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Published on: September 15, 2023
Bilateral internal thoracic artery grafting in isolated coronary artery bypass grafting: A 35-year experience
Youssef Shahin1,2,3, Tedy Sawma1, Yazan AlJamal1
1Mayo Clinic, Cardiovascular Surgery, Rochester, Minn.
Insights
Bilateral internal thoracic artery grafting offers superior long-term survival in coronary artery bypass grafting, yet its use has declined recently. Despite longer operative times, it shows comparable wound complication rates and should be more widely adopted.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Vascular Surgery
Background:
- The use of bilateral internal thoracic artery (BITA) grafting in coronary artery bypass grafting (CABG) has evolved over decades.
- Understanding trends and outcomes associated with BITA versus non-BITA strategies is crucial for optimizing CABG procedures.
Purpose of the Study:
- To analyze trends in BITA grafting during isolated CABG over a 35-year period.
- To compare the outcomes of BITA grafting with non-BITA strategies in a large patient cohort.
Main Methods:
- A retrospective analysis of 15,991 patients undergoing isolated multivessel CABG from 1990 to 2024.
- Assessment of grafting trends using chi-square tests and propensity score matching for outcome comparisons.
- Analysis of patient factors like obesity and diabetes prevalence.
Main Results:
- BITA grafting use increased initially but declined from 2020-2024, unrelated to patient risk factors.
- BITA grafting was associated with longer operative times but similar cardiopulmonary bypass and crossclamp durations.
- Kaplan-Meier analysis demonstrated superior 30-year survival for BITA grafting, with no increase in wound-healing complications.
Conclusions:
- BITA grafting is underutilized despite proven survival benefits and acceptable complication rates.
- The recent decline in BITA use is not explained by patient comorbidities, suggesting a need for increased adoption.
- Further research, including randomized trials, is warranted to optimize CABG strategies utilizing BITA grafts.
Objectives:
The study objectives were to analyze trends in bilateral internal thoracic artery grafting during isolated coronary artery bypass grafting over a 35-year interval and compare outcomes between bilateral internal thoracic artery and non-bilateral internal thoracic artery strategies.
Methods:
A cohort of 15,991 patients underwent isolated multivessel coronary artery bypass grafting at our institution between 1990 and 2024. Trends in bilateral internal thoracic artery, radial artery, and left internal thoracic artery + saphenous vein graft were assessed using chi-square tests with Bonferroni correction. Changes in obesity and diabetes prevalence across intervals were also analyzed. Propensity score matching (1:1) yielded 2013 pairs for outcome comparisons between bilateral internal thoracic artery and non-bilateral internal thoracic artery groups.
Results:
Between 1990 and 2024, use of bilateral internal thoracic artery and radial artery increased (11.0% and 13.2%, respectively), although bilateral internal thoracic artery declined during 2020 to 2024 as radial artery and left internal thoracic artery + saphenous vein graft use increased. This decline was unrelated to rising obesity or diabetes rates. Matched analysis revealed longer operative times for bilateral internal thoracic artery (+51 minutes, P < .001), whereas cardiopulmonary bypass and crossclamp durations remained similar. Wound-healing complication rates did not increase with bilateral internal thoracic artery grafting. Kaplan-Meier analysis showed superior 30-year survival for bilateral internal thoracic artery compared with other grafting strategies.
Conclusions:
Bilateral internal thoracic artery grafting remains underused, particularly in recent years, despite demonstrated survival benefits and comparable wound-healing risks. The decline is not explained by patient risk factors, highlighting the need for broader adoption of bilateral internal thoracic artery grafting and further randomized trials to optimize coronary artery bypass grafting strategies.
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