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Eur J Cardiothorac Surg 2006;30:318-323
© 2006 Elsevier Science NL

Does bilateral ITA grafting increase perioperative complications?

Outcome of 4462 patients with bilateral versus 4204 patients with single ITA bypass

Department of Cardiovascular Surgery, City-Hospital Munich-Bogenhausen, Englschalkingerstr. 77, 81925 Munich, Germany

Received 12 October 2005; received in revised form 9 May 2006; accepted 15 May 2006.

^_* Corresponding author. Tel.: +49 89 9270 2631; fax: +49 89 9270 2605. (Email: brigitte_gansera{at}web.de).

	Abstract

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion 5. Limitations of the... 6. Conclusions Appendix A References

 
Objective: Superior patency of internal thoracic artery (ITA) grafting to saphenous veins is conclusive. The aim of the present study was to compare the early outcome of patients receiving either bilateral ITA (BITA) or single ITA (SITA) grafts and to identify risk factors for perioperative complications, such as obesity, diabetes mellitus, or advanced age. Methods: All 8666 patients with isolated coronary artery bypass grafting (CABG, including emergent cases or redos) operated between January 1994 and June 2004 receiving either BITA (n = 4462) or SITA (n = 4204) grafting were analyzed retrospectively. Demographic data were comparable for both groups concerning mean age (65.3 ± 9.4 years vs 64.9 ± 9.3 years), range (35–89 years (p = 0.05)), diabetes incidence (29.3% vs 2.6% (p = 0.08)), dialysis-dependent renal failure (0.7% vs 0.6% (p = 0.4)), preoperative ejection fraction (EF) mean (61.8% vs 61.2% (p = 0.07)) but not for gender (80.4% vs 76.7% males (p = 0.00)), body mass index (BMI) mean (27.2 ± 3.6 vs 26.9 ± 3.5 (p = 0.00)), COPD (7.0% vs 8.5% (p = 0.00)), and hyperlipidemia (78.3% vs 74.3% (p = 0.00)). In the BITA group, right ITA (RITA) was directed preferentially to the left anterior descending artery (LAD), left ITA (LITA) to the lateral wall. In the SITA group, the LAD was revascularized with the left ITA. Additional bypasses were performed with saphenous vein grafts (SVG). Results: The number of anastomoses was higher in the BITA group (3.8 ± 0.9 vs 3.1 ± 0.9 (p = 0.00)); therefore, duration of surgery (mean: 189 ± 46.3 min vs 164 ± 46.2 min) and cross-clamp time (62.0 ± 17.9 min vs 51.0 ± 18.0 min) significantly prolonged (p = 0.00). Incidence of rethoracotomy due to bleeding (2.9% vs 0.6%; p = 0.00) or sternal refixation with (0.7% vs 0.2%; p = 0.00) or without infection (1.4% vs 0.6%; p = 0.00) was higher in the BITA group, strongly associated with diabetes mellitus and duration of surgery but not with BMI > 27. Thirty-day mortality revealed 2.6% versus 3.2% (p = 0.1) but was significantly lower for diabetic patients in the BITA group (3.1% vs 4.7%; p = 0.00). Conclusions: CABG using both ITAs can be performed routinely with good clinical results and low mortality. Compared with single ITA grafting, sternal and bleeding complications were slightly increased. Diabetes mellitus, BITA grafting, duration of surgery but not obesity or COPD could be identified as independent risk factors for sternal complications. Dialysis-dependent renal failure, EF < 30%, emergent cases, and the absence of BITA grafting were predictors for increased perioperative mortality.

Key Words: Bilateral ITA grafting

	1. Introduction

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion 5. Limitations of the... 6. Conclusions Appendix A References

 
Use of the left internal thoracic artery (LITA) to bypass preferentially the left anterior descending artery (LAD) has become a surgical standard in coronary artery bypass grafting (CABG), providing superior graft patency, reduced cardiac events, and enhanced survival rates compared with patients receiving isolated saphenous veins. Consequently the use of both internal thoracic arteries (ITAs) has expanded during the last decade with convincing beneficial advantages for patients’ long-term outcome.

