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Published on: October 14, 2013
Evolution of Bilateral Mammary Arterial Grafting Program in Veterans Affairs Medical Center
Sue X Wang1, Michelle Lee1, Chih-Chiun Chang1
1University of California San Francisco and San Francisco VA Medical Center, Department of Surgery, San Francisco, CA.
Insights
Bilateral mammary grafting, using a skeletonized technique, can be safely implemented in lower-volume centers. This approach shows comparable sternal wound infection rates to single mammary grafting, supporting its adoption for improved long-term survival.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Surgical Outcomes
Background:
- Bilateral internal mammary artery grafting improves long-term survival in coronary revascularization but is underutilized due to infection concerns.
- Dedicated programs are often high-volume, excluding federal institutions from data capture.
- This study examines the transition to a dedicated bilateral mammary grafting program using a skeletonized technique at a federal institution.
Purpose of the Study:
- To evaluate the feasibility and impact of transitioning to a dedicated bilateral mammary grafting program.
- To assess the rate of sternal wound infections following bilateral versus single internal mammary artery grafting.
- To determine the safety and efficacy of skeletonized bilateral mammary artery grafting in a lower-volume setting.
Main Methods:
- Retrospective cohort study of 200 patients undergoing first-time isolated, multi-vessel coronary artery bypass.
- Comparison of sternal wound infection rates between patients receiving bilateral versus single internal mammary artery grafts.
- Follow-up for wound complications for 3 months post-operatively.
Main Results:
- 61.5% of patients underwent bilateral mammary grafting.
- Deep sternal wound infection rates were 2.4% for bilateral and 1.3% for single mammary grafting (p=1.0).
- Superficial sternal wound infection rates were 6.5% for bilateral and 5.2% for single mammary grafting (p=0.77).
Conclusions:
- Transitioning to high bilateral mammary artery utilization is achievable within a year with low complication rates.
- Skeletonized bilateral mammary grafting can be adopted by surgeons, offering potential long-term survival benefits.
- This approach is feasible even in federal institutions, previously underrepresented in such data.
Background:
Coronary revascularization with bilateral internal mammary arteries is associated with increased long-term survival, but underutilized due to sternal wound infection concerns. Dedicated bilateral mammary grafting programs are typically high-volume academic or private practices, rather than lower-volume federal institutions whose results are not captured in the Society of Thoracic Surgeons database. Our institution used only single internal mammary arterial grafting in the year prior to implementing a dedicated bilateral grafting program using skeletonized technique. We describe our experience transitioning to bilateral mammary grafting and its impact on sternal wound infection.
Methods:
Retrospective cohort study at San Francisco Veterans Affairs Medical Center in 200 patients undergoing first-time isolated, multi-vessel coronary artery bypass from August 2014 to October 2017. Sternal wound infection was defined broadly to include any patient receiving antibiotics for suspicion of sternal infection. Patients were followed for wound complications until 3 post-operative months.
Results:
Of 200 total patients, 45.5% (n=91) were diabetic, 44% (n=88) had BMI >30, and 61.5% (n=123) underwent bilateral mammary grafting. Bilateral mammary grafting population had 2.4% (n=3/123) deep sternal wound infection with 1.6% (n=2/123) requiring sternal reconstruction while single mammary population had 1.3% (n=1/77, p=1.0). Bilateral mammary grafting population had 6.5% (n=8/123) superficial sternal wound infection compared to 5.2% (n=4/77, p=0.77) in single mammary grafting population.
Conclusions:
Transitioning to high rates of bilateral mammary utilization was possible in a year with low rates of complications. Based on our experience, surgeons should consider adopting a skeletonized bilateral mammary grafting approach given potential long-term survival benefit.
