title: Bilateral internal thoracic artery grafting in insulin-treated diabetics: should it be avoided?
abstract: BACKGROUND
  It has been advocated that skeletonized bilateral internal thoracic artery (BITA) grafting may be implemented safely in diabetics, thus bestowing these patients with the long-term benefits of this strategy. However, the feasibility of this approach in insulin-treated patients has yet to be determined.
  
  
  METHODS
  One-hundred twenty-four insulin-treated diabetics, operated on between April 1996 and December 2001, were compared according to the surgical technique used: BITA (n = 50) or single internal thoracic artery (SITA; n = 74). In the latter, complementary grafts used were saphenous veins and radial arteries.
  
  
  RESULTS
  The groups had comparable risk profiles, with the exception of more neurologic events in the SITA group (21% vs 4%, p = 0.008). There was no significant difference in 30-day mortality (6% vs 4%, p = 0.684), nor in the incidence of neurologic complications (2% vs 8%, p = 0.240). The rate of sternal infection was comparable (4% vs 2.7%, p = 1.000). Use of BITAs was associated with a lower return of angina (4% vs 20%, p = 0.025), less cardiac events (17% vs 38%, p = 0.01), and reduced cardiac mortality (none vs 10%, p = 0.04). Despite the similar 6-year survival (80.5% and 77.4%, p = NS), cardiac-related event-free survival was better in BITA patients (69% vs 23%, p < 0.0001). Multivariate analysis identified use of BITA as a protective factor resulting in less return of angina (p = 0.007) and improved cardiac-related event-free survival (p = 0.001).
  
  
  CONCLUSIONS
  Skeletonized BITA grafting can be performed in insulin-treated diabetics at acceptable risk. This approach may confer improved cardiac outcome. Thus, it should be considered in selected patients.
authors.affiliation: Department of Cardiothoracic Surgery, The Tel Aviv Sourasky Medical Center, Tel Aviv, Israel. orenlevran@hotmail.com
authors.forename: Oren
authors.initials: O
authors.lastname: Lev-Ran
authors.forename: Rephael
authors.initials: R
authors.lastname: Mohr
authors.forename: Kramer
authors.initials: K
authors.lastname: Amir
authors.forename: Menachem
authors.initials: M
authors.lastname: Matsa
authors.forename: Nahum
authors.initials: N
authors.lastname: Nehser
authors.forename: Chaim
authors.initials: C
authors.lastname: Locker
authors.forename: Gideon
authors.initials: G
authors.lastname: Uretzky
mesh_terms: D000368:Aged; D001158:Arteries / Q000637:transplantation*; D002423:Cause of Death; D015897:Comorbidity; D003327:Coronary Disease / Q000401:mortality / Q000601:surgery*; D023903:Coronary Restenosis / Q000209:etiology / Q000401:mortality; D003922:Diabetes Mellitus, Type 1 / Q000401:mortality / Q000601:surgery*; D003925:Diabetic Angiopathies / Q000401:mortality / Q000601:surgery*; D005240:Feasibility Studies; D005260:Female; D005500:Follow-Up Studies; D006083:Graft Occlusion, Vascular / Q000209:etiology / Q000401:mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology / Q000401:mortality; D012307:Risk Factors; D016019:Survival Analysis; D020858:Tissue and Organ Harvesting; D014680:Veins / Q000637:transplantation