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Bilateral internal thoracic artery grafting in India-Time to raise the bar
Lokeswara Rao Sajja1, Prashanthi Beri2
1Division of Cardiothoracic Surgery, STAR Hospitals, Hyderabad, India; Sajja Heart Foundation, Srinagar Colony, Hyderabad, India.
Insights
Bilateral internal thoracic artery (BITA) grafting is underutilized in India, with only 10% of surgeons using it. Key concerns include deep sternal wound infection and longer operative times, hindering wider adoption of this revascularization strategy.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Surgical Outcomes
Background:
- Bilateral internal thoracic artery (BITA) grafting is increasingly recognized for superior long-term outcomes in coronary artery bypass grafting (CABG) for multivessel coronary artery disease.
- Despite evidence supporting BITA, its adoption as a primary revascularization strategy remains limited among cardiac surgeons.
- This study investigates the current utilization patterns and perceived barriers to BITA grafting in India.
Purpose of the Study:
- To assess the current prevalence of BITA grafting use among Indian cardiac surgeons.
- To identify the specific clinical scenarios where BITA grafting is avoided.
- To determine the primary concerns and challenges associated with implementing BITA grafting in India.
Main Methods:
- A nationwide survey was conducted among 856 Indian cardiac surgeons specializing in adult cardiac surgery.
- A questionnaire was administered to gather data on the use of single versus bilateral internal thoracic artery (ITA) grafts.
- Surgeons were queried about their BITA grafting strategies in various patient populations and clinical situations.
Main Results:
- Only 10.7% of surveyed surgeons utilize BITA grafting, with 79% predominantly using single ITA grafts.
- Significant avoidance of BITA grafting was reported in patients with smoking history (53%), obesity (58%), and acute coronary syndrome (62%).
- The main concerns cited for limiting BITA use were deep sternal wound infection (DSWI) (40%), increased operative time (27%), and uncertainty regarding superiority (12%).
Conclusions:
- BITA grafting is underutilized in India, with its application restricted to approximately 10% of cases.
- Deep sternal wound infection (DSWI) and increased operative time are the principal obstacles hindering the broader adoption of BITA grafting.
- Addressing these concerns is crucial for increasing the utilization of BITA grafting for improved patient outcomes.
Objectives:
Bilateral internal thoracic artery (BITA) grafting strategy is the current trend in coronary artery bypass grafting for multivessel coronary artery disease. Although better long-term outcomes have been shown, BITA grafting is underutilized as a main strategy for revascularization by most of the surgeons. The survey was conducted to ascertain the current usage and concerns of BITA grafting in India.
Methods:
Database of 856 Indian cardiac surgeons currently with predominantly adult practice was prepared and a questionnaire was sent about use of single and bilateral ITA grafts and BITA grafting strategy in different clinical scenarios.
Results:
A total of 112 surgeons (13.08%) from 75 institutions responded and 92 surgeons (10.7%) completed the survey. Single ITA is used by 79% of surgeons in more than 90% of their patients. 31% and 29% of surgeons use BITA grafting in 5-10% and 11-98% of their patients respectively. 53% of surgeons avoided the usage of BITA grafting in patients with smoking, 35% of surgeons in chronic obstructive pulmonary disease, 58% of surgeons in obesity and 62% of surgeons in acute coronary syndrome, 36% of surgeons in patients with left ventricular dysfunction and 61% of surgeons in patients with poor coronary anatomy. The concerns for BITA usage are risk of deep sternal wound infection (DSWI) (40%), increased operative time (27%), unknown superiority (12%) and limited length of right ITA (5%).
Conclusions:
The usage of BITA grafting is restricted to 10% in India and main concerns are DSWI and increased operative time.
