Saphenous Vein vs Arterial Graft to the Right System in Left-Sided Arterial Revascularization.

BACKGROUND: To investigate clinical outcomes of various arterial grafts (AGs) vs saphenous vein grafts (VGs) to the right coronary system in patients who received left-sided bilateral internal thoracic artery revascularization. METHODS: We compared short- and long-term outcomes of all the patients operated in our center during 1996-2011, who received left-sided bilateral internal thoracic artery (left anterior descending and left circumflex) grafting and either a VG or an AG to the right coronary system. RESULTS: Of 1691 patients, 983 received a VG and 708 received an AG to the right coronary system: 387 gastroepiploic arteries and 321 internal thoracic artery grafts. The median follow-up was 15.7 ± 0.32 years. For the VG and AG groups, early mortality (1.6% for VG and 1.3% for AG, P = .55) and other early adverse outcomes did not differ. Long-term (up to 20 years) survival was similar (34.1% ± 3.4% for VG vs 36.0% ±2% for AG, P = .86). In multivariable analysis, VG to the right coronary artery was not found to be a predictor of inferior survival (hazard ratio: 0.99, 95% confidence interval 0.836-1.194, P = .99). Comparing 2 propensity-matched groups of 349 pairs with a VG or an AG, and accounting for the severity of the right coronary lesion, did not demonstrate differences in early outcome or late survival between the groups. CONCLUSIONS: Early outcomes and long-term survival were comparable among patients who received left-sided bilateral internal thoracic artery revascularization, between various graft types to the right coronary system.

Early and late outcomes of single versus bilateral internal thoracic artery revascularization for patients in critical condition.

OBJECTIVE: The optimal surgical approach for critically ill patients with complex coronary disease remains uncertain. We compared outcomes of bilateral internal thoracic artery (BITA) versus single ITA (SITA) revascularization in critical patients. METHODS: We evaluated 394 consecutive critical patients with multi-vessel disease who underwent CABG during 1996-2001. Outcomes measured were early mortality, strokes, myocardial-infarctions, sternal infections, revisions for bleeding, and late survival. The critical preoperative state was acknowledged concisely by one or more of the following: preoperative ventricular tachycardia/fibrillation, aborted sudden cardiac death, or the need for mechanical ventilation or for preoperative insertion of intra-aortic-balloon counter-pulsation. RESULTS: During the study period, 193 of our patients who underwent SITA and 201 who underwent BITA were in critical condition. The SITA group was older (mean 68.0 vs. 63.3 years, p = 0.001) and higher proportions were females (28.5% vs. 18.9% p = 0.025), after recent-MI (69.9% vs. 57.2% p = 0.009) and with left-main disease (38.3% vs. 49.3% p = .029); the median logistic EuroSCORE was higher (0.2898 vs. 0.1597, p<0.001). No statistically significant differences were observed between the SITA and BITA groups in 30-day mortality; and in rates of early CVA, MI and sternal infections (13.0% vs. 8.5%, p = 0.148; 4.1% vs. 6.0%, p = 0.49; 6.7% vs. 4.5%, p = 0.32 and 2.1% vs. 2.5%, p>0.99, respectively). Long-term survival (median follow-up of 15 years, interquartile-range: 13.57-15) was better in the BITA group (median 14.39 vs. 9.31± 0.9 years, p = 0.001). Propensity-score matching (132 matched pairs) also yielded similar early outcomes and improved long-term survival (median follow-up of 15 years, interquartile-range: 13.56-15) for the BITA group (median 12.49±1.71 vs. 7.63±0.99 years, p = 0.002). In multivariable analysis, BITA revascularization was found to be a predictor for improved survival (hazard-ratio of 0.419, 95%CI 0.23-0.76, p = 0.004). CONCLUSIONS: This study demonstrated long-term survival benefit for BITA revascularization in patients in a critical pre-operative state who presented for surgical revascularization.

Is gender a risk factor for bilateral internal thoracic artery grafting? A twenty-year follow-up.

