title: Outcomes associated with bilateral internal thoracic artery grafting: the importance of age.
abstract: BACKGROUND
  Although bilateral internal thoracic artery (BITA) grafting in coronary artery bypass grafting (CABG) is associated with low morbidity and good long-term results, controversy exists about the age after which BITA grafting is no longer beneficial. We sought to determine if such an age cutoff point exists.
  
  
  METHODS
  The study cohort consisted of 5,601 consecutive patients from a cardiac surgery registry who underwent isolated CABG (1,038 [19%] BITA grafts, 4,029 [72%] single internal thoracic artery [SITA] grafts, 534 [10%] vein-only grafts) between 1995 and 2008. A Cox model was used to compare survival by use of bilateral, single, or no internal thoracic artery (ITA) grafts, adjusting for baseline clinical and demographic characteristics.
  
  
  RESULTS
  Mean follow-up was 7.1 years. Patients undergoing BITA grafting had the lowest 1-year mortality (2.4% versus 4.3% SITA grafting and 8.2% vein-only grafting; p < 0.0001). Relative to SITA grafting, a crude survival benefit of 54% existed for BITA grafting (hazard ratio [HR] 0.46; 95% confidence interval [CI], 0.37 to 0.57; p < 0.0001) with worse survival for vein-only grafts (HR, 1.16; 95% CI, 0.99 to 1.37; p = 0.07). After adjustment, the benefit of BITA grafting was no longer statistically significant (HR, 0.87; 95% CI, 0.69 to 1.08; p = 0.2). However age may be an effect modifier: a spline analysis plotting HR (BITA grafting versus SITA grafting) against age suggested a potential survival advantage associated with BITA grafting in patients younger than 69.9 years.
  
  
  CONCLUSIONS
  Bilateral internal thoracic artery grafting is a reasonable revascularization strategy in suitable patients up to age 70 years. As benefits of arterial grafting become more obvious over time, a longer period of follow-up will be needed to confirm the advantage of a BITA grafting strategy. In the meantime the BITA grafting advantage for patients older than 70 years is not clear.
authors.affiliation: Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada. t.kieserprieur@ucalgary.ca
authors.forename: Teresa M
authors.initials: TM
authors.lastname: Kieser
authors.forename: Adriane M
authors.initials: AM
authors.lastname: Lewin
authors.forename: Michelle M
authors.initials: MM
authors.lastname: Graham
authors.forename: Billie-Jean
authors.initials: BJ
authors.lastname: Martin
authors.forename: P Diane
authors.initials: PD
authors.lastname: Galbraith
authors.forename: Doreen M
authors.initials: DM
authors.lastname: Rabi
authors.forename: Colleen M
authors.initials: CM
authors.lastname: Norris
authors.forename: Peter D
authors.initials: PD
authors.lastname: Faris
authors.forename: Merril L
authors.initials: ML
authors.lastname: Knudtson
authors.forename: William A
authors.initials: WA
authors.lastname: Ghali
mesh_terms: D000367:Age Factors; D000368:Aged; D000416:Alberta / Q000453:epidemiology; D001026:Coronary Artery Bypass / Q000379:methods* / Q000401:mortality; D003324:Coronary Artery Disease / Q000401:mortality / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008323:Mammary Arteries / Q000637:transplantation*; D008875:Middle Aged; D011446:Prospective Studies; D012307:Risk Factors; D015996:Survival Rate / Q000639:trends; D013997:Time Factors; D016896:Treatment Outcome