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Routine use of bilateral skeletonized internal thoracic artery grafting: long-term results
1Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center, 6 Weizman St, Tel Aviv 64239, Israel.
Insights
Skeletonized bilateral internal thoracic artery (ITA) grafting offers good long-term results with low morbidity. This technique is suitable for elderly patients and those with diabetes, but not for repeat operations or patients with COPD.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Vascular Grafting
Background:
- Skeletonized harvesting of the internal thoracic artery (ITA) reduces sternal devascularization.
- This technique aims to decrease postoperative sternal complications in patients undergoing bilateral ITA grafting.
Purpose of the Study:
- To evaluate the outcomes of skeletonized bilateral ITA grafting.
- To identify risk factors for sternal infection and long-term mortality.
Main Methods:
- A consecutive series of 1515 patients underwent skeletonized bilateral ITA grafting between 1996 and 2001.
- Data on operative mortality, early morbidity, and late survival were collected.
- Statistical analyses included multiple regression for sternal infection and Cox regression for overall mortality.
Main Results:
- Operative mortality was 2.8%. Early sternal infection occurred in 1.6% of patients.
- Risk factors for sternal infection included COPD, repeat operations, and diabetes mellitus.
- 10-year survival rates varied by age, with patients >75 years having 52% survival.
- Increased mortality was associated with peripheral vascular disease, advanced age, repeat operations, congestive heart failure, and renal failure.
- Operations without cardiopulmonary bypass showed better postoperative survival.
Conclusions:
- Bilateral ITA grafting demonstrates low morbidity and favorable long-term outcomes.
- Skeletonized bilateral ITA grafting is appropriate for elderly patients and those with diabetes.
- This technique is not recommended for patients undergoing repeat operations or those with COPD.
Background:
Skeletonized harvesting of the internal thoracic artery (ITA) decreases the severity of sternal devascularization, thus reducing the risk of postoperative sternal complications in patients undergoing bilateral ITA grafting.
Methods And Results:
Between 1996 and 2001, 1515 consecutive patients underwent skeletonized bilateral ITA grafting. Of the 1179 male and 336 female patients, 641 (42.3%) were >70 years of age, and 519 (34.2%) had diabetes mellitus. Operative mortality was 2.8%. Early postoperative morbidity included sternal infection (1.6%), cerebrovascular accident (3%), and perioperative myocardial infarction (1%). Multiple regression analysis showed chronic obstructive pulmonary disease (odds ratio, 11.3; 95% confidence interval [CI], 4.45 to 28.55), repeat operation (odds ratio, 12.7; 95% CI, 3.25 to 49.56), and diabetes mellitus (non-insulin dependent: odds ratio, 4.64; 95% CI, 1.85 to 11.59; insulin dependent: odds ratio, 6.9; 95% CI, 1.35 to 35.27) to be associated with increased risk of sternal infection. Follow-up (between 5 and 12 years) revealed 305 late deaths. Kaplan-Meier 10-year survival rates for patients <65, 65 to 74, and >75 years of age were 87%, 75%, and 52%, respectively. Cox regression analysis revealed increased overall mortality (early and late) in patients with peripheral vascular disease (hazard ratio [HR], 1.8; 95% CI, 1.39 to 2.33), patients >75 years of age (HR, 7.23; 95% CI, 4.16 to 12.55), those undergoing repeat operations (HR, 2.22; 95% CI, 1.27 to 3.89), patients with preoperative congestive heart failure (HR, 1.64; 95% CI, 1.29 to 3.75), and those with chronic renal failure (HR, 1.52; 95% CI, 1.11 to 2.01). Operations performed without cardiopulmonary bypass were associated with better postoperative survival (HR, 0.66; 95% CI, 0.49 to 0.87).
Conclusions:
Bilateral ITA grafting is associated with low morbidity and good long-term results. Use of skeletonized bilateral ITA is appropriate for the elderly and most patients with diabetes; however, it is not recommended for repeat operations or for patients with chronic obstructive pulmonary disease.
