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Current trends in bilateral internal thoracic artery use for coronary revascularization: Extending benefit to
Nishant Saran1, Chaim Locker1, Sameh M Said1
1Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn.
Insights
Bilateral internal thoracic artery use in coronary artery bypass grafting is increasing and offers a survival advantage, even for high-risk patients. This technique demonstrates a consistent benefit, supporting its expanded application in cardiac surgery.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Medical Trends
Background:
- Investigating trends in bilateral internal thoracic artery (BITA) utilization for coronary artery bypass grafting (CABG).
- Assessing the persistent survival advantage of BITA revascularization in high-risk patient populations compared to left internal thoracic artery (LITA) alone.
Purpose of the Study:
- To identify trends in BITA use for CABG.
- To evaluate the survival benefit of BITA versus LITA alone, particularly in high-risk patients.
Main Methods:
- Retrospective review of isolated CABG patients (2000-2015) at Mayo Clinic.
- Propensity score matching of 1011 pairs comparing BITA and LITA grafts.
- Analysis of survival in high-risk subsets (low ejection fraction, obesity, advanced age, comorbidities).
Main Results:
- BITA use increased significantly over time, doubling from 2012 to 2015.
- Propensity-matched analysis revealed a significant survival advantage for BITA (HR 0.81, P=0.043).
- No adverse survival effect of BITA was observed in high-risk patient subsets; deep sternal wound infection risk was not significantly different.
Conclusions:
- BITA use in CABG is increasing and associated with a survival benefit.
- This benefit extends to patients with higher-risk comorbidities.
- Further expansion of BITA utilization in CABG is warranted.
Background:
We sought to identify the trends in bilateral internal thoracic artery use and determine the degree to which the survival advantage of bilateral internal thoracic artery revascularization persists among perceived "high-risk" patients, compared with the use of left internal thoracic artery alone.
Methods:
A retrospective review was conducted of patients who underwent isolated coronary artery bypass grafting for multivessel coronary artery disease at the Mayo Clinic between January 2000 and December 2015. Propensity score matching was performed between patients with bilateral internal thoracic artery and left internal thoracic artery alone grafts (1011 matched pairs). Effect of bilateral internal thoracic artery use on survival in "high-risk" patients (ejection fraction <40%, body mass index ≥30, age ≥70 years, diabetes, chronic lung disease, cerebrovascular accident) was evaluated.
Results:
A total of 6468 isolated coronary artery bypass grafts were performed (5431 using left internal thoracic artery alone, 1037 using bilateral internal thoracic artery). There was an increasing trend in bilateral internal thoracic artery use (P value for linear trend = .005), with the percentage of coronary artery bypass grafting cases with bilateral internal thoracic artery doubling over the last 4 years (13% in 2012 to 27% in 2015). Propensity-matched comparisons showed a survival advantage for bilateral internal thoracic artery (hazard ratio, 0.81; 95% confidence interval, 0.66-0.99; P = .043). Risk of deep sternal wound infection, although higher in the bilateral internal thoracic artery group, was not significant (1.2% vs 0.5%; P = .088). None of the "high-risk" subsets of patients showed an adverse effect of bilateral internal thoracic artery on survival.
Conclusions:
Bilateral internal thoracic artery use in coronary artery bypass grafting is increasing over time. There is a consistent survival benefit with bilateral internal thoracic artery use, extending to patients with higher-risk comorbidities, suggesting the need for further expansion in use of this technique.
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