Arterial grafting for coronary revascularisation and the illusive search for truth

The art of medicine might well be described as the ability to make the right decisions based on incomplete information. Try as we might to provide ‘evidence–based’ care, the more scientifically candid among us will confess that the ‘definitive study’ on any given topic never has been (nor ever will be) performed. Indeed, a careful 2009 review of the vaunted American College of Cardiology (ACC)/American Heart Association (AHA) guidelines available at that time demonstrated that, in total, less than 10% of recommendations were based on level of evidence (LOE) A (randomised controlled trials (RCTs) or meta-analyses of RCTs), whereas more than half relied on LOE C (studies without controls or expert opinion).1

Despite remarkable and ongoing advances in percutaneous interventions, both meta-analyses of RCTs2 and longitudinal analyses of large registry data3 continue to document the comparative long-term survival benefit of surgical revascularisation for patients...