Does Bilateral Internal Thoracic Artery Grafting Increase Long-Term Survival of Diabetic Patients?

doi:10.1016/j.athoracsur.2005.07.082

The Annals of Thoracic Surgery

Volume 81, Issue 2, February 2006, Pages 599-607

Presented at the Forty-first Annual Meeting of The Society of Thoracic Surgeons, Tampa, FL, Jan 24–26, 2005.

https://doi.org/10.1016/j.athoracsur.2005.07.082 Get rights and content

Background

The purpose of the present study was to determine whether long-term survival in diabetic patients increased after bilateral internal thoracic artery (BITA) coronary bypass compared with matched patients with single internal thoracic artery (SITA) coronary bypass.

Methods

The propensity for BITA was determined using logistic regression analysis and each BITA patient was matched with one SITA patient. Between January 1992 and March 2002, 980 matched diabetic patients (490 BITA versus 490 SITA) underwent coronary artery bypass surgery. Long-term survival data were obtained from the National Death Index (mean follow-up, 4.7 ± 3.0 years). Groups were compared by Cox proportional hazard models and Kaplan-Meier survival plots.

Results

Multivariate Cox regression analysis determined that BITA grafting had no significant effect on long-term survival (hazard ratio 0.89, 95% confidence interval: 0.69 to 1.14, p = 0.343). There were no differences in 30-day mortality (3.9% for BITA versus 3.7%, p = 0.999) and major postoperative complications except for length of stay (11.4 days for BITA versus 12.7 days, p < 0.001). Five-year survival rate was 79.9% in the BITA group and 75.7% in the SITA group (p = 0.252). There was no difference in 5-year survival rate between matched patients younger than 60 or from 70 to 79 years old. However, BITA patients aged 60 to 69 years had better 5-year survival rates (84.1% versus 71.0%, p = 0.0196), whereas the opposite was observed in patients aged more than 79 years (5-year survival for BITA 43.1% versus 70.0%, p = 0.016).

Conclusions

Bilateral internal thoracic artery grafting had no significant effect on long-term survival for diabetic patients, but it may increase long-term survival in patients aged 60 to 69 years, whereas SITA grafting may be beneficial for patients more than 79 years old.

Section snippets

Patient Population and Data Collection

Our database consisted of 1,215 consecutive diabetic patients who underwent isolated BITA or SITA coronary artery bypass between January 1992 and March 2002 at the St. Luke’s–Roosevelt Hospital Center, a university hospital of Columbia University. In the present study, we analyzed 980 propensity-matched patients in a ratio of 1:1.

Data were prospectively collected during admission as part of routine clinical practice and entered into the New York State adult cardiac surgery report for the

Results

The mean age within the study sample (n = 980) was 64.0 ± 9.7 years, and 44.4% (n = 435) were female. During the 4,578 person-years of follow-up (mean follow-up, 4.7 ± 3.0 years), 260 deaths (26.5%) were recorded. Multivariate logistic regression analysis found that female patients were less likely to get a BITA grafting than male patients (odds ratio [OR] 0.67, 95% CI: 0.53 to 0.85, p = 0.001), patients with BITA grafting were more likely to be of white race (OR 1.26, 95% CI: 1.00 to 1.60, p =

Comment

In diabetic patients, cardiovascular disease is the leading cause of death, and almost 80% of all deaths result from ischemic heart disease [17]; thus, an increasing number of patients undergoing CABG are diabetic patients [18]. Although this subgroup of CABG patients may benefit from an operation that is more resistant to the enhanced atherosclerotic process, the advantage of BITA grafting versus SITA grafting has been a controversial topic with respect to long-term survival. For diabetic

References (28)