BACKGROUND: Although bilateral internal thoracic artery (BITA) grafting is associated with improved survival, many surgeons are reluctant to use this technique, especially in female patients, due to its greater complexity and potential increased risk of sternal infection. The aim of this study was to compare the outcomes of male and female patients who underwent BITA grafting. METHODS: We evaluated at the early outcome and late mortality, 551 female versus 2525 male patients who underwent isolated BITA grafting between January 1996 and December 2011. To adjust for differences in demographic and clinical characteristics, a multivariate risk analysis and propensity score matching were performed. Kaplan-Meier analysis was performed for the entire cohort and for the matched cohort. RESULTS: Female patients were older and were more likely than males to have congestive heart failure, unstable angina pectoris, and diabetes. Sternal infection was more frequent in females than males (3.3% vs. 1.8%; p = .04). Differences were not observed in operative mortality (2.9% vs. 1.9%; p = .15) and stroke incidence (3.4% vs. 2.6; p = .30). After multivariate risk analysis and propensity score matching, the female gender was not found to be a predictor of worse outcomes. There was no difference in median survival among female and male patients (14.3 and 14.2 years, respectively; p = .68). CONCLUSION: Our results support the routine use of BITA grafting in proper selected female patients who undergo myocardial revascularization.

Late Outcomes of In Situ Versus Composite Bilateral Internal Thoracic Artery Revascularization.

BACKGROUND: We compared 2 configurations for revascularization of the internal thoracic arteries to the anterior and lateral walls. In the "in situ" configuration, an in situ right internal thoracic artery supplies the left anterior descending territory, and an in situ left internal thoracic artery is grafted to the left circumflex territory. In the "composite" configuration, an in situ left internal thoracic artery is grafted to the left anterior descending artery and a free right internal thoracic artery is attached end-to-side to the left internal thoracic artery and supplies the lateral wall. METHODS: We compared outcomes of all the patients treated in our center by the described strategies during 1996 through 2011. RESULTS: Of 2951 patients, 1220 underwent composite grafting and 1731 underwent in situ grafting; the median follow-up was 15.1 years (interquartile range, 11.2-18.6 years). Early mortality (2.2% vs 2.0%, P = .787) and other early adverse outcomes did not differ significantly between the groups. Long-term (15-year) survival was marginally significant in favor of the in situ group (53.5% vs 49.5%, P = .05); this difference disappeared after 20 years. Configuration strategy was not a predictor for better 15-year survival in multivariable analysis (hazard ratio, 0.97; 95% confidence interval, 0.85-1.09; P = .568). An additional analysis compared matched groups of 995 patients each who underwent the 2 configuration strategies and found no differences in early outcome or late survival between the groups. CONCLUSIONS: This study demonstrated the safety and effectiveness of 2 strategies for bilateral internal thoracic artery revascularization to the left side, with comparable early outcomes and long-term survival.

Is the Use of BITA vs SITA Grafting Safe and Beneficial in Octogenarians?

BACKGROUND: Bilateral internal thoracic artery (BITA) grafting is questionable in octogenarians because of shorter life expectancy and increased risk of perioperative complications. The aim of this study was to examine the safety and effectiveness of performing BITA and single internal thoracic artery (SITA) grafts in patients older than 80 years of age. METHODS: This study compared outcomes in 201 consecutive octogenarians who underwent isolated BITA grafting with those of 280 consecutive octogenarians who underwent SITA and saphenous vein grafting during 1996 to 2011. Insulin-dependent diabetes, ejection fraction <30, and emergency operations were more common among patients who underwent SITA, and the prevalence of left main coronary artery disease was lower. Propensity score matching was used to control for these differences, thus generating well-matched groups of 190 patients each. RESULTS: There were no significant differences in early mortality between the unmatched groups: 3.2% in the BITA group and 8.6% in the SITA group (P = .12). Rates of sternal wound infection were also similar, 1.5% vs 1.7%, respectively. Differences were not observed in the occurrences of perioperative stroke (3.5% vs 2.5%; P = .999) and myocardial infarction (1.5% vs 3.6%; P = .166). The results were similar for the matched groups. Long-term survival between the unmatched groups and survival between the matched groups were not significantly different. CONCLUSIONS: This study shows equal long-term survival for BITA and SITA grafting in octogenarians. BITA is an acceptable alternative to SITA grafting in low-risk octogenarians and in the presence of a calcified aorta or poor-quality saphenous vein graft.

Bilateral internal thoracic artery grafting in patients with left main disease: a single-center experience.

