Can surgeons do complete revascularization in diabetic patients using the off-pump technique?

: The arguments are discussed as to whether or not to proceed with multivessel percutaneous coronary intervention, with or without a drug-eluting stent, in patients with diabetes mellitus (DM), including (1) surgeons unable to complete revascularization because of smaller native arteries; and (2) diabetic patients being sicker and having higher operative mortality rates than nondiabetic patients (non-DM), particularly with the conventional coronary artery bypass surgery (on-pump) technique. To support or dispute the claims, a retrospective review of 480 consecutive patients at a single institution (195 DM and 285 non-DM) was carried out. Observations were made to see whether diabetes is a predictor of poor outcomes.

: The preoperative comorbidity, intraoperative measurement of the size of the artery at the site of anastomosis with different gauged probes, and the number of grafts per patient were recorded. Intraoperative and postoperative variables between two groups were compared. The observed number of grafts (O) after surgery was compared with the number of grafts predicted (P) before surgery. The O/P ratio or "completion index" of ≥1 signifies complete revascularization. Logistic regression analysis was used to test the possibility that diabetes is a predictor of poor outcomes.

: Diabetic patients were older, with more comorbidity (congestive heart failure, peripheral vascular diseases, dialysis-dependent). The number of grafts per patient was 4.2 ± 1.3 (DM) and 4.2 ± 1.3 (non-DM). The size of 742 DM and 949 non-DM arteries were gauged. There was no statistical difference in size between DM and non-DM (in millimeters) at each artery. All ratios ranged from 0.9 to 1.2, indicating similarity between DM and non-DM. The only significant risk factor for operative death was low left ventricular ejection fraction (P = 0.001).

: Patients with DM were sicker but tolerated off-pump coronary artery bypass grafting as well as non-DM patients. The number of grafts per patient and O/P ratio signify the ability to perform complete revascularization. We are able to bypass the small target vessels, as anticipated. Diabetes is not a predictor of the outcomes.