title: Routine use of bilateral internal thoracic artery grafts for left-sided myocardial revascularization in insulin-dependent diabetic patients: early and long-term outcomes.
abstract: OBJECTIVE
  Despite encouraging late outcomes, the use of bilateral internal thoracic artery (BITA) grafting for myocardial revascularization in diabetic patients remains controversial because of an increased risk of sternal complications. In the present study, early and long-term outcomes of the routine use of left-sided BITA grafting in insulin-dependent diabetic patients were reviewed retrospectively.
  
  
  METHODS
  Among the 2701 consecutive patients who underwent isolated BITA grafting at the authors' institution from 1999 throughout 2012, 188 (mean age: 67 ± 9 years) were insulin-dependent diabetic patients. The mean expected operative risk, calculated according to the European System for Cardiac Operative Risk Evaluation II, was 11 ± 10.8%.
  
  
  RESULTS
  There were 6 (3.2%) hospital deaths. Prolonged invasive ventilation (17.6%), multiple transfusion (16.5%), deep sternal wound infection (DSWI, 11.7%) and acute kidney injury (10.6%) were the most frequent major postoperative complications. Chronic lung disease (P = 0.08), low cardiac output (P = 0.039), multiple transfusion (P = 0.034) and mediastinal re-exploration (P = 0.071) were risk factors for DSWI. The mean follow-up was 5.7 ± 3.6 years. The 10-year non-parametric estimates of overall survival, freedom from cardiac and cerebrovascular death, and major adverse cardiac and cerebrovascular events were 57.7 [95% confidence interval (CI): 45.1-66.2], 83.6 (95% CI: 76.6-90.7) and 55.4% (95% CI: 44.7-66.1), respectively. Predictors of decreased late survival were old age (P = 0.013), chronic lung disease (P = 0.004), renal impairment (P = 0.009) and left ventricular dysfunction (P = 0.035).
  
  
  CONCLUSIONS
  Left-sided BITA grafting may be performed routinely even in insulin-dependent diabetic patients. The increased rates of postoperative complications do not prevent low early mortality and good long-term outcomes.
authors.affiliation: Division of Cardiac Surgery, Ospedali Riuniti, Trieste, Italy gius.gatti@gmail.com.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Gatti
authors.affiliation: Division of Cardiac Surgery, Ospedali Riuniti, Trieste, Italy.
authors.forename: Petar
authors.initials: P
authors.lastname: Soso
authors.affiliation: Division of Cardiology, Ospedali Riuniti, Trieste, Italy.
authors.forename: Luca
authors.initials: L
authors.lastname: Dell'Angela
authors.affiliation: Division of Cardiac Surgery, Ospedali Riuniti, Trieste, Italy.
authors.forename: Luca
authors.initials: L
authors.lastname: Maschietto
authors.affiliation: Division of Cardiac Surgery, Ospedali Riuniti, Trieste, Italy.
authors.forename: Lorella
authors.initials: L
authors.lastname: Dreas
authors.affiliation: Division of Cardiac Surgery, Ospedali Riuniti, Trieste, Italy.
authors.forename: Bernardo
authors.initials: B
authors.lastname: Benussi
authors.affiliation: Division of Infective Diseases, Ospedali Riuniti, Trieste, Italy.
authors.forename: Roberto
authors.initials: R
authors.lastname: Luzzati
authors.affiliation: Division of Cardiology, Ospedali Riuniti, Trieste, Italy.
authors.forename: Gianfranco
authors.initials: G
authors.lastname: Sinagra
authors.affiliation: Division of Cardiac Surgery, Ospedali Riuniti, Trieste, Italy.
authors.forename: Aniello
authors.initials: A
authors.lastname: Pappalardo
mesh_terms: D058186:Acute Kidney Injury / Q000209:etiology; D000368:Aged; D003324:Coronary Artery Disease / Q000150:complications* / Q000601:surgery; D003922:Diabetes Mellitus, Type 1 / Q000150:complications* / Q000601:surgery; D005260:Female; D006801:Humans; D008297:Male; D008323:Mammary Arteries / Q000637:transplantation*; D009204:Myocardial Revascularization / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D011183:Postoperative Complications / Q000209:etiology; D012189:Retrospective Studies; D018570:Risk Assessment; D013530:Surgical Wound Infection / Q000209:etiology; D016019:Survival Analysis; D016896:Treatment Outcome
keywords: Arterial grafts; CABG; Comorbidity; Diabetes mellitus; Outcomes; Sternal wound infection