While bilateral internal thoracic artery (BITA) can improve long-term survival [1–5], some reports have shown an increased perioperative mortality, a higher incidence of complications, or reoperations for bleeding [6–8] as well as the absence of a significant benefit after BITA grafting.

Despite the legitimate enthusiasm for BITA grafting, the influence of the selected target vessel remains still a matter of debate. Imperfect outcomes were described for right internal thoracic artery (RITA) to RCA bypasses [9,10]. Studies in which RITA and left internal thoracic artery were used to bypass preferentially important vessels of the left coronary system showed excellent results [9,2–5,11–13], and superior graft patency [9,2–5,11–15] with long-term freedom of cardiac events and reoperations.

Respecting excellent long-term results of other groups [1,2–5,11–13,16,17,15] after revascularizing important left coronary vessels with both in situ ITAs, we have attempted routinely – since 1997 – a surgically standardized technique to revascularize the left anterior descending artery with the RITA anterior to the aorta, and circumflex artery, or a dominant branch on the lateral wall, with the LITA.

Meanwhile this procedure has been performed in more than 5000 patients, without selection, confirming low perioperative complication rates and mortality compared to patients with single ITA (SITA).

In our series, consisting of 663 symptomatic patients after CABG (operated between January 1994 and June 2002) who underwent midterm reangiography due to reappearence of angina, superior patency of BITA to SITA grafting was shown and documented angiographically [9].

The present report analyzes the early clinical results, mortality, and incidence of complications comparing a revascularization procedure in a large cohort of nonselected patients with single ITA (LITA–LAD and vein grafts) to a double arterial revascularization technique with RITA bypass to the LAD, LITA bypass to the left lateral wall. The main purpose of this study was to identify patient-related risk factors, such as obesity (body mass index (BMI) > 27), diabetes mellitus, COPD, dialysis-dependent renal failure, lower ejection fraction (EF), emergent operations, redos, as well as gender and age over 70 years.

	2. Material and methods

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion 5. Limitations of the... 6. Conclusions Appendix A References

 
Clinical outcome of 8666 patients with isolated CABG, operated between January 1994 and June 2004, was analyzed retrospectively. Four thousand four hundred and sixty-two patients received bilateral ITA and 4204 patients single ITA bypasses. We included all patients with isolated CABG (emergent cases, redos), operated within this period and receiving either one or both ITAs but without randomizing them to each group. Harvesting of ITA grafts was performed regularly with a small pedicle of surrounding tissue by five experienced surgeons, intending to keep the pleural space closed. The use of bone wax was avoided in the whole study population for both groups. All additional bypasses were done with saphenous vein grafts (SVG) or radial arteries. For postoperative routine anticoagulation therapy, all patients received 100 mg of acetylsalicylacid or 75 mg ticlopidine (rarely) per day, after 12 h postoperatively. In case of atrial fibrillation, heparin was administered intravenously, again 12 h postoperatively. If possible preoperative application of acetylsalicylacid or clopidogrel was stopped for an interval of 5 days, of course, not in emergent cases. For these patients with emergent indication for revascularization and preoperative clopidogrel application, we provided one or two units of platelets, which were only used if bleeding was obviously increased.

We evaluated operative data, incidence of bleeding and wound-healing complications, perioperative infarction rate, and 30-day mortality with respect to specific patients risk factors. Statistical analysis was performed using chi-square test for continuous variables as well as a multivariate logistic regression analysis. A p-value less 0.05 was considered to be statistically significant.