OBJECTIVE: We compared early and long-term outcomes between bilateral internal thoracic artery (BITA) grafting and single internal thoracic artery (SITA) grafting in patients with LM disease. METHODS: We evaluated the outcomes of all patients with LM disease who underwent revascularization in our center during 1996-2011. Variables that were adjusted for in a multivariate analysis and in propensity matching included age, sex, comorbid diseases, repeat operation, the number of diseased vessels, other conduits used, the use of sequential grafting, the number of grafts constructed, and the operative era (1996-2000 vs. 2001-2011). RESULTS: In total, 949 patients with LM disease underwent BITA grafting and 564 underwent SITA grafting during the study period. SITA patients were more often female and more likely to have comorbidities such as chronic obstructive pulmonary disease, ejection fraction <30%, recent myocardial infarction, diabetes, congestive heart failure, chronic renal failure, and peripheral vascular disease, and to have undergone an emergency operation. We found no statistically significant difference between the SITA and BITA groups in 30-day mortality (4.8% vs. 3.3%, P = 0.136), sternal wound infection (2.0% vs. 2.4%, P = 0.548), and stroke (3.2% vs. 4.4%, P = 0.234). BITA patients had improved long-term survival (70.1% vs. 52.0% p<0.001), median follow-up of 15 years. In multivariate analysis, after propensity score matching (477 matched pairs), this finding was not statistically significant (P = 0.135). CONCLUSION: This study did not demonstrate a clear benefit of BITA grafts among patients with LM disease.

A simple-to-use nomogram to predict long term survival of patients undergoing coronary artery bypass grafting (CABG) using bilateral internal thoracic artery grafting technique.

BACKGROUND: Several risk scores have been created to predict long term mortality after coronary artery bypass grafting (CABG). Several studies demonstrated a reduction in long-term mortality following bilateral internal thoracic arteries (BITA) compared to single internal thoracic artery. However, these prediction models usually referred to long term survival as survival of up to 5 years. Moreover, none of these models were built specifically for operation incorporating BITA grafting. METHODS: A historical cohort study of all patients who underwent isolated BITA grafting between 1996 and 2011 at Tel-Aviv Sourasky medical center, a tertiary referral university affiliated medical center with a 24-bed cardio-thoracic surgery department. Study population (N = 2,935) was randomly divided into 2 groups: learning group which was used to build the prediction model and validation group. Cox regression was used to predict death using pre-procedural risk factors (demographic data, patient comorbidities, cardiac characteristics and patient's status). The accuracy (discrimination and calibration) of the prediction model was evaluated. METHODS AND FINDINGS: The learning (1,468 patients) and validation (1,467 patients) groups had similar preoperative characteristics and similar survival. Older age, diabetes mellitus, chronic obstructive lung disease, congestive heart failure, chronic renal failure, old MI, ejection fraction ≤30%, pre-operative use of intra-aortic balloon, and peripheral vascular disease, were significant predictors of mortality and were used to build the prediction model. The area under the ROC curves for 5, 10, and 15-year survival ranged between 0.742 and 0.762 for the learning group and between 0.766 and 0.770 for the validation group. The prediction model showed good calibration performance in both groups. A nomogram was built in order to introduce a simple-to-use tool for prediction of 5, 10, and 15-year survival. CONCLUSIONS: A simple-to-use validated model can be used for a prediction of 5, 10, and 15-year mortality after CABG using the BITA grafting technique.

Left anterior descending artery revascularization with the right internal thoracic artery T-graft: the 'reverse composite' configuration.

OBJECTIVES: The use of bilateral internal thoracic artery graft for myocardial revascularization has improved the long-term survival and decreased the rate of repeat interventions in patients. A key technical factor for complete arterial revascularization is sufficient length of the internal thoracic artery (ITA) graft. The purpose of this study was to compare early and long-term outcomes of 'standard composite' grafting and 'reverse composite' grafting. In the former, the left ITA (LITA) is connected to the left anterior descending artery, and the right ITA is connected end-to-side to the LITA for revascularization of the left circumflex artery. In 'reverse composite' grafting, the LITA is connected to the left circumflex artery, and the right ITA is connected end-to-side to the LITA, for revascularization of the left anterior descending artery. METHODS: We compared the outcomes of 1365 patients who underwent coronary artery bypass grafting in Tel-Aviv Sourasky Medical Centre, using bilateral ITA as standard composite versus 'reverse composite' grafts, between January 1996 and December 2011. A propensity score matching analysis compared 132 pairs of patients who underwent bilateral ITA by the 2 modes. RESULTS: Twelve hundred and thirty patients underwent standard 'composite' grafts and 135 underwent 'reverse composite' grafts. Early mortality and early adverse effects did not differ significantly between the groups. After matching, the difference in late mortality between the groups was not statistically significant. CONCLUSIONS: This study suggests that revascularization of the left anterior descending with the right ITA, arising from an in situ LITA, is safe and provides early outcomes and long-term survival that are not significantly different from those of the standard composite grafting technique. However, there was evidence of better survival in the standard composite group.

