Influence of diabetes and bilateral internal thoracic artery grafts on long-term outcome for multivessel coronary artery bypass grafting.

Department of Surgery, Montreal Heart Institute, 5000 Belanger Street East, Montreal, Que., Canada H1T 1C8.
European Journal of Cardio-Thoracic Surgery (Impact Factor: 2.67). 03/2005; 27(2):281-8. DOI:10.1016/j.ejcts.2004.10.048
Source: PubMed

ABSTRACT Diabetes mellitus is a major independent risk factor for morbidity and mortality after coronary artery bypass grafting (CABG). The aim of this study was to assess the effect of bilateral (B) internal thoracic artery grafting (ITA) in diabetic patients with multivessel CABG.
Between 1985 and 1995, 4382 patients underwent primary isolated multivessel CABG with ITA grafting and concomitant saphenous vein grafting (SVG). Outcome of diabetic and nondiabetic patients undergoing single (S) ITA+SVG (n=419 and 2079) and BITA+SVG (n=214 and 1594) grafting was obtained at a mean follow-up of 11+/-3 years.
Diabetic patients were older, included more women, and had more obesity, hypertension and peripheral vascular disease than nondiabetic patients. Deep sternal wound infection rate was 1.9% for diabetic patients vs 1.2% for nondiabetic patients (P=0.2) and 30-day mortality was 1.7 vs 1.8% (P=0.9). Cox regression analysis with interaction term and propensity scoring showed that BITA grafting decreased the risk of death (Hazard Ratio=0.72 [0.57-0.91, 95%CI]) and coronary reoperation (HR=0.38 [0.19-0.77]) in both diabetic and nondiabetic patients, with no significant interaction noted. BITA grafting decreased the risk of myocardial infarction at long-term follow-up in nondiabetic patients (HR=0.72 [0.60-0.86]) but not in diabetic patients. Ten-year freedom rate from myocardial infarction in diabetic patients was 80 and 76% for SITA and BITA grafting patients, respectively. However, survival following myocardial infarction was better for patients who underwent BITA grafting, in both diabetic and nondiabetic subgroups.
BITA+SVG grafting in diabetic patients improves survival and decrease coronary reoperation compared with SITA+SVG at long-term follow-up. Survival following myocardial infarction is improved with BITA grafting.

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    ABSTRACT: BACKGROUND: The advantageous survival outcome of bilateral internal mammary artery grafting (BIMA) has been well established. However, this meta-analysis aims to make clear whether BIMA grafting increases the risk of sternal wound infection (SWI) when compared with single internal mammary artery grafting (SIMA). METHODS: A literature search was performed in PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials. The observational studies reporting a comparison between SIMA and BIMA were included. The outcome of interest was the risk of SWI. Literature search, data extraction, and quality assessment were performed. Sensitivity and publication bias were also assessed in this research. RESULTS: We identified 4,701 titles and included 32 studies finally. The meta-analysis showed that the risk of SWI in the BIMA group was higher (relative risk [RR] 0.62, 95% confidence interval [CI] 0.55 to 0.71) than that in the SIMA group. Moreover, BIMA grafting was also associated with a higher risk of SWI in diabetic patients (RR 0.65, 95% CI 0.52 to 0.81) as well as elderly patients (RR 0.45, 95% CI 0.33 to 0.62). When skeletonization technique was adopted, the risk of SWI in BIMA patients was just a little higher than that in SIMA patients, but the difference did not reach statistical significance (RR 0.84, 95% CI 0.54 to 1.31). CONCLUSIONS: The BIMA grafting increases the risk of SWI when compared with SIMA grafting. This adverse effect further extends to diabetic and elderly patients. As regarding the method of procurement, skeletonized BIMA is safe and effective, thus it should be the procedure recommended.
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    ABSTRACT: OBJECTIVES The use of bilateral internal thoracic arteries (BITAs) grafting has been documented to be advantageous over left internal thoracic artery (LITA) grafting. It has been shown to significantly improve clinical outcomes and increase long-term survival in patients with diabetes. However, harvesting BITAs may result in a greater risk of superficial wound infection (SWI) or deep sternal wound infection (DSWI) and cardiovascular complications (major adverse cardiac and cerebrovascular events; MACCE) in such a patient group. The objective of this study was to compare the incidence of SWI or DSWI and cardiovascular events in a series of isolated coronary artery bypass grafting (CABG) patients who underwent BITA grafting vs LITA grafting.METHODSA total of 147 patients with coronary artery disease and diabetes underwent isolated CABG at John Paul II Hospital. Of these, 38 procedures were performed using BITA grafting and 109 with LITA-saphenous vein grafting.RESULTSMACCE were similar in bilateral groups (7.9%-BITA group and 9.2%-LITA group). No significant difference was found in mortality and length of stay between bilateral groups. The MACCE risk factor was age. The incidence of SWI and DSWI and sternal re-fixation did not differ between the BITA or LITA groups (5.2 vs 9.1%, 5.2 vs 7.3% and 5.2 vs 6.4%). The risk factors for DSWI were age (odds ratio 3.47, P = 0.032 for every 10 years) and body mass index >30 kg/m(2).CONCLUSIONS Perioperative complications do not increase with the use of BITAs in this group of diabetic patients. There are no statistically significant differences in the number of superficial or deep wound infections or number of sternal resuturing between the BITA and LITA groups.
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