Bilateral internal thoracic artery grafting in diabetic patients: short-term and long-term results of a 515-patient series.
BACKGROUND
Despite potential long-term benefits, bilateral internal thoracic artery grafting in diabetics remains controversial because of the risk of sternal infection. We sought to assess the short- and long-term outcome after left-sided bilateral internal thoracic artery grafting and to determine the configuration of choice in diabetic subsets.


METHODS
Between 1996 and 2001, 515 diabetics underwent isolated left-sided skeletonized bilateral internal thoracic artery grafting. The outcome of 468 consecutive oral-treated diabetics and 47 selective insulin-treated patients was analyzed. Patients undergoing T-grafting were compared with those undergoing in situ bilateral internal thoracic artery arrangements.


RESULTS
The respective rates for early mortality and sternal infections were 2.4% and 1.9% in oral-treated diabetics and 6.3% and 4.3% in insulin-treated diabetics. Multivariate correlates of sternal infection were chronic lung disease (odds ratio, 10), obesity (odds ratio, 7), reoperation (odds ratio, 22), and a creatinine level of 2 mg/dL or more (odds ratio, 8). Five-year survival was 82%. The T-graft (n = 437) and in situ (n = 162) subgroups had comparable baseline profiles. Freedom from cardiac mortality at 6.5 years was 95.6% and 87.6% (P =.277), and freedom from repeat revascularization was 91.5% and 92.7% (P =.860), respectively. The choice of bilateral internal thoracic artery configuration did not appear as a correlate of mortality, cardiac mortality, or major adverse cardiac events. Complementary right-sided gastroepiploic artery (hazard ratio, 0.36) and sequential (hazard ratio, 0.55) grafting were identified as protective factors against the occurrence of major adverse cardiac events.


CONCLUSIONS
Routine skeletonized bilateral internal thoracic artery grafting can be implemented safely in oral-treated diabetics. This strategy is associated with a favorable late cardiac outcome and is thus recommended. Both left-sided bilateral internal thoracic artery configurations provide comparable short- and long-term outcomes.
Lev-Ran
Oren
O
Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center, Israel. orenlevran@hotmail.com
Mohr
Rephael
R
Pevni
Dmitri
D
Nesher
Nahum
N
Weissman
Yona
Y
Loberman
Dan
D
Uretzky
Gideon
G
D000284:Administration, Oral; D000368:Aged; D001026:Coronary Artery Bypass; D003920:Diabetes Mellitus / Q000453:epidemiology / Q000628:therapy*; D003925:Diabetic Angiopathies / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007004:Hypoglycemic Agents / Q000627:therapeutic use; D007328:Insulin / Q000627:therapeutic use; D008297:Male; D008323:Mammary Arteries / Q000601:surgery*; D008875:Middle Aged; D009017:Morbidity; D011183:Postoperative Complications / Q000453:epidemiology / Q000209:etiology; D011237:Predictive Value of Tests; D012307:Risk Factors; D016019:Survival Analysis; D013995:Time; D013997:Time Factors; D016896:Treatment Outcome
D007004:Hypoglycemic Agents; D007328:Insulin