Are two internal thoracic grafts better than one? An analysis of 5301 cases.

OBJECTIVES: Although bilateral internal thoracic artery (BITA) grafting is associated with improved survival, many surgeons are reluctant to use this technique due to its greater complexity and the potentially increased risk of sternal infection. This observational study examined if BITA grafting provides improved outcomes compared with single internal thoracic artery (SITA) grafting in patients with multivessel coronary disease. METHODS: Patients in our institution who underwent BITA grafting during 1996-2011 were compared to those who underwent SITA grafting during the same period. To adjust for differences in demographic and clinical characteristics, patients were matched by propensity score. The Cox model was used to identify predictors of decreased survival and the Kaplan-Meier analysis was performed, both for the entire cohort and for the matched cohort. RESULTS: SITA patients were older than BITA patients, included more females, and were more likely to have chronic obstructive lung disease, an ejection fraction <30%, diabetes, renal insufficiency, peripheral vascular disease and emergency and repeat operations. Three-vessel and left main diseases were more common among BITA patients, and operative mortality was reduced (2.1% vs 3.6% for SITA, P = 0.002). Sternal infection and stroke rates were similar for the groups. Ten-year Kaplan-Meier survival of BITA patients was better (71.2% vs 56.8%, respectively, P < 0.001). BITA grafting was found to be a predictor of better survival in the analysis of the matched cohort (P < 0.001). CONCLUSIONS: Our results support the routine use of BITA grafting in patients who undergo myocardial revascularization.

Does bilateral versus single thoracic artery grafting provide survival benefit in female patients?

OBJECTIVES: Bilateral internal thoracic artery (BITA) grafting is associated with improved survival, but this technique is reluctantly used in women due to an increased risk of sternal wound infection. The aim of this study was to compare the long-term survival of women who underwent BITA grafting and single internal thoracic artery (SITA) grafting. METHODS: We performed a retrospective analysis of 556 consecutive female BITA patients and 685 female SITA patients. RESULTS: SITA patients were older and more likely to have comorbidities (diabetes mellitus, chronic lung disease, chronic renal failure, peripheral vascular disease and cerebral vascular disease). Operative mortality showed a trend towards a benefit for BITA (2.9% vs 5.0% for SITA, P = 0.06). The sternal wound infection rates were similar (3.4% vs 2.9%, P = 0.6); however, the occurrence of stroke was significantly lower in the SITA group (3.4% vs 1.2%, P = 0.007). The median survival of the BITA group was significantly better {13.8 years [95% confidence interval (CI) 12.8-14.9] vs 10.3 years [95% CI 9.6-11.1], P = 0.001}. After propensity score matching (491 pairs), the assignment to BITA was not associated with increased early mortality or complication rates, and the choice of BITA grafting was associated with better survival [14.5 years (95% CI 13.3-15.6) vs 11.8 years (95% CI 10.7-12.9)]. Only the choice of conduits was associated with increased late mortality (multivariable analysis, hazard ratio 1.28, 95% CI 1.024-1.591; P = 0.03). CONCLUSIONS: The low early mortality and complication rate, and the long-term survival benefit of BITA compared to SITA grafting, support the use of BITA grafting in women.

Are two internal thoracic grafts better than one in patients with peripheral vascular disease?

