14-Year Results of Bilateral versus Single Internal Thoracic Artery Grafts for Left-Sided Myocardial Revascularization in Young Diabetic Patients
18 May 2016
27 September 2016
17 November 2016 (online)
Objectives Despite encouraging late outcomes, the use of bilateral internal thoracic artery (BITA) grafting for myocardial revascularization in diabetic patients remains controversial because of an increased risk of sternal wound complications. In the present study, early- and long-term outcomes of the use of left-sided BITA versus single internal thoracic artery (SITA) grafting in young (< 65 years of age) diabetic patients were reviewed retrospectively.
Methods A total of 250 propensity score pair-matched diabetic patients, operated on between February 2000 and December 2011, receiving either BITA (n = 125) or SITA (n = 125) grafting were analyzed retrospectively. In each group, 104 patients were males, and mean age was 60.1 ± 5.3 years. Follow-up was 2.1 to 14.8 years (mean, 9.3 ± 3.5 years) and complete for 100%.
Results Incidence of deep sternal wound infection was 2.4 versus 3.2% (p = 0.722). Rethoracotomy due to bleeding occurred in 4.8 versus 3.2% (p = 0.608). The 5-, 10-, and 14-year estimates of survival were 93.4, 76.6, and 67.5% (BITA) versus 89.5, 81.5, and 32.8% (SITA); p = 0.288. Freedom from reangiography/intervention (60.5 vs. 63.9%) during follow-up was comparable (p = 0.507) as well as infarction rate (93.8 vs. 95.1%, p = 0.833) and redoes (p = 0.672, exclusively valve surgery) were comparable. Freedom from thromboembolic or cerebrovascular events did not show any significant differences (94.0 vs. 94.0%, p = 0.78). Multivariate analysis identified poor ejection fraction as predictor for decreased long-term survival. Neither age nor gender or urgency had an influence on long-term mortality.
Conclusion Left-sided BITA grafting may be performed routinely even in diabetic patients without increased incidence of postoperative wound-healing complications. Survival rates after 5, 10, and 14 years were comparable for BITA and SITA grafting.
This study was presented at the 45th Annual Meeting of the German Society for Thoracic and Cardiovascular Surgery, Leipzig; February 13–16, 2016.
- 1 Kurlansky PA, Traad EA, Dorman MJ, Galbut DL, Zucker M, Ebra G. Thirty-year follow-up defines survival benefit for second internal mammary artery in propensity-matched groups. Ann Thorac Surg 2010; 90 (1) 101-108
- 2 Taggart DP, D'Amico R, Altman DG. Effect of arterial revascularisation on survival: a systematic review of studies comparing bilateral and single internal mammary arteries. Lancet 2001; 358 (9285): 870-875
- 3 Dorman MJ, Kurlansky PA, Traad EA, Galbut DL, Zucker M, Ebra G. Bilateral internal mammary artery grafting enhances survival in diabetic patients: a 30 year follow-up of propensity score-matched cohorts. Circulation 2012; 126 (25) 2935-2942
- 4 Hemo E, Mohr R, Uretzky G , et al. Long-term outcomes of patients with diabetes receiving bilateral internal thoracic artery grafts. J Thorac Cardiovasc Surg 2013; 146 (3) 586-592
- 5 Puskas JD, Sadiq A, Vassiliades TA, Kilgo PD, Lattouf OM. Bilateral internal thoracic artery grafting is associated with significantly improved long-term survival, even among diabetic patients. Ann Thorac Surg 2012; 94 (3) 710-715 , discussion 715–716
- 6 Mastrobuoni S, Gawad N, Price J , et al. Use of bilateral internal thoracic artery during coronary artery bypass graft surgery in Canada: the bilateral internal thoracic artery survey. J Thorac Cardiovasc Surg 2012; 144 (4) 874-879
- 7 De Paulis R, de Notaris S, Scaffa R , et al. The effect of bilateral internal thoracic artery harvesting on superficial and deep sternal infection: the role of skeletonization. J Thorac Cardiovasc Surg 2005; 129 (3) 536-543
- 8 Kamiya H, Akhyari P, Martens A, Karck M, Haverich A, Lichtenberg A. Sternal microcirculation after skeletonized versus pedicled harvesting of the internal thoracic artery: a randomized study. J Thorac Cardiovasc Surg 2008; 135 (1) 32-37
- 9 Boodhwani M, Lam BK, Nathan HJ , et al. Skeletonized internal thoracic artery harvest reduces pain and dysesthesia and improves sternal perfusion after coronary artery bypass surgery: a randomized, double-blind, within-patient comparison. Circulation 2006; 114 (8) 766-773
- 10 Deo SV, Shah IK, Dunlay SM , et al. Bilateral internal thoracic artery harvest and deep sternal wound infection in diabetic patients. Ann Thorac Surg 2013; 95 (3) 862-869
- 11 Gatti G, Soso P, Dell'Angela L , et al. Routine use of bilateral internal thoracic artery grafts for left-sided myocardial revascularization in insulin-dependent diabetic patients: early and long-term outcomes. Eur J Cardiothorac Surg 2015; 48 (1) 115-120
- 12 Bridgewater B ; Society for Cardiothoracic Surgery in GB and Ireland. Cardiac registers: the adult cardiac surgery register. Heart 2010; 96 (18) 1441-1443
- 13 Tabata M, Grab JD, Khalpey Z , et al. Prevalence and variability of internal mammary artery graft use in contemporary multivessel coronary artery bypass surgery. Circulation 2009; 120: 935-940
- 14 Itagaki S, Cavallaro P, Adams DH, Chikwe J. Bilateral internal mammary artery grafts, mortality and morbidity: an analysis of 1 526 360 coronary bypass operations. Heart 2013; 99 (12) 849-853
- 15 Taggart DP, Lees B, Gray A, Altman DG, Flather M, Channon K. ART Investigators. A randomized trial to compare survival following bilateral versus single internal mammary grafting in coronary revascularization. Trials 2006; 7: 7-17
- 16 Albes JM. Conflicts, compromises, and common sense. Thorac Cardiovasc Surg 2016; 64 (3) 195-196
- 17 Gansera B, Schmidtler F, Angelis I, Kiask T, Kemkes BM, Botzenhardt F. Patency of internal thoracic artery compared to vein grafts - postoperative angiographic findings in 1189 symptomatic patients in 12 years. Thorac Cardiovasc Surg 2007; 55 (7) 412-417
- 18 Gatti G, Dell'Angela L, Maschietto L, Luzzati R, Sinagra G, Pappalardo A. The impact of diabetes on early outcomes after routine bilateral internal thoracic artery grafting. Heart Lung Circ 2016; 25 (8) 862-869