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Early and late outcomes of single versus bilateral internal thoracic artery revascularization for patients in
Michal Fertouk1, Amit Gordon1, Dmitry Pevni1
1Department of Cardiothoracic Surgery, Tel-Aviv Sourasky Medical Center and Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
Insights
Bilateral internal thoracic artery (BITA) revascularization offers improved long-term survival for critically ill patients with complex coronary disease compared to single ITA (SITA). This surgical approach is recommended for better patient outcomes in high-risk cardiac surgery.
Area of Science:
- Cardiovascular Surgery
- Cardiac Anesthesia
- Thoracic Surgery
Background:
- The optimal surgical strategy for critically ill patients with complex coronary artery disease is not well-defined.
- Coronary artery bypass grafting (CABG) is a common treatment, but the choice between single internal thoracic artery (SITA) and bilateral internal thoracic artery (BITA) grafts in high-risk patients requires further investigation.
Purpose of the Study:
- To compare the clinical outcomes of bilateral internal thoracic artery (BITA) versus single internal thoracic artery (SITA) revascularization in critically ill patients undergoing CABG.
- To evaluate the impact of BITA versus SITA on early mortality, perioperative complications, and long-term survival.
Main Methods:
- A retrospective analysis of 394 critically ill patients with multi-vessel disease who underwent CABG between 1996 and 2001.
- Patients were categorized into SITA (n=193) and BITA (n=201) groups, with critical preoperative status defined by specific clinical criteria.
- Outcomes included 30-day mortality, stroke, myocardial infarction, sternal infection, bleeding revisions, and late survival, analyzed using propensity-score matching and multivariable analysis.
Main Results:
- The BITA group exhibited significantly better long-term survival (median 14.39 years) compared to the SITA group (median 9.31 years) (p=0.001).
- Propensity-score matching confirmed improved long-term survival for BITA (median 12.49 years) versus SITA (median 7.63 years) (p=0.002).
- BITA revascularization was identified as an independent predictor of improved survival (HR 0.419, p=0.004), with no significant differences in early mortality or complications.
Conclusions:
- Bilateral internal thoracic artery (BITA) revascularization provides a significant long-term survival benefit for critically ill patients with complex coronary artery disease.
- The findings support the use of BITA grafting in high-risk surgical candidates to enhance long-term patient outcomes.
Objective:
The optimal surgical approach for critically ill patients with complex coronary disease remains uncertain. We compared outcomes of bilateral internal thoracic artery (BITA) versus single ITA (SITA) revascularization in critical patients.
Methods:
We evaluated 394 consecutive critical patients with multi-vessel disease who underwent CABG during 1996-2001. Outcomes measured were early mortality, strokes, myocardial-infarctions, sternal infections, revisions for bleeding, and late survival. The critical preoperative state was acknowledged concisely by one or more of the following: preoperative ventricular tachycardia/fibrillation, aborted sudden cardiac death, or the need for mechanical ventilation or for preoperative insertion of intra-aortic-balloon counter-pulsation.
Results:
During the study period, 193 of our patients who underwent SITA and 201 who underwent BITA were in critical condition. The SITA group was older (mean 68.0 vs. 63.3 years, p = 0.001) and higher proportions were females (28.5% vs. 18.9% p = 0.025), after recent-MI (69.9% vs. 57.2% p = 0.009) and with left-main disease (38.3% vs. 49.3% p = .029); the median logistic EuroSCORE was higher (0.2898 vs. 0.1597, p<0.001). No statistically significant differences were observed between the SITA and BITA groups in 30-day mortality; and in rates of early CVA, MI and sternal infections (13.0% vs. 8.5%, p = 0.148; 4.1% vs. 6.0%, p = 0.49; 6.7% vs. 4.5%, p = 0.32 and 2.1% vs. 2.5%, p>0.99, respectively). Long-term survival (median follow-up of 15 years, interquartile-range: 13.57-15) was better in the BITA group (median 14.39 vs. 9.31± 0.9 years, p = 0.001). Propensity-score matching (132 matched pairs) also yielded similar early outcomes and improved long-term survival (median follow-up of 15 years, interquartile-range: 13.56-15) for the BITA group (median 12.49±1.71 vs. 7.63±0.99 years, p = 0.002). In multivariable analysis, BITA revascularization was found to be a predictor for improved survival (hazard-ratio of 0.419, 95%CI 0.23-0.76, p = 0.004).
Conclusions:
This study demonstrated long-term survival benefit for BITA revascularization in patients in a critical pre-operative state who presented for surgical revascularization.
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