Pure arterial CABG using BIMA
To the Editor, We read with interest the paper by Itagaki et al in Heart (1). The authors investigate the impact of bilateral internal mammary artery (BIMA) use in 1 526 360 isolated coronary artery bypass operations on inhospital mortality and deep sternal wound infection (DSWI). While there is survival benefit with BIMA, it was associated with higher incidence of DSWI but only in patients with chronic complications of diabetes mellitus. This finding correlates with those of the Arterial Revascularisation Trial where half the patients requiring sternal reconstruction in the BIMA group had diabetes (2). By harvesting the IMA in a skeletonised fashion (3) , longer conduits are obtained, the risks of kinking are reduced. Moreover, a beneficial reduction in sternal wound infection has been observed with this effect being more evident in diabetic patients undergoing BIMA grafting (4). Furthermore, since diabetic patients present with coronary artery disease earlier and have poorer outcomes with vein grafts or when treated with percutaneous coronary interventions; pure IMA revascularization offers the best prospective in terms of outcomes and can be performed using BIMA (3). Would the authors comment on the impact of harvesting technique, sternal wound closure technique and perioperative blood sugar control on DSWI in this huge series of patients? References: 1. Itagaki S, Cavallaro P, Adams DH, Chikwe J. Bilateral internal mammary artery grafts, mortality and morbidity: an analysis of 1 526 360 coronary bypass operations. Heart (2013). doi:10.1136/heartjnl-2013-303672 2. Taggart DP, Altman DG, Gray AM, et al; ART Investigators. Randomized trial to compare bilateral vs. single internal mammary coronary artery bypass grafting: 1-year results of the Arterial Revascularisation Trial (ART). Eur Heart J. 2010;31:2470-81. 3. Al-Attar N, Nataf P. Multiple extensive coronary artery stenting: does it compromise future surgical revascularization? Curr Opin Cardiol. 2007;22:529-33. 4. Saso S, James D, Vecht JA, et al. Effect of skeletonization of the internal thoracic artery for coronary revascularization on the incidence of sternal wound infection. Ann Thorac Surg. 2010;89:661-70.
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