BACKGROUND: The use of two bilateral internal thoracic artery grafting (BITA) was shown to lead to survival benefit. However, operators are reluctant to use BITA with peripheral vascular disease (PVD) because of concerns of increased rates of sternal wound infection and lack of studies supporting survival benefit compared with single internal thoracic artery (SITA) grafting. The aim of this study is to compare outcome BITA grafting versus of SITA and vein grafts in PVD patients. PATIENTS AND METHODS: Six hundred and twenty-one PVD patients who underwent BITA between 1996 and 2011 were compared with 372 patients who underwent SITA. RESULTS: SITA patients were older and more likely more likely to have comorbidities (female, insulin-dependent diabetes, chronic obstructive lung disease, congestive heart failure, previous coronary artery bypass grafting, renal insufficiency, cerebrovascular disease, and emergency operation). Operative mortality (5.1 vs. 4.5%, in the SITA and BITA, respectively, P=0.758), rate of sternal wound infection (5.1 vs. 3.9%, P=0.421), and strokes (4.8 vs. 7.4%, P=0.141) were not significantly different between groups. BITA patients did not have significantly better 10-year survival (52.6 vs. 45.9%, P=0.087) and after propensity score matching (302 well-matched pairs), BITA was not associated with improved survival (hazard ratio: 0.902; 95% confidence interval: 0.742-1.283; P=0.784) (Cox model). CONCLUSION: The routine use of BITA versus SITA in PVD patients does not improve long-term survival. Selective use of BITA in lower risk patients might unmask the benefits of BITA.

Correction: Are two internal thoracic grafts better than one in patients with chronic obstructive lung disease? Analysis of 387 cases between 1996-2011.

[This corrects the article DOI: 10.1371/journal.pone.0201227.].

Are two internal thoracic grafts better than one in patients with chronic obstructive lung disease? Analysis of 387 cases between 1996-2011.

OBJECTIVES: Bilateral internal thoracic artery (ITA) grafting is associated with improved survival. However, potential survival benefit of using two ITA`s in patients with chronic lung disease (CLD) is questionable due to their increased risk of sternal wound infection (SWI) compared to operations incorporating single ITA (SITA). The purpose of this study is to compare early and long-term outcome of bilateral internal thoracic artery (BITA) grafting to that of grafting with single internal thoracic grafts and vein grafts or radial artery (SITA) in CLD patients with multi-vessels coronary disease. METHODS: One hundred and forty eight CLD patients who underwent BITA between 1996 and 2011 were compared with 239 who underwent SITA at the same period. RESULTS: SITA patients were more often female, more likely to have insulin treated diabetes (DM), DM with end organ damage, neurologic dysfunction and unstable angina. Despite of the difference in preoperative characteristics, early mortality (5.4% vs. 5.4%, in the SITA and BITA respectively, p = 0 < .999) and occurrences of SWI (6.3% vs 9.5%, p = 0.320) and strokes (3.8% vs 5.4%,p = 0.611) were not significantly different between groups. BITA patients did not have better Kaplan-Meier 10 year survival (52.8% vs. 42.6%, p = 0.088) and after matching, BITA and SITA had similar adjusted survival (HR 0.983[95%CI 0.755-1.280] p = 0.901) (cox model). CONCLUSION: Our study results suggest that in patients with CLD, the choice of BITA grafting technique did not provide survival benefit compared to SITA with other conduits.

Should Bilateral Internal Thoracic Artery Grafting Be Used in Patients After Recent Myocardial Infarction?

BACKGROUND: Bilateral internal thoracic artery grafting (BITA) is associated with improved survival. However, surgeons do not commonly use BITA in patients after myocardial infarction (MI) because survival is good with single internal thoracic artery grafting (SITA). We aimed to compare the outcomes of BITA with those of SITA and other approaches in patients with multivessel disease after recent MI. METHODS AND RESULTS: In total, 938 patients with recent MI (<3 months) who underwent BITA between 1996 and 2011 were compared with 682 who underwent SITA. SITA patients were older and more likely to have comorbidities (diabetes mellitus, chronic obstructive pulmonary disease, chronic renal failure, peripheral vascular disease), to be female, and to have had a previous MI. Acute MI and 3-vessel disease were more prevalent in the BITA group. Operative mortality of BITA patients was lower (3.0% versus 5.8%, P=0.01), and sternal infections and strokes were similar. Median follow-up was 15.21 years (range: 0-21.25 years). Survival of BITA patients was better (70.3% versus 52.5%, P<0.001). Propensity score matching was used to account for differences in preoperative characteristics between groups. Overall, 551 matched pairs had similar preoperative characteristics. BITA was a predictor of better survival in the matched groups (hazard ratio: 0.679; P=0.002; Cox model). Adjusted survival of emergency BITA and SITA patients was similar (hazard ratio: 0.883; P=0.447); however, in the nonemergency group, BITA was a predictor of better survival (hazard ratio: 0.790; P=0.009; Cox model). CONCLUSIONS: This study suggests that survival is better with BITA compared with SITA in nonemergency cases after recent MI, with proper patient selection.

