Bilateral internal thoracic artery coronary grafting: risks and benefits in elderly patients
Zhuoming Zhou1,2, Guangguo Fu1,2, Suiqing Huang1,2
1Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan II Road, Guangzhou 510080, China.
Insights
Bilateral internal thoracic artery (BITA) grafting offers improved long-term survival in elderly patients undergoing coronary artery bypass grafting (CABG), but carries a higher risk of deep sternal wound infection (DSWI). This survival benefit was not observed in octogenarians.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Geriatric Medicine
Background:
- The efficacy of bilateral internal thoracic artery (BITA) grafting versus single internal thoracic artery (SITA) grafting in elderly patients undergoing coronary artery bypass grafting (CABG) is not well-established.
- Elderly patients often present with limited life expectancy and severe comorbidities, complicating surgical decisions.
- Understanding the risks and benefits of BITA grafting in this population is crucial for optimizing patient outcomes.
Approach:
- A comprehensive meta-analysis was conducted, synthesizing data from one randomized controlled trial, nine propensity score-matched studies, and six unmatched studies.
- The analysis included a total of 18,146 patients, comparing outcomes between BITA and SITA grafting.
Key Points:
- BITA grafting was associated with an increased risk of deep sternal wound infection (DSWI) (OR: 1.67; 95% CI: 1.22-2.28), irrespective of the skeletonization technique.
- BITA grafting demonstrated a significant long-term survival advantage (HR: 0.83; 95% CI: 0.77-0.90) compared to SITA grafting, although this benefit was not observed in octogenarians.
- No significant differences were found in early mortality, perioperative myocardial infarction, perioperative cerebrovascular accidents, or re-exploration for bleeding.
Conclusions:
- BITA grafting offers a long-term survival advantage for elderly CABG patients, but this benefit is uncertain in octogenarians.
- Elderly patients undergoing BITA grafting face an increased risk of DSWI, which is not mitigated by the skeletonization technique.
- The decision for BITA grafting in elderly patients requires careful consideration of the trade-off between improved long-term survival and increased risk of DSWI.
Aims:
Whether bilateral internal thoracic artery (BITA) grafting benefits elderly patients in coronary artery bypass grafting (CABG) remains unclear since they tend to have a limited life expectancy and severe comorbidities. We aim to evaluate the outcomes of BITA vs. single internal thoracic artery (SITA) grafting in elderly patients.
Methods And Results:
A meta-analysis was performed by database searching until May 2021. Studies comparing BITA and SITA grafting among elderly patients were included. One randomized controlled trial, nine propensity score matching, and six unmatched studies were identified, with a total of 18 146 patients (7422 received BITA grafting and 10 724 received SITA grafting). Compared with SITA grafting, BITA grafting had a higher risk of deep sternal wound infection (DSWI) [odds ratio: 1.67; 95% confidence interval (CI): 1.22-2.28], and this risk could not be significantly reduced by the skeletonization technique. Meanwhile, BITA grafting was associated with a higher long-term survival [hazard ratio: 0.83; 95% CI: 0.77-0.90], except for the octogenarian subgroup. Reconstructed Kaplan-Meier survival curves revealed 4-year, 8-year, and 12-year overall survival rates of 85.5%, 66.7%, and 45.3%, respectively, in the BITA group and 79.3%, 58.6%, and 34.9%, respectively, in the SITA group. No significant difference was observed in early mortality, perioperative myocardial infarction, perioperative cerebral vascular accidents, or re-exploration for bleeding.
Conclusion:
Compared with SITA grafting, BITA grafting could provide a long-term survival benefit for elderly patients, although this benefit remained uncertain in octogenarians. Meanwhile, elderly patients who received BITA were associated with a higher risk of DSWI and such a risk could not be eliminated by the skeletonization technique.
