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Sequential internal thoracic artery bypass is safe but does not improve survival
Keven Gagné1, Alain Deschamps2, Raymond Cartier1
1Department of Cardiovascular Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
Insights
Bilateral internal thoracic artery (ITA) grafting improves survival in coronary artery surgery. Adding sequential ITA bypass grafting is safe but offers no significant survival benefit in off-pump procedures.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Vascular Surgery
Background:
- The established benefit of internal thoracic artery (ITA) sequential bypass grafting to single or bilateral ITA grafts for enhanced arterial revascularization remains unclear.
- Coronary artery bypass grafting (CABG) is a common surgical procedure for treating coronary artery disease.
Purpose of the Study:
- To evaluate the safety and efficacy of ITA sequential bypass grafting in coronary artery surgery.
- To compare outcomes between single and bilateral ITA grafting strategies, with and without sequential bypass.
Main Methods:
- Retrospective review of 1,400 patients undergoing off-pump CABG for multivessel disease.
- Patients were categorized into four groups: single ITA alone, single ITA with sequential, bilateral ITA alone, and bilateral ITA with sequential.
- Analysis included assessment of complete revascularization, perioperative outcomes, and long-term survival.
Main Results:
- Bilateral ITA grafting was associated with improved overall survival and reduced major adverse cardiac events (MACE) compared to single ITA grafting.
- No significant difference in complete revascularization, perioperative mortality, or myocardial infarction rates was observed across groups.
- Adding sequential ITA bypass grafting did not significantly improve survival or MACE-free survival in either single or bilateral ITA configurations.
Conclusions:
- Bilateral ITA grafting demonstrates superior long-term survival benefits in patients undergoing off-pump CABG for multivessel disease.
- While safe, the addition of sequential ITA bypass grafting does not confer additional survival advantages.
- These findings support the use of bilateral ITA grafting for improved patient outcomes in specific CABG scenarios.
Background:
The benefit of adding an internal thoracic artery (ITA) sequential bypass to single or bilateral ITA graft to improve arterial revascularization is not established. The goal of this study is to evaluate the safety and the potential benefit of ITA sequential bypass in coronary artery surgery.
Methods:
We retrospectively reviewed a cohort of 1,400 consecutive, prospectively followed patients who underwent off-pump coronary artery bypass surgery for multivessel disease between September 1996 and November 2007 at the Montreal Heart Institute. Among them, 1,315 (93.9%) patients had 2- or 3-vessel disease and received at least 1 ITA graft. The following 4 groups were investigated: group 1, single ITA grafting alone (n=758); group 2, single ITA+sequential grafting (n=151); group 3, bilateral ITA grafting alone (n=308); and group 4, bilateral ITA+sequential grafting (n=98).
Results:
Mean follow-up was 63±33 months and completed in 97% of the cohort. Single ITA patients were older, had more diabetes, chronic obstructive pulmonary disease, peripheral vascular disease, emergency surgery, and heart failure. The rates of complete revascularization, conversion to cardiopulmonary bypass, perioperative mortality, and myocardial infarction were similar in all groups. After correcting for risk factors, better overall, cardiac, and major adverse cardiac event (MACE)-free survival were observed in the bilateral ITA groups compared with the single ITA groups. Adding sequential ITA bypass grafting did not significantly impact survival or MACE-free survival.
Conclusions:
In our series, bilateral ITA grafting improved overall and MACE-free survival. Adding a sequential ITA bypass grafting was safe but did not add significant benefit in off-pump coronary artery bypass surgery.