	3. Results

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion 5. Limitations of the... 6. Conclusions Appendix A References

 
Demographic data (depicted in Table 1 ) were comparable for both groups concerning mean age (65.3 ± 9.4 years vs 64.9 ± 9.3 years), range (35–89 years (p = 0.05)), diabetes incidence (29.3% vs 27.6% (p = 0.08)), dialysis-dependent renal failure (0.7% vs 0.6% (p = 0.4)), preoperative ejection fraction mean (61.8% vs 61.2% (p = 0.07)) but not for gender (80.4% vs 76.7% males (p = 0.00)), BMI mean (27.2 ± 3.6 vs 26.9 ± 3.5 (p = 0.00)), COPD (7.0% vs 8.5% (p = 0.00)), and hyperlipidemia (78.3% vs 74.3% (p = 0.00)).

In the BITA group, right ITA was preferentially directed to the LAD, left ITA to the lateral wall. In the SITA group, the LAD was revascularized with the left ITA (Tables 2 and 3 ).

	4. Discussion

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion 5. Limitations of the... 6. Conclusions Appendix A References

Using the left internal thoracic artery to bypass the left anterior descending artery has become a standard practice in coronary surgery with clinically and angiographically proven superior patency of the arterial graft to saphenous veins [1,9]. After 10 years, patency rate of LITA amounts to about 90% versus only 50–60% for saphenous veins, resulting in improved long-term survival of patients receiving LITA [1,2–5,11–13,16,17,15]. An additional benefit concerning long-term morbidity and mortality was described after a surgical technique revascularizing preferentially left-sided coronary arteries (LAD and circumflex artery) with both ITAs [1,3,5,11,14,15].One of our studies, concerning angiographic findings in midterm follow-up (mean 2.7 years) of 663 symptomatic patients, showed the unambiguous superior patency of ITA, especially BITA grafts to saphenous veins in a negative-selected, symptomatic large patient population [9]. This study compares favorably to the most recent studies concerning this subject and carried out by Dion et al. [1] and Schmidt et al. [11]. Concerning freedom from cardiac events and necessity of interventions (PTCA/STENT) as well as reoperation, the results of this study were similar to those of Pick et al. [2] and Lytle et al. [3]. Nevertheless, there exist no randomized data comparing BITA and SITA surgical strategies in large cohorts—different target vessels and different surgical techniques (in situ/free grafts/pedicled/unpedicled); many confounding variables make statistical analyses difficult. The largest patient population (2001 BITA grafts) with the longest postoperative interval was issue of a nonrandomized study from the Cleveland Clinic [5], and documented clearly the superior benefit concerning decreased risk of death by 6.3% and decreased risk of reoperation by at least 8.3%, by 12 postoperative years if patients received BITA grafts rather than SITA grafts.

On the contrary, bilateral ITA grafting is thought to be associated with an increased perioperative risk of morbidity and mortality [6,18] as well as an extended incidence of sternal complications [6,18]. However, one of our previous studies involving 1487 unselected patients with bilateral ITA grafting [7] did not show any higher mortality after BITA grafting. In this previous study, a higher incidence of sternal complications occurred only in patients with body mass index > 27, neither diabetes mellitus nor advanced age influenced these complications [7]. Now, four years later, with the experience of nearly 5000 bilateral ITA bypasses, the results have changed. In our previous study, consisting of 1487 patients with BITA grafting, the incidence of sternal instability revealed 2.0% for the SITA group versus 4.2% for the BITA group. Meanwhile this complication is reduced to 0.6% versus 1.4%—in our opinion, a remarkable improvement depending on advantages in surgical techniques (lower traumatic and faster, ‘small-pedicled’ harvesting of ITA grafts/the use of seven or eight wires for sternal closure—avoiding the use of bone wax). Our results compare only partly with those of Baskett et al. [19]: ‘Is mediastinitis a preventable complication? A 10-year review’ of 9771 patients in which the use of single or bilateral ITA grafts per se was not associated with mediastinitis. In this study, only the use of BITA grafts in diabetic patients, the use of bone wax, and the presence of chronic obstructive pulmonary disease revealed statistical significance for this complication. Opposing results were published by Walkes et al. [18]: 4.4% incidence of mediastinitis after BITA versus 2.2% in the single ITA group, certainly in a very small patient population (180 patients with bilateral ITAs in 10 years).

