title: Are two really always better than one? Results, concerns and controversies in the use of bilateral internal thoracic arteries for coronary artery bypass grafting in the elderly: a systematic review and meta-analysis.
abstract: BACKGROUND
  Bilateral internal thoracic artery grafting appears to be the preferred method to achieve durable long-term coronary artery revascularization. However, data reporting the benefit of this technique in the elderly is very conflicting.
  
  
  METHODS
  We performed a systematic review of available literature (till November 2014) using multiple databases to identify studies comparing clinical events in patients undergoing coronary artery bypass grafting using either a single or double internal thoracic artery in the elderly. While early mortality was the primary end-point of inclusion, other adverse events compared were sternal wound infection (deep and superficial), stroke and peri-operative myocardial infarction. Individual and pooled odd's ratios were calculated using the Mantel-Haenzel method (random effect model); sensitivity analysis was performed. Results are presented using 95% confidence intervals.
  
  
  RESULTS
  Nine retrospective studies (4479 BITA, 7733 LITA patients) fulfilled search criteria. Deep sternal wound infection was significantly higher after BITA harvest [OR 1.86 (1.3-2.5); I(2) = 0%; p < 0.01]. Early mortality (BITA 3.6% vs SITA 3.1%; p = 0.86), stroke [OR 0.7(0.4-1.1); p = 0.1], and peri-operative myocardial infarction (BITA 4.3% vs SITA 2.3%; p = 0.1) were comparable in both cohorts. Long-term survival favored the BITA cohort in two propensity matched studies.
  
  
  CONCLUSIONS
  The incidence of deep sternal wound infection may be significantly higher after the harvest of both internal thoracic arteries in the elderly. While other post-operative adverse events are comparable, data regarding the long-term survival advantage in this cohort is conflicting. Hence, the use of both internal thoracic arteries in this age group needs to be invidualized.
authors.affiliation: Division of Cardiac Surgery, Harrington Heart and Vascular Institute, Case Medical Center, University Hospitals, Cleveland, OH, USA. Electronic address: svd14@case.edu.
authors.forename: Salil V
authors.initials: SV
authors.lastname: Deo
authors.affiliation: Department of Cardiovascular Surgery, Queen Alia Heart Institute, Amman, Jordan.
authors.forename: Salah E
authors.initials: SE
authors.lastname: Altarabsheh
authors.affiliation: Department of Surgery, University of Minnesota, Minneapolis-St.Paul, MN, USA.
authors.forename: Ishan K
authors.initials: IK
authors.lastname: Shah
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Sungkyunkwan School of Medicine, Samsung Hospital, Seoul, South Korea.
authors.forename: Yang Hyun
authors.initials: YH
authors.lastname: Cho
authors.affiliation: Health Sciences Library, Case Western Reserve University, Cleveland, OH, USA.
authors.forename: Michael
authors.initials: M
authors.lastname: McGraw
authors.affiliation: Division of Cardiac Surgery, Harrington Heart and Vascular Institute, Case Medical Center, University Hospitals, Cleveland, OH, USA.
authors.forename: Basar
authors.initials: B
authors.lastname: Sarayyepoglu
authors.affiliation: Division of Cardiac Surgery, Harrington Heart and Vascular Institute, Case Medical Center, University Hospitals, Cleveland, OH, USA.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Medalion
authors.affiliation: Division of Cardiac Surgery, Harrington Heart and Vascular Institute, Case Medical Center, University Hospitals, Cleveland, OH, USA.
authors.forename: Alan H
authors.initials: AH
authors.lastname: Markowitz
authors.affiliation: Division of Cardiac Surgery, Harrington Heart and Vascular Institute, Case Medical Center, University Hospitals, Cleveland, OH, USA.
authors.forename: Soon J
authors.initials: SJ
authors.lastname: Park
mesh_terms: D000368:Aged; D003324:Coronary Artery Disease / Q000601:surgery; D006801:Humans; D007387:Internal Mammary-Coronary Artery Anastomosis / Q000009:adverse effects / Q000379:methods*; D009203:Myocardial Infarction / Q000209:etiology; D056346:Sternotomy / Q000009:adverse effects; D020521:Stroke / Q000209:etiology; D013530:Surgical Wound Infection / Q000209:etiology / Q000517:prevention & control
keywords: Coronary artery bypass grafting; Coronary artery disease; Internal thoracic artery; Sternal wound infection; Survival