title: Surgical revascularization techniques that minimize surgical risk and maximize late survival after coronary artery bypass grafting in patients with diabetes mellitus.
abstract: OBJECTIVE
  To identify surgical revascularization techniques that minimize surgical risk and maximize late survival in patients with diabetes undergoing coronary artery bypass grafting (CABG).
  
  
  METHODS
  From January 1972 to January 2011, 11,922 patients with diabetes underwent primary isolated CABG. The revascularization techniques investigated included bilateral internal thoracic artery (BITA) grafting (n=938; 7.9%) versus single ITA (SITA) grafting, off-pump (n=602; 5.0%) versus on-pump CABG, and incomplete (n=2109; 18%) versus complete revascularization. The median follow-up was 7.8 years and total follow-up, 104,516 patient-years. Multivariable analyses were performed to assess the effects of surgical techniques on hospital outcomes and long-term mortality.
  
  
  RESULTS
  After adjusting for patient characteristics, BITA versus SITA grafting was associated with a 21% lower late mortality (68% confidence limits, 16%-26%). However, BITA grafting was also associated with more deep sternal wound infections (DSWIs), but the considerable mortality from DSWI minimally affected overall survival because of its rare occurrence. The risk factors for DSWI were female sex (80% increased risk), higher body mass index (7% increased risk per kg/m2), medically treated diabetes (73% increased risk), previous myocardial infarction (58% increased risk), and peripheral arterial disease (73% increased risk). Off-pump and on-pump CABG had similar results. Complete versus incomplete revascularization had similar hospital outcomes; however, complete revascularization was associated with 10% lower late mortality (68% confidence limits, 7.0%-13%).
  
  
  CONCLUSIONS
  BITA grafting with complete revascularization maximizes long-term survival and is recommended for patients with diabetes undergoing CABG. BITA grafting should be used in all patients with diabetes whose risk of DSWI is low. It might be best avoided in obese diabetic women with diffuse atherosclerotic burden-those at greatest risk of developing these infections.
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Sajjad
authors.initials: S
authors.lastname: Raza
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address: sabikj@ccf.org.
authors.forename: Joseph F
authors.initials: JF
authors.lastname: Sabik
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Khalil
authors.initials: K
authors.lastname: Masabni
authors.affiliation: Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Ponnuthurai
authors.initials: P
authors.lastname: Ainkaran
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Bruce W
authors.initials: BW
authors.lastname: Lytle
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Eugene H
authors.initials: EH
authors.lastname: Blackstone
mesh_terms: D000368:Aged; D001026:Coronary Artery Bypass; D003324:Coronary Artery Disease / Q000401:mortality / Q000601:surgery*; D048909:Diabetes Complications; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007387:Internal Mammary-Coronary Artery Anastomosis / Q000379:methods* / Q000401:mortality; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008323:Mammary Arteries / Q000637:transplantation*; D008875:Middle Aged; D009204:Myocardial Revascularization / Q000379:methods* / Q000401:mortality; D051437:Renal Insufficiency / Q000453:epidemiology; D012086:Reoperation; D012121:Respiration, Artificial / Q000706:statistics & numerical data; D012306:Risk; D012307:Risk Factors; D020521:Stroke / Q000453:epidemiology; D013530:Surgical Wound Infection / Q000453:epidemiology; D015996:Survival Rate; D016896:Treatment Outcome