B.W. Lytle et al.
Two internal thoracic artery grafts are better than one
J Thorac Cardiovasc Surg
(1999)
Z. Szabo et al.
Early postoperative outcome and medium-term survival in 540 diabetic and 2239 nondiabetic patients undergoing coronary artery bypass grafting
Ann Thorac Surg
(2002)
T. Hirotani et al.
Effects of coronary artery bypass grafting using internal mammary arteries for diabetic patients
J Am Coll Cardiol
(1999)
I.K. Toumpoulis et al.
The impact of deep sternal wound infection on long-term survival after coronary artery bypass grafting
Chest
(2005)
D. Abramov et al.
Trends in coronary artery bypass surgery resultsa recent, 9-year study
Ann Thorac Surg
(2000)
O. Lev-Ran et al.
Bilateral internal thoracic artery grafting in diabetic patientsshort-term and long-term results of a 515-patient series
J Thorac Cardiovasc Surg
(2004)
A.P. Furnary et al.
Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures
Ann Thorac Surg
(1999)
J.P. Ioannidis et al.
Early mortality and morbidity of bilateral versus single internal thoracic artery revascularizationpropensity and risk modeling
J Am Coll Cardiol
(2001)
T. Hirotani et al.
Risks and benefits of bilateral internal thoracic artery grafting in diabetic patients
Ann Thorac Surg
(2003)
O. Lev-Ran et al.
Bilateral versus single internal thoracic artery grafting in oral-treated diabetic subsetscomparative seven-year outcome analysis
Ann Thorac Surg
(2004)

O. Lev-Ran et al.

Bilateral internal thoracic artery grafting in insulin-treated diabeticsshould it be avoided?

Ann Thorac Surg

(2003)

Seven-year outcome in the Bypass Angioplasty Revascularization Investigation (BARI) by treatment and diabetic status

J Am Coll Cardiol

(2000)

J.J. Morris et al.

Influence of diabetes and mammary artery grafting on survival after coronary bypass

Circulation

(1991)

I.K. Toumpoulis et al.

The impact of diabetes mellitus on long-term survival after coronary artery bypass grafting

Eur Heart J

(2004)

Cited by (45)