Hirotani et al. [13] observed no difference in the incidence of chest wound infection in 200 patients with BITA and 43 patients with unilateral ITA grafting, although 127 diabetic patients were included.

Ruyun et al. [20] in 2005 published an important contribution concerning the question whether obesity is a risk factor for mortality in CABG. They analyzed 16,218 patients using sophisticated logistic regression models with BMI group (underweight, normal, overweight and three subgroups of obesity) as categorical variable. In summary, BMI was not a significant risk factor for CABG mortality, but the lowest mortality was found in the high, normal, and overweight subgroups compared with obese and underweight. The results of this study were confirmative to our own, where whether BMI > 27 or BMI > 30 did reach statistical significance for increased perioperative mortality.

Nevertheless, even advocates of BITA grafting emphasize a restrictive use of both ITAs in the presence of diabetes mellitus and obesity [12,21]. This combination may represent a relative contraindication for the use of both ITAs, regarding sternal complications.

In summary, these studies showing no benefit of BITA grafting or higher perioperative mortality contain regularly smaller patient cohorts and shorter follow-ups, whereas those investigations that demonstrated a survival benefit or low perioperative complication rates tended to include larger patient cohorts [5].

Directing right ITA mostly to the LAD, anterior to the aorta, might lead to surgical difficulties in case of reoperation. Meanwhile we had to perform 10 such reoperations mostly due to valve replacements. Only two patients with graft failure and experienced that coating right ITA in a PTFE ITA sleeve as a secure method to prevent graft damage.

	5. Limitations of the study

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion 5. Limitations of the... 6. Conclusions Appendix A References

 
With regard to the nonrandomized character and retrospective nature of the study, as well as the period of more than 10 years implicating a temporal ‘learning-curve’, especially in surgical technique of ITA preparation for interpretation of results, a certain loss of valency (more BITA bypasses were performed in the later period) should be taken into account and might be regarded as substantial limitation of the present study.

	6. Conclusions

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion 5. Limitations of the... 6. Conclusions Appendix A References

 
CABG using BITA conduits can be performed in nearly all patients as a surgical routine technique with good clinical results and low mortality. Compared to single ITA grafting sternal dehiscences, wound infections (mediastinitis) and bleeding complications were shown to have undergone slight but, due to the large patient cohort, statistically significant increase.

Multivariate logistic regression analysis identified BITA grafting, diabetes mellitus, but not obesity with BMI > 30, COPD, or female gender as independent risk factors for these complications, but the absence of BITA grafting as a predictor for increased mortality, in particular for increased cardiac-related mortality.

The results of this study confirm, moreover, the well-known poorer outcome of patients with dialysis-dependent renal failure, emergent indication for operation and lower ejection fraction (EF < 30%) compared to those with higher ejection fraction (EF > 30%).

	Appendix A

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion 5. Limitations of the... 6. Conclusions Appendix A References

 
Conference discussion

Dr U. Myhre (Johor Bahru, Malaysia): There has been some work showing that sternum perfusion is much better with skeletonized harvesting of the mammary arteries. In your graphic depictions it looked like you were using pedicle grafts and going in front of the pericardium instead of transpericardial. Is that your uniform technique, using pedicle grafts and not going transpericardially?

Dr Gansera: We only use small pedicle grafts. We do not go transpericardial. We try to avoid the use of electrocoagulation, and therefore you see the bleeding complications slightly increased, but we seldom use skeletonized ITA grafts, but some small pedicle.

Dr B. Osswald (Heidelberg, Germany): Wouldn’t you expect an indication bias in your nonrandomized study? What was the rationale to take either SITA or BITA? Did you select your approach according to the coronary status?

Dr Gansera: As you saw we did not perform 100% BITA grafting. Some peripheral localization of stenosis forbid the use of both in situ ITAs, so we could perform T-graft, everything like this. It's not possible to reach 100% bilateral ITA grafting. The restriction is defined by the localization of stenosis. You can never reach 100%.