Comparison of radial and bilateral internal thoracic artery grafting in patients with peripheral vascular disease†.

OBJECTIVES: The composite T-graft with radial artery (RA) attached end-to-side to the left internal thoracic artery (ITA) provides arterial myocardial revascularization without the increased risk of deep sternal wound infection associated with harvesting 2 ITAs. However, many surgeons are reluctant to use RA in patients with peripheral vascular disease (PVD) due to concerns regarding the quality of the conduit in this subset of patients. The purpose of this study is to compare early- and long-term outcomes of arterial grafting with bilateral ITAs (BITA) to that of single ITA and RA in patients with PVD. METHODS: Between 1999 and 2010, 619 consecutive patients with PVD (500 BITAs and 119 single ITA and RA) underwent myocardial revascularization in our institution. RESULTS: Occurrence of following risk factors as female sex, age 70+, diabetes, unstable angina, emergency operation, cerebrovascular disease and chronic obstructive pulmonary disease was higher in the RA-ITA group. The RA-ITA group also had a higher logistic EuroSCORE (22.1 vs 13.3). Operative mortality and occurrence of deep sternal wound infection of the two groups was similar (4.2% vs 5.0% and 2.5% vs 4.0% for the radial and bilateral ITA, respectively). Median follow-up was 9.75 years. Unadjusted Kaplan-Meier 10-year survival of the two groups was similar (44.1% vs 49.6%, P = 0.7). After propensity score matching (100 pairs), assignment to BITA was not associated with better adjusted survival (hazard ratio 0.593, 95% confidence interval 0.265-1.327, P = 0.20, Cox model). CONCLUSIONS: In patients with PVD, complete arterial revascularization with left ITA and RA can be justified with regards to survival.

One or Two Internal Thoracic Grafts? Long-Term Follow-Up of 957 Off-Pump Coronary Bypass Surgeries.

BACKGROUND: The potential survival benefit of bilateral internal thoracic artery (BITA) grafting in patients undergoing off-pump coronary artery bypass graft surgery (OPCABG) is controversial owing to the technical complexity of these operations. Our objective was to compare the outcome of patients undergoing OPCABG with BITA to the outcome of patients undergoing OPCABG with a single internal thoracic artery (SITA) and saphenous vein grafts or radial artery. METHODS: Five hundred and thirty-five consecutive patients who underwent OPCABG BITA at our institute between 2000 and 2008 were compared with 422 patients who underwent OPCABG with SITA. Propensity score matching was used to account for differences between groups in preoperative characteristics. RESULTS: Being female (20.9% versus 36.0%, p < 0.001), having diabetes mellitus (36.6% versus 55.7%, p > 0.001), recent myocardial infarction (23.6% versus 33.2%, p > 0.001), aged 70 years or more (41.1% versus 49.8%, p = 0.001), peripheral vascular disease (26.1% versus 46.7%, p > 0.001), and chronic renal failure (7.9% versus 15.9%, p > 0.001) were less frequent in the BITA group than in the SITA group, respectively. The European System for Cardiac Operative Risk Evaluation score was significantly higher for the SITA group (7.62, versus 5.46 for BITA group, p = 0.001), whereas operative mortality (1.7% BITA versus 2.6% SITA) and sternal wound infections (1.7% BITA versus 2.1% SITA) were similar. The mean follow-up was 11.6 ± 3.5 years. The BITA patients' 10-year survival (Kaplan-Meier) was better (72.2% versus 55.1% for SITA, p > 0.001). However, after propensity matching, survival for BITA and SITA were similar. CONCLUSIONS: This large cohort study suggests that long-term outcomes for patients undergoing OPCABG are not better with BITA grafting.

Should Bilateral Internal Thoracic Artery Grafting Be Used in Patients With Diabetes Mellitus?

