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Published on: December 11, 2017
Twenty-five-year outcomes after multiple internal thoracic artery bypass
Cyrus J Parsa1, Linda K Shaw2, J Scott Rankin3
1Duke University Medical Center, Durham, NC.
Insights
Multiple internal thoracic artery grafts significantly improve coronary artery bypass grafting outcomes, offering greater benefits than single internal thoracic artery grafts. Increased use of multiple internal thoracic artery grafts is recommended to reduce long-term cardiac event risks.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Cardiac Surgery Outcomes
Background:
- Coronary artery bypass grafting (CABG) is a common procedure for multivessel coronary artery disease.
- The use of multiple internal thoracic artery (ITA) grafts in CABG remains a subject of clinical debate.
- Assessing single-institution outcomes of multiple ITA grafting is crucial for guiding clinical decisions.
Purpose of the Study:
- To evaluate the clinical outcomes associated with single versus multiple internal thoracic artery grafts in patients undergoing multivessel coronary artery bypass grafting.
- To provide evidence-based guidance for the application of multiple ITA grafting in clinical practice.
Main Methods:
- A prospective database of 19,482 patients undergoing multivessel CABG between 1984 and 2009 was analyzed.
- Patients were categorized into three groups: no ITA graft, single ITA graft, and multiple ITA grafts.
- Outcomes including myocardial infarction, percutaneous coronary intervention, reoperative CABG, and all-cause death were assessed using multivariable Cox modeling and AUC analysis.
Main Results:
- Patients receiving multiple ITA grafts were younger and had lower rates of congestive heart failure, diabetes, and female gender compared to other groups.
- No significant differences were observed in the number of diseased vessels or grafts per patient across groups.
- Risk-adjusted analysis showed that multiple ITA grafting reduced the composite outcome by 30% (HR 0.70) compared to no ITA graft, while single ITA grafting reduced it by 21% (HR 0.79).
Conclusions:
- This study confirms that multiple internal thoracic artery grafting significantly improves patient outcomes after coronary artery bypass grafting.
- Multiple ITA grafting provides substantially greater benefits compared to single ITA grafting alone.
- Increased utilization of multiple ITA grafting is encouraged to minimize long-term cardiac event risks and associated costs.
Objective:
Coronary artery bypass grafting with multiple internal thoracic artery grafts is currently controversial. This study assessed single institutional outcomes with multiple internal thoracic artery grafting for guidance with future clinical decisions.
Methods:
In 19,482 patients undergoing multivessel coronary artery bypass grafting (1984-2009), baseline characteristics were recorded in a prospective databank, and follow-up was obtained by questionnaires, phone contact, or National Death Index. Outcomes examined were subsequent myocardial infarction, percutaneous coronary intervention, reoperative coronary artery bypass grafting, all-cause death, and a composite of the 4. Three groups were defined: (1) no internal thoracic artery graft (1874/19,482 or 9%); (2) single internal thoracic artery grafts and adjunctive venous conduits (single internal thoracic artery; 16,881/19,482 or 87%); and (3) multiple internal thoracic artery grafts (728/19,482 or 4%). Multivariable Cox modeling adjusted for differences in baseline characteristics, and comparisons were performed using area under the curve analysis.
Results:
Differences in baseline characteristics for the no internal thoracic artery graft, single internal thoracic artery, and multiple internal thoracic artery groups were as follows: median age 66, 64, and 59 years, respectively; congestive heart failure 22%, 18%, and 13%, respectively; ejection fraction 0.50, 0.52, and 0.51, respectively; reoperation 10%, 3%, and 7%, respectively; diabetes 27%, 30%, and 15%, respectively; and female gender 33%, 28%, and 20%, respectively. No differences existed in the median number of diseased vessels (3, 3, and 3, respectively) or number of grafts per patient (3, 3, and 3, respectively). Composite outcome improved with increasing internal thoracic artery grafts, whether assessing unadjusted or risk-adjusted data. Compared with no internal thoracic artery graft, the adjusted hazard ratio was 0.79 (confidence interval, 0.74-0.83) for single internal thoracic artery grafting and 0.70 (confidence interval, 0.62-0.80) for multiple internal thoracic artery grafting (both P < .001), reducing risk by 21% and 30%, respectively.
Conclusions:
This study confirms improved patient outcomes with multiple internal thoracic artery grafting, achieving half again as much benefit as single internal thoracic artery grafting alone. The data suggest that increasing application of multiple internal thoracic artery grafting should be encouraged to mitigate the inherent risks and costs of long-term cardiac events.