Dr V. Shipulin (Tomsk, Russia): Did you use right internal mammary anterior for anastomosis with distal part of right coronary artery, especially when you had big heart with huge left ventricle?

Dr Gansera: We use it if length is enough. You can gain length with skeletonized ITAs. We don’t need it often.

In our experience, in most of the cases, also with enlarged ventricle, the right ITA is long enough to reach the apex of the LAD.

Dr Shipulin: Do you have good follow-up results in such patients in 2 or 3 years? Do you have good follow-up results in such patients with very huge left ventricle when you use right artery?

Dr Gansera: In this study, as I have shown in one of the slides, the results are not that bad with these patients with ejection fraction lower than 30%.

Dr C. Muneretto (Brescia, Italy): The question was about midterm follow-up at 3 years.

Dr Gansera: We performed a lot of follow-ups. One such study is yet to be published. It analyzed 5–6-year follow-up of nearly 2000 patients with bilateral versus single ITA-grafts and clearly resulted in a superior clinical outcome of these patients with bilateral ITA-grafting.

Dr M. Ezzat (Cairo, Egypt): Do you use the right mammary for the RCA?

Dr Gansera: Rarely. We perform RITA to RCA very seldom. But I think, and we also know from the literature, that poorer results were detected in angiographic follow-ups for RITA to RCA bypasses, than if you bypass preferentially the left coronary artery system with both ITAs. We perform it if we can reach the stenosis easily, that means in case of proximal RCS stenosis. In case of peripheral RCA lesions, we don’t perform it.

Dr Muneretto: One technical question: Could you elaborate a little bit about the way you put the PTF sleeve on the right mammary.

Dr Gansera: It's a sleeve of about 15 cm in length and we put it along the whole length of the ITA for wrapping and graft completely inside it, and then we fix the sleeve with some clips. We cut it off and put some clips to stabilize it. We don’t need any sutures or something like this. It's very simple. Ten clips, you cut it off, cover the ITA with 10 clips to affix it. In these cases of redos, it was very helpful.

Dr Muneretto: I would like to add a comment about this issue. Everybody knows that bilateral ITA harvesting decreases significantly the vascularization of the sternal body.

Three issues are very important in decreasing the rate of sternal wound complications: the first is that skeletonization of mammary artery reduces the trauma to the surrounding vessels. The second issue concerns the energy used for harvesting: ultrasound device also reduces the trauma to the surrounding tissues when compared to cautery. And finally, the third issue is the division of distal mammary artery that should preserve the bifurcation in distal branches allowing a back bloodflow to the distal sternum, just before the distal branches. I think that when you use bilateral ITA approach, especially in old patients with diabetes, you have to consider these three issues conveniently.

Dr K. Wrobel (Krakow, Poland): Have you analyzed specifically a group of patients, insulin-dependent diabetic patients?

Dr Gansera: We performed a study consisting of a subgroup of diabetic patients. This study was published in the Journal of Thoracic Cardiovascular Surgery in 2002.

Concerning clinical outcome, in particular wound healing complications, we could not identify isolated diabetes as an independent risk factor. But the combination of diabetes, bilateral ITA-grafting, advanced age and obesity (BMI > 30) was the main risk factor for sternal complications.

	Footnotes

 
Presented at the joint 19th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 13th Annual Meeting of the European Society of Thoracic Surgeons, Barcelona, Spain, September 25–28, 2005.

	References

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion 5. Limitations of the... 6. Conclusions Appendix A References

 

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This Article Abstract Full Text (PDF) CME: Take the activity for this article: Does bilateral ITA grafting increase ... Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Brigitte Gansera Guido Gillrath Klaus Wenke Josef Weingartner Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Gansera, B. Articles by Kemkes, B. M. Search for Related Content PubMed PubMed Citation Articles by Gansera, B. Articles by Kemkes, B. M. Related Collections Coronary disease