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Published on: December 11, 2017
Late Outcomes of In Situ Versus Composite Bilateral Internal Thoracic Artery Revascularization
Yanai Ben-Gal1, Amit Gordon1, Tomer Ziv-Baran2
1Department of Cardiothoracic Surgery, Tel-Aviv Sourasky Medical Center and Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel.
Insights
Bilateral internal thoracic artery revascularization using in situ or composite configurations showed similar early and long-term survival outcomes. Both strategies for coronary artery bypass grafting are safe and effective for left-sided revascularization.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Cardiac Surgery
Background:
- Two configurations for internal thoracic artery (ITA) revascularization to the anterior and lateral walls were evaluated.
- The 'in situ' configuration uses bilateral ITAs for distinct territories.
- The 'composite' configuration involves grafting a free right ITA to a left ITA for broader coverage.
Purpose of the Study:
- To compare the outcomes of "in situ" versus "composite" configurations for bilateral internal thoracic artery revascularization.
- To assess the safety and effectiveness of these two strategies in coronary artery bypass grafting (CABG).
Main Methods:
- A retrospective analysis of patients undergoing CABG with either in situ or composite bilateral ITA grafting between 1996 and 2011.
- Comparison of early mortality, adverse outcomes, and long-term survival between the two groups.
- Multivariable analysis and matched-pair analysis were performed to evaluate the impact of configuration strategy.
Main Results:
- No significant differences in early mortality or adverse outcomes were observed between the in situ and composite groups (2.2% vs 2.0%).
- Long-term (15-year) survival showed a marginal benefit for the in situ group (53.5% vs 49.5%, P=.05), which diminished after 20 years.
- Multivariable and matched-pair analyses confirmed no significant difference in survival based on the configuration strategy.
Conclusions:
- Both in situ and composite bilateral ITA revascularization strategies are safe and effective for left-sided CABG.
- The choice of configuration does not significantly impact early outcomes or long-term survival.
- These findings support the use of either strategy based on surgical preference and patient anatomy.
Background:
We compared 2 configurations for revascularization of the internal thoracic arteries to the anterior and lateral walls. In the "in situ" configuration, an in situ right internal thoracic artery supplies the left anterior descending territory, and an in situ left internal thoracic artery is grafted to the left circumflex territory. In the "composite" configuration, an in situ left internal thoracic artery is grafted to the left anterior descending artery and a free right internal thoracic artery is attached end-to-side to the left internal thoracic artery and supplies the lateral wall.
Methods:
We compared outcomes of all the patients treated in our center by the described strategies during 1996 through 2011.
Results:
Of 2951 patients, 1220 underwent composite grafting and 1731 underwent in situ grafting; the median follow-up was 15.1 years (interquartile range, 11.2-18.6 years). Early mortality (2.2% vs 2.0%, P = .787) and other early adverse outcomes did not differ significantly between the groups. Long-term (15-year) survival was marginally significant in favor of the in situ group (53.5% vs 49.5%, P = .05); this difference disappeared after 20 years. Configuration strategy was not a predictor for better 15-year survival in multivariable analysis (hazard ratio, 0.97; 95% confidence interval, 0.85-1.09; P = .568). An additional analysis compared matched groups of 995 patients each who underwent the 2 configuration strategies and found no differences in early outcome or late survival between the groups.
Conclusions:
This study demonstrated the safety and effectiveness of 2 strategies for bilateral internal thoracic artery revascularization to the left side, with comparable early outcomes and long-term survival.
