Bilateral internal thoracic artery grafting is associated with significantly improved long-term survival, even among diabetic patients.
ABSTRACT This study examines if bilateral internal thoracic artery (BITA) grafting provides improved outcomes compared with single internal thoracic artery (SITA) grafting, in the modern era, in which diabetes mellitus and obesity are more prevalent.
The Society of Thoracic Surgeons database at a single large academic center was reviewed for all consecutive isolated coronary artery bypass grafting patients with two or more distal anastomoses from January 1, 2002, through December 31, 2010. Propensity-adjusted logistic and Cox regression models were used to estimate the effect of BITA on short-term outcomes and long-term survival for diabetic and nondiabetic patients.
A total of 3,527 coronary artery bypass grafting operations (812 BITA, 2,715 SITA) were performed. Fewer BITA than SITA patients had diabetes (28.6% vs 44.7% p<0.001). There was no significant difference in 30-day rates of death, stroke, or myocardial infarction between nondiabetic patients who had BITA vs SITA, or between diabetic patients who had BITA vs SITA. BITA grafting conferred a 35% reduction (95% confidence interval, 12% to 52%, p=0.006) in the long-term hazard of death equally for nondiabetic and diabetic patients (p=0.93). Deep sternal wound infection was more common among diabetic than among nondiabetic patients (1.5% vs 0.7%), but was similar within nondiabetic (1.0% vs 0.6%) and diabetic patients (1.7% vs 1.5%) who had BITA vs SITA. Overall, BITA and SITA patients had similar rates of deep sternal wound infection (1.2% vs 1.0%).
BITA grafting confers a long-term survival advantage and should be performed whenever suitable coronary anatomy exists and patient risk factors allow an acceptable risk of deep sternal wound infection.
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ABSTRACT: Skeletonization of the internal mammary artery (IMA) facilitates arterial grafting and has been shown to reduce deep sternal infection but is more time-consuming and tedious than pedicle harvest. We wished to determine if use of harmonic technology (HT) facilitates skeletonization of the IMA and is as safe as the conventional technique of skeletonization. In a consecutive series of 1057 patients with isolated coronary artery bypass graft (CABG) surgery from 2003 to 2013, adverse events and recorded harvest times were compared between harmonic (965 patients) and non-harmonic patients (86 patients). HT was used to harvest 1640 IMAs in 965 (91%) of 1057 consecutive CABG patients and skeletonization with the traditional technique (use of an electrocautery tip as a dissector) was used to harvest 147 IMAs in 86 patients. Six patients had no IMA harvested with this surgery (4 patients had an IMA used from a previous CABG, 1 had no disease of the left anterior descending coronary artery and 1 patient was in cardiogenic shock precluding IMA use). Excluding patients with single-vessel disease, 730/987 (74%) of patients received bilateral IMAs. Demographics of patients with and without harmonic skeletonization, respectively, were the following: mean age: 64.7 vs 67.7 years; diabetes: 33 vs 34%; women: 21 vs 26% and median European System for Cardiac Operative Risk Evaluation: 2.9 vs 3.2. The mean harvest time for 77 non-harmonic skeletonized mammary arteries (49 surgeries) was 32.2 min (95% confidence interval (CI): 30.1, 34.3), for harmonic skeletonized arteries after 450 surgeries was 28.4 min, (95% CI: 27.8, 29.1) and in the last 100 IMAs harvested for the isolated harmonic device use/mammary was 15.4 min (95% CI: 14.0, 16.7). Major adverse events for patients with and without harmonic skeletonization, respectively, were: reoperation for bleeding: 2.7 vs 3.5% (difference = 0.8%, 95% CI: -3.2, 4.8); damaged mammaries: 0.4 vs 0.7% (difference = 0.3%, 95% CI: -1.0, 1.7); deep sternal infection: 1.6 vs 1.2% (difference = -0.4%, 95% CI: -2.8, 2.0) and perioperative infarction: 1.7 vs 2.3% (difference = 0.7%, 95% CI: -2.6, 4.0). In this largest series to date of harmonic IMA skeletonization, this technique results in rare damage, is quicker and with a comparable adverse event rate compared with the non-harmonic method.European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 02/2014; · 2.40 Impact Factor
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ABSTRACT: Patients with diabetes develop more widespread and more severe atherosclerotic coronary artery disease than patients without diabetes. Medical management of this coronary disease is inferior to revascularization for more complex or more widespread disease. Revascularization by percutaneous intervention (PCI) for patients with diabetes is associated with high mortality and complication rates. Surgical revascularization by coronary artery bypass grafting, yields superior results to PCI for patients with diabetes and coronary artery disease. Patients with diabetes benefit from the same medical management of their coronary artery disease and secondary risk modification as patients without diabetes.Endocrinology and metabolism clinics of North America 03/2014; 43(1):59-73. · 3.56 Impact Factor
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ABSTRACT: The optimal treatment for multivessel coronary artery disease in patients with end-stage renal disease (ESRD) is unresolved. Compare clinical adverse events after percutaneous intervention with drug-eluting stents (DESs) and coronary artery bypass grafting (CABG) in patients with ESRD. MEDLINE, Web of Science, and Scopus were searched for appropriate studies published in the English language (between January 2000 and August 2013). The pooled odds ratio (OR) was estimated by the Peto method with a random effect model. Data are presented with 95% confidence interval; p < 0.05 is significant. Five observational studies (12,035 DES patients; 6317 CABG) with a follow-up period of 27.4 ± 6.3 months were included. Early mortality (CABG 8% and DES 2.6%) was less in the DES cohort (OR 0.29 [0.14-0.59]; p = 0.0006; I(2) = 18%). Repeat intervention (DES 29% and CABG 12%) was more likely in the DES cohort (OR 3.72 [2.24-6.18]: p < 0.0001). Late mortality (27.4 ± 7.3 months) was comparable in both cohorts (OR 0.72 [0.40-1.29]; p = 0.27). While DES cohort (32%) patients suffered a slightly higher incidence of major adverse cardiac and cerebrovascular events (MACCE) as compared to CABG (25%), this was not significant (1.35 [0.72-2.53]; p = 0.35; I(2) = 30%). Data regarding this topic are limited to small retrospective studies. Early mortality is lower with DESs compared with coronary artery bypass in patients with ESRD. Rate of reintervention is significantly higher in the DES cohort. At a mean pooled follow-up of two years, both mortality and MACCE are comparable in both cohorts.Journal of Cardiac Surgery 01/2014; · 1.35 Impact Factor