title: Routine use of bilateral skeletonized internal thoracic artery grafting: long-term results.
abstract: BACKGROUND
  Skeletonized harvesting of the internal thoracic artery (ITA) decreases the severity of sternal devascularization, thus reducing the risk of postoperative sternal complications in patients undergoing bilateral ITA grafting.
  
  
  RESULTS
  Between 1996 and 2001, 1515 consecutive patients underwent skeletonized bilateral ITA grafting. Of the 1179 male and 336 female patients, 641 (42.3%) were >70 years of age, and 519 (34.2%) had diabetes mellitus. Operative mortality was 2.8%. Early postoperative morbidity included sternal infection (1.6%), cerebrovascular accident (3%), and perioperative myocardial infarction (1%). Multiple regression analysis showed chronic obstructive pulmonary disease (odds ratio, 11.3; 95% confidence interval [CI], 4.45 to 28.55), repeat operation (odds ratio, 12.7; 95% CI, 3.25 to 49.56), and diabetes mellitus (non-insulin dependent: odds ratio, 4.64; 95% CI, 1.85 to 11.59; insulin dependent: odds ratio, 6.9; 95% CI, 1.35 to 35.27) to be associated with increased risk of sternal infection. Follow-up (between 5 and 12 years) revealed 305 late deaths. Kaplan-Meier 10-year survival rates for patients <65, 65 to 74, and >75 years of age were 87%, 75%, and 52%, respectively. Cox regression analysis revealed increased overall mortality (early and late) in patients with peripheral vascular disease (hazard ratio [HR], 1.8; 95% CI, 1.39 to 2.33), patients >75 years of age (HR, 7.23; 95% CI, 4.16 to 12.55), those undergoing repeat operations (HR, 2.22; 95% CI, 1.27 to 3.89), patients with preoperative congestive heart failure (HR, 1.64; 95% CI, 1.29 to 3.75), and those with chronic renal failure (HR, 1.52; 95% CI, 1.11 to 2.01). Operations performed without cardiopulmonary bypass were associated with better postoperative survival (HR, 0.66; 95% CI, 0.49 to 0.87).
  
  
  CONCLUSIONS
  Bilateral ITA grafting is associated with low morbidity and good long-term results. Use of skeletonized bilateral ITA is appropriate for the elderly and most patients with diabetes; however, it is not recommended for repeat operations or for patients with chronic obstructive pulmonary disease.
authors.affiliation: Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center, 6 Weizman St, Tel Aviv 64239, Israel.
authors.forename: D
authors.initials: D
authors.lastname: Pevni
authors.forename: G
authors.initials: G
authors.lastname: Uretzky
authors.forename: A
authors.initials: A
authors.lastname: Mohr
authors.forename: R
authors.initials: R
authors.lastname: Braunstein
authors.forename: A
authors.initials: A
authors.lastname: Kramer
authors.forename: Y
authors.initials: Y
authors.lastname: Paz
authors.forename: I
authors.initials: I
authors.lastname: Shapira
authors.forename: R
authors.initials: R
authors.lastname: Mohr
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D001026:Coronary Artery Bypass / Q000379:methods*; D003324:Coronary Artery Disease / Q000401:mortality / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D008323:Mammary Arteries / Q000637:transplantation*; D008875:Middle Aged; D011183:Postoperative Complications / Q000382:microbiology; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D016896:Treatment Outcome