Off-pump bilateral skeletonized internal thoracic artery grafting in patients with chronic kidney disease

We compared the outcomes in propensity score-matched patients who had chronic kidney disease (CKD) undergoing off-pump coronary bypass grafting, with either a bilateral or single skeletonized internal thoracic artery (ITA).

Of 1254 consecutive patients undergoing isolated coronary bypass surgery (1248 by the off-pump technique without emergent conversion to cardiopulmonary bypass), the 1203 who received a skeletonized, single (n = 453) or bilateral (n = 750), ITA graft were enrolled, after excluding the 6 patients who received preoperative percutaneous cardiopulmonary support and the 75 who had only 1 target vessel in the left coronary area. A total of 412 pairs were matched using propensity scores. Kaplan-Meier analyses were used to assess all-cause and cardiac-related mortality, by CKD stage (assessed by glomerular filtration rate [GFR]: <30; 30-60; >60 mL/minute/1.73 m(2)). Multivariate Cox proportional hazard models were used to assess for association of bilateral grafting with mortality. A test for interaction of bilateral ITA grafting and estimated GFR was conducted.

No significant difference was found in the incidence of 30-day mortality, stroke, or deep sternal infection between the 2 groups. Although an advanced stage of CKD decreased overall survival, a benefit of bilateral ITA grafting for all-cause and cardiac-related mortality occurred relatively early in the follow-up period and was not influenced by CKD stage. Bilateral ITA grafting was independently associated with a lower risk of both all-cause and cardiac-related mortality in patients with an estimated GFR of <60. No interaction was found between bilateral ITA grafting and estimated GFR in either model.

In patients who have CKD, off-pump, skeletonized, left-side bilateral ITA grafting is associated with lower risk of all-cause and cardiac-related mortality, and does not increase operative risk.