Very Long-term Outcome of Bilateral Internal Thoracic Artery in Diabetic Patients: A Systematic Review and Reconstructed Time-To-Event Meta-analysis
2024, Current Problems in Cardiology
The benefits of single (SITA) and bilateral internal thoracic arteries (BITA) in diabetics undergoing coronary bypass grafting (CABG) are conflicting. We undertook a study-level meta-analysis to compare early and long-term outcomes of both CABG configurations. PubMed, CENTRAL, and EMBASE were searched for studies comparing BITA versus SITA for isolated CABG surgery in diabetics. Randomized trials or observational studies were considered eligible for the analysis. Kaplan-Meier curves of long-term survival were reconstructed and compared with Cox linear regression; incidence rate ratios (IRR) with 95% confidence intervals (CI) for long-term survival were calculated. Landmark analysis and time-varying hazard ratio (HR) were analyzed. Odds ratios (OR) were extracted for early mortality, postoperative stroke, deep sternal wound infection (DSWI), and myocardial infarction (MI). A random effects meta-analysis was performed. Sensitivity analyses included leave-one-out-analyses and meta-regression. Thirteen studies (7332 patients) were included. Overall, at 20-year follow-up, BITA was associated with higher survival (HR = 0.77; 95% CI, 0.71-0.84; P < 0.0001). Time-varying HR and landmark analysis reported BITA was associated with a higher rate of 10-year survival (HR = 0.75, 95% CI 0.68-0.82, P < 0.0001), while from 10 to 20-year follow-up no difference was revealed (HR = 0.99, 95% CI 0.82-1.19, P = 0.93). There was no increase in early mortality, postoperative MI, stroke, or DSWI between the groups. At meta-regression, the higher the age, the higher the long-term overall survival in patients with BITA. In diabetics, the BITA approach is associated with improved 10-year survival with no increase in early mortality, MI, stroke, or DSWI. In the 10–20-year timeframe, BITA and SITA showed comparable survival.
Coronary artery bypass grafting using bilateral internal thoracic arteries in patients with diabetes and obesity: A systematic review and meta-analysis
2023, IJC Heart and Vasculature
Patients with diabetes and obesity are at higher risk of adverse long-term outcomes following coronary artery bypass grafting. The use of bilateral internal thoracic arteries (BITA) can potentially offer survival benefit in higher risk patients compared to single internal thoracic artery (SITA), but BITA is not routinely used due to lack of clear evidence of efficacy and concerns over sternal wound complications.
Medline, Embase and the Cochrane Library were searched for studies comparing the efficacy and safety of BITA and SITA grafting in patients with diabetes and obesity. Meta-analysis of mortality and sternal wound complications was performed.
We identified eight observational and ten propensity matched studies, and one RCT, comparing BITA and SITA which included patients with diabetes (n = 19,589); two propensity matched studies and one RCT which included patients with obesity (n = 6,972); mean follow up was 10.5 and 11.3 years respectively. Meta-analysis demonstrated a mortality reduction for BITA compared to SITA in patients with diabetes (risk ratio [RR] 0.79; 95% confidence interval [CI] 0.70–0.90; p = 0.0003). In patients with obesity there was a non-significant reduction in mortality in the BITA group (RR 0.73, 95% CI 0.47–1.12; p = 0.15). There was a significantly higher rate of sternal wound complications following BITA observed in patients with diabetes (RR 1.53, 95% CI 1.23–1.90; p = 0.0001) and obesity (RR 2.24, 95% CI 1.63–3.07; p < 0.00001).
BITA is associated with better long-term survival in patients with diabetes. The effects of BITA grafting in patients with obesity are uncertain. BITA is associated with higher rates of sternal wound complications compared to SITA in both patients with diabetes and obesity.
Bilateral internal thoracic artery grafting in elderly patients: Any benefit in survival?
2022, Journal of Thoracic and Cardiovascular Surgery
The purpose of the present study was to compare survival outcomes in propensity score–matched patients aged 70 years or greater receiving a bilateral internal thoracic artery graft with patients receiving a single internal thoracic artery graft.
Among 4083 consecutive patients with isolated coronary artery bypass grafting who underwent operation between January 2001 and December 2018, we identified 1300 patients aged 70 years or greater; of these, 968 received a bilateral internal thoracic artery (bilateral internal thoracic artery group) and 332 received a single internal thoracic artery (single internal thoracic artery group). Propensity score matching was used to reduce the preoperative patient differences. The 10-year survival and postoperative complications were compared between the 2 groups.
A Kaplan–Meier curve at 10 years of follow-up showed that crude survival was significantly superior in patients with bilateral internal thoracic artery grafts than in patients with single internal thoracic artery grafts (67.0% ± 2.5% vs 56.0% ± 3.4%, respectively; P < .016). In the actuarial survival, estimates for propensity score–matched patients with a bilateral internal thoracic artery showed a significantly higher rates of survival than patients with a single internal thoracic artery by the end of follow-up (66.0% ± 5.3% vs 53.0% ± 3.9%, respectively; hazard ratio, 0.64; 95% confidence interval, 0.44-0.94; P = .022, univariable Cox Model and multivariable analysis hazard ratio, 0.66; 95% confidence interval, 0.45-0.97; P = .036 Cox model). Postoperative complications were all similar between the single internal thoracic artery and bilateral internal thoracic artery groups.
