title: Are all forms of total arterial revascularization equal? A comparison of single versus bilateral internal thoracic artery grafting strategies.
abstract: OBJECTIVE
  Total arterial revascularization (TAR) with internal thoracic arteries (ITAs) and radial arteries (RA) is associated with greater long-term survival compared with the use of a single internal thoracic artery supplemented by veins. The optimal conduit choice and configuration in achieving TAR remains controversial, with uncertainty regarding the individual prognostic impact of ITAs and RAs. As such, among patients solely undergoing TAR, we compared long-term survival between patients receiving single thoracic arteries and those receiving bilateral ITAs.
  
  
  METHODS
  From 1995 to 2010, 2821 patients with 3-vessel coronary artery disease at 8 centers underwent primary isolated coronary artery bypass with TAR using ITAs and RAs. Bilateral ITAs were used in 912 patients. In 380 cases, bilateral in situ ITAs were grafted to the left coronary system. RAs were used in 848 patients (93%) receiving bilateral ITAs and 1906 patients (99.8%) receiving single ITAs. Survival data were obtained using the National Death Index. Separate 1:1 propensity score-matched analyses were performed for (1) bilateral ITA versus single ITA and (2) bilateral ITA incorporating a free right ITA versus single ITA and RAs. Among the 912 patients with bilateral ITAs, those receiving an in situ right ITA to the left coronary system were compared with those receiving a free right ITA.
  
  
  RESULTS
  In the propensity score-matched analysis comparing bilateral versus single ITAs (591 matched pairs), there were similar rates of 30-day mortality and deep sternal wound infection. Bilateral ITA use was associated with greater 15-year survival (79% ± 3.9% vs 67% ± 4.7%, P < .001). In the analysis between bilateral ITA incorporating a free right ITA versus single ITA + RAs (380 matched pairs), bilateral ITA use demonstrated comparable survival at 15 years (79% ± 4.7% vs 67% ± 5.7%, P = .09). Among patients receiving bilateral ITAs, comparison between in situ right ITA versus free right ITA recipients (206 matched pairs) revealed comparable 15-year survival (84% ± 6.1% vs 79% ± 6.7%, P = .13). Multivariable Cox regression found bilateral ITA use to be protective from mortality (hazard ratio, 0.73; 95% confidence interval, 0.59-0.90, P = .004).
  
  
  CONCLUSIONS
  The use of bilateral ITAs as an in situ or free conduit is associated with greater survival and seems to offer a prognostic advantage over the use of only a single ITA supplemented by RAs. Therefore, all configurations of TAR are not equivalent.
authors.affiliation: Department of Cardiac Surgery, Austin Hospital, Melbourne, Australia; Department of Cardiothoracic Surgery, St Vincent's Hospital, Melbourne, Australia. Electronic address: william.shi@austin.org.au.
authors.forename: William Y
authors.initials: WY
authors.lastname: Shi
authors.affiliation: Department of Cardiac Surgery, Austin Hospital, Melbourne, Australia.
authors.forename: Philip A
authors.initials: PA
authors.lastname: Hayward
authors.affiliation: Department of Cardiothoracic Surgery, Royal Melbourne Hospital, Melbourne, Australia; Department of Surgery, University of Melbourne, Australia.
authors.forename: James
authors.initials: J
authors.lastname: Tatoulis
authors.affiliation: Department of Cardiothoracic Surgery, St Vincent's Hospital, Melbourne, Australia; Department of Surgery, University of Melbourne, Australia.
authors.forename: Alexander
authors.initials: A
authors.lastname: Rosalion
authors.affiliation: Department of Cardiothoracic Surgery, St Vincent's Hospital, Melbourne, Australia; Department of Surgery, University of Melbourne, Australia.
authors.forename: Andrew E
authors.initials: AE
authors.lastname: Newcomb
authors.affiliation: Victorian Heart Centre, Epworth Hospital, Melbourne, Australia.
authors.forename: John A
authors.initials: JA
authors.lastname: Fuller
authors.affiliation: Department of Cardiac Surgery, Austin Hospital, Melbourne, Australia; Department of Surgery, University of Melbourne, Australia; Victorian Heart Centre, Epworth Hospital, Melbourne, Australia.
authors.forename: Brian F
authors.initials: BF
authors.lastname: Buxton
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003324:Coronary Artery Disease / Q000601:surgery*; D005260:Female; D006801:Humans; D007387:Internal Mammary-Coronary Artery Anastomosis / Q000379:methods*; D008297:Male; D008875:Middle Aged; D057216:Propensity Score; D017534:Radial Artery / Q000637:transplantation*; D016019:Survival Analysis; D013895:Thoracic Arteries / Q000637:transplantation*; D016896:Treatment Outcome
keywords: arterial grafting; coronary artery bypass grafting; coronary artery disease; coronary revascularization; internal thoracic artery; radial artery; surgery