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Should Diabetes Be a Contraindication to Bilateral Internal Mammary Artery Grafting?
Alexander Iribarne1, Benjamin M Westbrook2, David J Malenka3
1Department of Surgery, Section of Cardiac Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
Insights
Bilateral internal mammary artery (BIMA) grafting in diabetic patients undergoing coronary artery bypass grafting (CABG) shows no increased short-term risk. BIMA grafting significantly improves long-term survival compared to single internal mammary artery (SIMA) grafting in this population.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Diabetic Complications
Background:
- Coronary artery bypass grafting (CABG) is a common procedure for treating coronary artery disease.
- The choice between single internal mammary artery (SIMA) and bilateral internal mammary artery (BIMA) grafting is critical, especially for diabetic patients.
- Diabetic patients often have poorer outcomes after cardiac surgery, necessitating optimized graft selection.
Purpose of the Study:
- To compare the postoperative morbidity and long-term survival rates between BIMA and SIMA grafting in diabetic patients undergoing CABG.
- To determine if BIMA grafting offers a survival advantage without increasing short-term complications in this high-risk group.
- To provide evidence-based recommendations for graft selection in diabetic CABG patients.
Main Methods:
- A multicenter, retrospective analysis of 47,984 CABGs was performed.
- A propensity-matched cohort of 430 diabetic patients (217 SIMA, 213 BIMA) was analyzed.
- Primary endpoint: long-term survival. Secondary endpoints: postoperative morbidity, length of stay, in-hospital mortality.
Main Results:
- No significant differences in mediastinitis, sternal dehiscence, or in-hospital mortality between BIMA and SIMA groups.
- Similar median length of stay (5 days) for both grafting strategies.
- Diabetic patients receiving BIMA demonstrated significantly improved long-term survival (HR 0.75, p=0.034) compared to SIMA.
Conclusions:
- Bilateral internal mammary artery grafting in diabetic patients undergoing CABG does not increase in-hospital morbidity or mortality.
- BIMA grafting confers a significant long-term survival advantage over SIMA grafting in diabetic patients.
- Diabetic patients should be more frequently considered for bilateral internal mammary artery grafting.
Background:
This study evaluates the influence of bilateral internal mammary artery (BIMA) versus single internal mammary artery (SIMA) grafting on postoperative morbidity and long-term survival among diabetic patients undergoing coronary artery bypass grafting (CABG).
Methods:
A multicenter, retrospective analysis of 47,984 consecutive CABGs performed from 1992 to 2014 at 7 medical centers was conducted. Among the study population, 1,482 CABGs with BIMA were identified, and 1,297 BIMA patients were propensity-matched to 1,297 SIMA patients. The study cohort for this analysis, drawn from matched data, included 430 diabetic patients: 217 SIMA and 213 BIMA. The primary endpoint was long-term survival. Secondary endpoints included postoperative morbidity, length of stay, and in-hospital mortality.
Results:
The median duration of follow-up was 9.3 (range, 4.3 to 13.9) years. Among propensity-matched diabetic patients, there was no significant difference in age, body mass index, or major baseline comorbidities. The groups were also well matched on the number of diseased coronary arteries and number of distal anastomoses performed. There was no difference in the rate of mediastinitis or sternal dehiscence (p = 0.503) or in-hospital mortality (p = 0.758) between groups. Both groups had a similar median length of stay of 5 (range, 4 to 7) days. Diabetic patients who received a BIMA had significantly improved long-term survival when compared with SIMA patients (hazard ratio 0.75 [95% confidence interval 0.57 to 0.98], p = 0.034).
Conclusions:
Among diabetics undergoing CABG, use of BIMA grafting does not result in increased in-hospital morbidity or mortality and confers a long-term survival advantage when compared with SIMA grafting. Thus, diabetic patients should be considered for BIMA grafting more frequently.
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