sequential grafts, limiting use of venous conduits, for women limiting use of composite grafting, while for men an adherence to an anoartic technique and the use of composite grafting.
Conclusions. The developed algorithm for surgical management is based on a sex and gender approach and a comprehensive analysis of a wide range of CABG techniques aimed at improving patient outcomes after coronary revascularization, particularly reducing the burden of adverse CABG outcomes among women. Recommended approach for both women and men involves complete arterial revascularization and sequential anastomoses; for women we advise surgical techniques that reduce the risk of sternal and wound complications, along with limiting the use of composite grafts; for men the use of composite grafts is permissible and the no-touch-aorta (NTA) technique is advised.

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