BACKGROUND: Bilateral internal thoracic artery (BITA) grafting in patients with diabetes mellitus is controversial because of a higher risk for sternal infection. The purpose of this study is to compare the outcome of BITA grafting to that of single ITA (SITA) grafting in patients with diabetes. METHODS: Between 1996 and 2010, 964 diabetic patients with multivessel disease who underwent primary coronary artery bypass graft surgery with BITA were compared with 564 patients who underwent coronary artery bypass graft surgery with SITA and saphenous vein grafts. RESULTS: The SITA patients were older, more often female, more likely to have chronic obstructive pulmonary disease, ejection fraction 30% or less, insulin-dependent diabetes, recent myocardial infarction, renal insufficiency, peripheral vascular disease, and emergency operation. The BITA patients more often underwent coronary artery bypass graft surgery with three or more grafts. The two groups had similar operative mortality, 2.6% BITA versus 3.0% SITA, and sternal infection, 3.1% versus 3.9%, respectively. The mean follow-up was 12.2 ± 4.3 years. Unadjusted Kaplan-Meier 10-year survival of the BITA group was better than that of the SITA group (65.3% ± 3.1% versus 55.5% ± 4.5%, respectively; p = 0.004), After propensity score matching (490 well-matched pairs), Kaplan-Meier 10-year survival was not significantly different between the matched groups; however, the Cox-adjusted survival of the BITA patients was better (hazard ratio 0.729, 95% confidence interval: 0.551 to 0.964, p = 0.027). CONCLUSIONS: The findings of this large cohort study suggest that the long-term outcome of patients with diabetes and multivessel disease who undergo BITA grafting is better than that of diabetic patients who undergo coronary artery bypass graft surgery with SITA and saphenous vein grafts.

Long-term outcome of revascularization with composite T-grafts: Is bilateral mammary grafting better than single mammary and radial artery grafting?

OBJECTIVE: Bilateral internal mammary artery (BIMA) grafting is associated with improved survival. However, many surgeons are reluctant to use this technique, owing to the potentially increased risk of sternal infection. The composite T-graft with radial artery (RA) attached end-to-side to the left internal mammary artery (IMA) provides complete arterial revascularization without increased risk of sternal infection. The purpose of this study is to compare outcomes of these 2 strategies. METHODS: Patients who underwent BIMA grafting using the composite T-graft technique, between 1996 and 2010 (n = 1329), were compared with 389 patients who underwent composite grafting with a single IMA + RA during the same time period. RESULTS: Patients undergoing single IMA grafting were older, more often women, and more likely to have diabetes, peripheral vascular disease, and COPD, and to need an emergency operation. Congestive heart failure, left main disease, and recent myocardial infarction were more prevalent with bilateral grafting. Propensity-score matching was used to account for differences between groups in preoperative patient characteristics. The 268 matched pairs had similar characteristics. The median follow-up time was 14.19 (95% confidence interval 13.43-14.95) years. Operative mortality and Kaplan-Meier 10-year survival of the 2 matched groups were similar (3.4% vs 3.7%, and 61.6% vs 64%, for the groups treated with BIMA and single IMA, respectively). Cox-adjusted survival was similar (P = .514). Age, chronic renal failure, and performance of <3 bypass grafts were independent predictors of decreased survival. CONCLUSIONS: This study suggests that long-term outcomes of arterial revascularization with a composite T-graft constructed using left IMA and RA are not inferior to outcomes after BIMA grafting.

Arterial coronary artery bypass grafting is safe and effective in elderly patients.

OBJECTIVES: Bilateral internal thoracic artery grafting in elderly patients is controversial. We compared the outcome of bilateral internal thoracic artery grafting with that of single internal thoracic artery and saphenous vein and radial artery conduits in these patients. METHODS: Patients aged 70 years or more who underwent bilateral internal thoracic artery grafting between 1996 and 2008 (n = 1045) were compared with patients who underwent coronary artery bypass grafting with a single internal thoracic artery + saphenous vein graft (n = 582) or a single internal thoracic artery + radial artery (n = 249). RESULTS: Prevalence of female gender, diabetes, emergency operation, and chronic obstructive pulmonary disease was lower in the bilateral internal thoracic artery grafting group compared with the internal thoracic artery + radial artery and internal thoracic artery + saphenous vein graft groups, whereas congestive heart failure and recent myocardial infarction were more prevalent in the bilateral internal thoracic artery grafting group. Operative mortality and sternal wound infections were not significantly different between groups. The mean follow-up was 8.17 ± 4.45 years. Ten-year survival (Kaplan-Meier) in the internal thoracic artery + saphenous vein graft group was significantly lower than in the bilateral internal thoracic artery grafting and internal thoracic artery + radial artery groups (P < .001). Assignment to the saphenous vein graft group was also associated with decreased adjusted survival (P < .001) compared with the bilateral internal thoracic artery and internal thoracic artery + radial artery groups. CONCLUSIONS: This study supports the use of arterial grafts in elderly patients undergoing coronary artery bypass grafting.