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Should Bilateral Internal Thoracic Artery Grafting Be Used in Patients With Diabetes Mellitus?
Dmitry Pevni1, Benjamin Medalion2, Rephael Mohr1
1Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center, Faculty of Medicine, Tel Aviv University, Israel.
Insights
Bilateral internal thoracic artery (BITA) grafting offers better long-term survival for diabetic patients with multivessel disease compared to single internal thoracic artery (SITA) grafting. This study found improved outcomes despite initial concerns about sternal infection risks.
Area of Science:
- Cardiovascular Surgery
- Diabetology
- Thoracic Surgery
Background:
- Bilateral internal thoracic artery (BITA) grafting in diabetic patients is debated due to sternal infection risks.
- Comparison of BITA versus single internal thoracic artery (SITA) grafting outcomes in diabetic patients is crucial.
Purpose of the Study:
- To compare the long-term outcomes of BITA grafting versus SITA grafting in diabetic patients with multivessel coronary artery disease.
Main Methods:
- A cohort study compared 964 diabetic patients undergoing BITA grafting with 564 undergoing SITA grafting (1996-2010).
- Propensity score matching was used to control for baseline differences between groups.
- Long-term survival and sternal infection rates were primary outcome measures.
Main Results:
- Operative mortality and sternal infection rates were similar between BITA and SITA groups (2.6% vs 3.0% and 3.1% vs 3.9%, respectively).
- Unadjusted 10-year survival favored BITA grafting (65.3% vs 55.5%).
- After propensity score matching, Cox-adjusted survival analysis showed significantly better outcomes for BITA patients (HR 0.729, p=0.027).
Conclusions:
- BITA grafting demonstrates superior long-term survival compared to SITA grafting in diabetic patients with multivessel disease.
- The study suggests BITA grafting is a viable and beneficial option for this patient population.
- Long-term benefits of BITA outweigh potential risks in carefully selected diabetic patients.
Background:
Bilateral internal thoracic artery (BITA) grafting in patients with diabetes mellitus is controversial because of a higher risk for sternal infection. The purpose of this study is to compare the outcome of BITA grafting to that of single ITA (SITA) grafting in patients with diabetes.
Methods:
Between 1996 and 2010, 964 diabetic patients with multivessel disease who underwent primary coronary artery bypass graft surgery with BITA were compared with 564 patients who underwent coronary artery bypass graft surgery with SITA and saphenous vein grafts.
Results:
The SITA patients were older, more often female, more likely to have chronic obstructive pulmonary disease, ejection fraction 30% or less, insulin-dependent diabetes, recent myocardial infarction, renal insufficiency, peripheral vascular disease, and emergency operation. The BITA patients more often underwent coronary artery bypass graft surgery with three or more grafts. The two groups had similar operative mortality, 2.6% BITA versus 3.0% SITA, and sternal infection, 3.1% versus 3.9%, respectively. The mean follow-up was 12.2 ± 4.3 years. Unadjusted Kaplan-Meier 10-year survival of the BITA group was better than that of the SITA group (65.3% ± 3.1% versus 55.5% ± 4.5%, respectively; p = 0.004), After propensity score matching (490 well-matched pairs), Kaplan-Meier 10-year survival was not significantly different between the matched groups; however, the Cox-adjusted survival of the BITA patients was better (hazard ratio 0.729, 95% confidence interval: 0.551 to 0.964, p = 0.027).
Conclusions:
The findings of this large cohort study suggest that the long-term outcome of patients with diabetes and multivessel disease who undergo BITA grafting is better than that of diabetic patients who undergo coronary artery bypass graft surgery with SITA and saphenous vein grafts.
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