The use of bilateral internal thoracic artery grafting in older patients improves 10-year survival, with similar postoperative morbidity. This surgical technique might have beneficial effects in survival in patients aged more than 70 years. Its use could be considered more frequently.
Commentary: Improving outcomes in diabetic coronary artery bypass grafting recipients: More arterial conduits, but even more medicine
2022, Journal of Thoracic and Cardiovascular Surgery
Effect of bilateral internal thoracic artery harvesting on deep sternal wound infection in diabetic patients: Review of literature
2021, Annals of Medicine and Surgery
Citation Excerpt :
Puskas et al. (2012) recommended avoiding BITA in a morbidly obese diabetic female with pre-operative HbA1c greater than 7.5% may decrease the risk of DSWI [6]. Toumpoulis et al. (2006) supported the idea of BITA in diabetic patients whose age is 70 years or less and who do not need emergency surgery [43]. Lev-Ran et al. (2003) suggested that BITA should be avoided in obese, IDDM patients with BMI > 29 kg/m2 associated with COPD or undergoing emergency surgery.
Instead of its documented superiority of patency and long-term outcomes, the bilateral internal thoracic artery grafts are underused in the general population, and its use is controversial and debatable in diabetic patients due to long surgery duration, post-surgical bleeding, and sternal wound complications such as sternal wound infection, mediastinitis, and sternal wound dehiscence. This review article is particularly focused on deep sternal wound infection (DSWI) of bilateral internal thoracic artery (BITA) grafts in diabetic patients with comparison to single internal thoracic artery (SITA) graft.
Is the era of bilateral internal thoracic artery grafting coming for diabetic patients? An updated meta-analysis
2019, Journal of Thoracic and Cardiovascular Surgery
Because of an increased risk of sternal wound complications, the use of bilateral internal thoracic artery grafting in diabetic patients remains controversial. The objective of the present meta-analysis is to compare the safety and efficacy of single internal thoracic artery and bilateral internal thoracic artery grafting in the diabetic population.
Four electronic databases, including PubMed, the Cochrane Library, Embase, and ISI Web of Knowledge, were comprehensively searched. Prospective randomized trials or observational studies comparing single internal thoracic artery and bilateral internal thoracic artery were considered eligible for the current study.
A literature search yielded 1 randomized controlled trial and 17 observational studies (129,871 diabetic patients: 124,233 single internal thoracic arteries and 5638 bilateral internal thoracic arteries). Pooled analysis demonstrated overall incidence of deep sternal wound infection in the bilateral internal thoracic artery grafting group was significantly higher than in the single internal thoracic artery grafting group (3.26% for bilateral internal thoracic artery vs 1.70% for single internal thoracic artery). No significant difference was found between both groups in terms of risk of deep sternal wound infection when the skeletonized harvesting technique was adopted. Furthermore, in-hospital mortality was comparable between both groups (2.80% for bilateral internal thoracic artery vs 2.36% for single internal thoracic artery). However, compared with single internal thoracic artery grafting, bilateral internal thoracic artery grafting could confer a lower risk for long-term overall mortality (hazard ratio, 1.41; 95% confidence interval, 1.18-1.67; P < .001; I² = 63%) and cardiac mortality (hazard ratio, 3.15; 95% confidence interval, 2.23-4.46; P < .001; I² = 0%).
Compared with single internal thoracic artery grafting, bilateral internal thoracic artery grafting is associated with enhanced long-term survival among diabetic patients. Skeletonization of bilateral internal thoracic artery is not associated with an increased risk of deep sternal wound infection. Therefore, surgeons should be encouraged to adopt bilateral internal thoracic artery grafting in a skeletonized manner more routinely in diabetic patients.

View all citing articles on Scopus

View full text

Original articleCardiovascularDoes Bilateral Internal Thoracic Artery Grafting Increase Long-Term Survival of Diabetic Patients?

Background

Methods

Results

Conclusions

Section snippets

Patient Population and Data Collection

Results

Comment

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Am Coll Cardiol

Chest

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Am Coll Cardiol

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Seven-year outcome in the Bypass Angioplasty Revascularization Investigation (BARI) by treatment and diabetic status

J Am Coll Cardiol

Influence of diabetes and mammary artery grafting on survival after coronary bypass

Circulation

The impact of diabetes mellitus on long-term survival after coronary artery bypass grafting

Eur Heart J

Original article
Cardiovascular
Does Bilateral Internal Thoracic Artery Grafting Increase Long-Term Survival of Diabetic Patients?