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Long-term outcomes of patients with diabetes receiving bilateral internal thoracic artery grafts
Eli Hemo1, Rephael Mohr, Gideon Uretzky
1Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.
Insights
Bilateral internal thoracic artery (BITA) grafting is safe for diabetic patients, offering favorable survival outcomes that outweigh the risks of sternal infection. This study identifies key factors for patient selection to optimize results.
Area of Science:
- Cardiovascular Surgery
- Diabetic Complications
- Surgical Outcomes
Background:
- Bilateral internal thoracic artery (BITA) grafting in diabetic patients presents a dilemma due to increased sternal infection risk versus potential survival benefits.
- Careful patient selection is crucial for optimizing outcomes in this population.
Purpose of the Study:
- To evaluate factors influencing early and long-term outcomes of BITA grafting in patients with diabetes.
- To identify criteria for selecting diabetic patients who are most likely to benefit from BITA grafts.
Main Methods:
- Retrospective analysis of 791 diabetic patients (insulin-treated and orally treated) who underwent isolated skeletonized BITA grafting between 1996 and 2006.
- Patients were stratified by age: <65, 65-74, and ≥75 years.
- Analysis included operative mortality, sternal infection rates, and long-term survival, comparing observed outcomes with predicted scores (EuroSCORE, Charlson Comorbidity Index).
Main Results:
- Operative mortality was significantly lower than predicted (2.9% vs 7%, P < .001).
- Predictors of mortality included critical preoperative state and age. Sternal infection occurred in 3.7% of patients, associated with reoperation, peripheral vascular disease, obesity, chronic lung disease, and female sex.
- 10-year survival rates were significantly better than predicted, particularly for younger patients. Age, congestive heart failure, and peripheral vascular disease predicted decreased survival. Off-pump surgery correlated with better long-term survival.
Conclusions:
- BITA grafting demonstrates safety and efficacy in diabetic patients.
- Favorable short- and long-term outcomes justify the use of BITA grafts, with sternal infection risk being manageable.
- Patient selection based on identified risk factors is essential for maximizing the benefits of BITA grafting in this cohort.
Objectives:
Bilateral internal thoracic artery (BITA) grafting in patients with diabetes are controversial because of increased risk of sternal infection. On the other hand, patients with diabetes may benefit from BITA grafts because of the associated improved survival. This study evaluated factors affecting early and long-term outcomes for better selection of patients with diabetes for BITA grafts.
Methods:
Between 1996 and 2006, 69 patients with insulin-treated diabetes and 732 with orally treated diabetes received isolated skeletonized BITA grafts. Of these patients, 338 were younger than 65 years, 322 were between 65 and 74 years old, and 141 were 75 years or older.
Results:
Operative mortality was lower than logistic EuroSCORE-calculated mortality (2.9% vs 7%, P < .001). Predictors of increased mortality were critical preoperative state (P < .001) and age (P = .008). There were 30 cases of sternal infection (3.7%); predictors were reoperation (P < .001), peripheral vascular disease (P = .009), obesity (P = .012), chronic lung disease (P = .009), and female sex (P = .020). Mean follow-up was 8.4 ± 4 years. Kaplan-Meier 10-year survivals were 75%, 59%, and 39% for patients younger than 65, 65 to 74, and at least 75 years, respectively (P < .001). They were better than corresponding Charlson comorbidity index-predicted survivals (36%, 10%, and 3%, respectively; P < .001). Predictors of decreased survival were age (P < .001), congestive heart failure (P < .001), and peripheral vascular disease (P < .001). Off-pump surgery was independently associated with better long-term survival (P = .003).
Conclusions:
BITA grafts are safe in patients with diabetes. Favorable short- and long-term outcomes outweigh increased sternal infection risk.
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