Propensity matched analysis of bilateral internal mammary artery versus single left internal mammary artery grafting at 17-year follow-up: validation of a contemporary surgical experience

Abstract

Objectives: Bilateral internal mammary arteries (BIMA) remains widely underutilized in coronary artery bypass grafting (CABG). Although prior research has demonstrated a long-term benefit of the use of BIMA over left internal mammary artery (LIMA)-only, validation of these results is lacking in a contemporary surgical experience. We compared complications and survival at 17-year follow-up in a large series of consecutive CABG patients from a single institution that underwent BIMA grafting with a propensity-matched group where LIMA only was used.

Methods: Propensity scores representing the estimated probabilities of patients receiving either BIMA or LIMA alone were developed based on 22 observed baseline covariates in a logistic regression model with procedure group as the dependent variable. The nearest-neighbour-matching algorithm with Greedy 5-1 Digit Matching was used to produce two patient cohorts of 928 patients each balanced for baseline factors. We compared 30-day morbidity and mortality, as well as long-term survival at 5-year intervals up to 17-year follow-up.

Results: In-hospital and 30-day mortality was 0.8% for the BIMA group and 1.1% for the LIMA-saphenous vein grafting (SVG). No significant difference was found in complications, mortality and/or length-of-stay between these two groups. Off-pump was done in 48.9% of BIMA cases and 51.3% of LIMA cases. Regardless of the types of grafts used, on-pump patients were more likely to have postoperative permanent strokes and longer postoperative lengths of stay. Use of the BIMA over LIMA-only had a statistically significant impact conferring a 10% survival advantage at 10-year and 18% at 15-year follow-up. The Kaplan-Meier survival curves comparing off-/on-pump BIMA and off-/on-pump LIMA-SVG patients demonstrated a 22% survival advantage for off-pump BIMA patients when compared with on-pump LIMA-SVG patients at 15-year follow-up.

Conclusions: Perioperative complications do not increase with the use of BIMAs. Long-term survival is optimized with off-pump CABG and BIMA grafting. The low morbidity and mortality rates in this series are likely due to the continuous evolution of technology and the adoption of less invasive options for CABG patients. A more widespread use of BIMAs in CABG patients would continue to improve the overall excellent short- and long-term results of this operation.