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Bilateral internal thoracic artery grafting is associated with significantly improved long-term survival, even among
John D Puskas1, Adil Sadiq, Thomas A Vassiliades
1Clinical Research Unit, Division of Cardiothoracic Surgery, Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia 30308, USA. john.puskas@emoryhealthcare.org
Insights
Bilateral internal thoracic artery (BITA) grafting offers improved long-term survival compared to single internal thoracic artery (SITA) grafting for coronary artery bypass surgery. This survival benefit applies equally to diabetic and nondiabetic patients.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Cardiac Surgery Outcomes
Background:
- Investigating bilateral internal thoracic artery (BITA) vs. single internal thoracic artery (SITA) grafting outcomes in the contemporary era.
- Addressing increased prevalence of diabetes mellitus and obesity in cardiac surgery patients.
Purpose of the Study:
- To compare the efficacy of BITA versus SITA grafting in isolated coronary artery bypass grafting (CABG).
- To evaluate short-term and long-term outcomes, including survival, in relation to grafting strategy and diabetic status.
Main Methods:
- Retrospective review of the Society of Thoracic Surgeons database (2002-2010).
- Inclusion of consecutive isolated CABG patients with ≥2 distal anastomoses.
- Application of propensity-adjusted logistic and Cox regression models to assess BITA's effect on outcomes and survival for diabetic and nondiabetic cohorts.
Main Results:
- 3,527 CABG operations analyzed (812 BITA, 2,715 SITA).
- BITA grafting demonstrated a 35% reduction in long-term mortality hazard for both diabetic and nondiabetic patients (p=0.006).
- No significant differences in 30-day mortality, stroke, or myocardial infarction rates; deep sternal wound infection rates were similar between BITA and SITA groups.
Conclusions:
- BITA grafting provides a significant long-term survival advantage in CABG patients.
- The decision to use BITA should consider suitable coronary anatomy and acceptable risk of deep sternal wound infection.
- BITA grafting is recommended when anatomically feasible and patient risk factors permit.
Background:
This study examines if bilateral internal thoracic artery (BITA) grafting provides improved outcomes compared with single internal thoracic artery (SITA) grafting, in the modern era, in which diabetes mellitus and obesity are more prevalent.
Methods:
The Society of Thoracic Surgeons database at a single large academic center was reviewed for all consecutive isolated coronary artery bypass grafting patients with two or more distal anastomoses from January 1, 2002, through December 31, 2010. Propensity-adjusted logistic and Cox regression models were used to estimate the effect of BITA on short-term outcomes and long-term survival for diabetic and nondiabetic patients.
Results:
A total of 3,527 coronary artery bypass grafting operations (812 BITA, 2,715 SITA) were performed. Fewer BITA than SITA patients had diabetes (28.6% vs 44.7% p<0.001). There was no significant difference in 30-day rates of death, stroke, or myocardial infarction between nondiabetic patients who had BITA vs SITA, or between diabetic patients who had BITA vs SITA. BITA grafting conferred a 35% reduction (95% confidence interval, 12% to 52%, p=0.006) in the long-term hazard of death equally for nondiabetic and diabetic patients (p=0.93). Deep sternal wound infection was more common among diabetic than among nondiabetic patients (1.5% vs 0.7%), but was similar within nondiabetic (1.0% vs 0.6%) and diabetic patients (1.7% vs 1.5%) who had BITA vs SITA. Overall, BITA and SITA patients had similar rates of deep sternal wound infection (1.2% vs 1.0%).
Conclusions:
BITA grafting confers a long-term survival advantage and should be performed whenever suitable coronary anatomy exists and patient risk factors allow an acceptable risk of deep sternal wound infection.
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