Bilateral internal thoracic artery grafting may improve outcome of coronary artery surgery. Risk-adjusted survival

Abstract

Background: Excellent clinical results of the patients with single left internal thoracic artery (ITA) grafting compared with saphenous vein grafting have prompted surgeons to use both ITAs. However, long-term benefits of the bilateral ITA grafting have not been proven.

Methods and results: We reviewed our experience of 2826 patients (age 62 +/- 9 years [mean +/- 1 SD], 2350 men, mean follow-up 52 months) who underwent surgery with ITAs, supplemented by saphenous vein grafts when required, between 1985 and 1995. Single ITA grafting (n = 1557) was compared with double (n = 1269), by means of the Cox proportional hazards model. Significant predictors of all-cause mortality were as follows: (1) peripheral vascular disease, rate ratio (RR) = 2.4 (1.7 to 3.4 [95% CI]); (2) prior myocardial infarction, RR = 2.1 (1.5 to 3.1); (3) severe left ventricular dysfunction, RR = 3.9 (2.6 to 5.9) and moderate left ventricular dysfunction, RR = 2.0 (1.5 to 2.6); (4) age > or = 70 years, RR = 3.4 (2.4 to 4.8), and age 60 to 69 years, RR = 1.7 (1.3 to 2.4); (5) diabetes mellitus, RR = 1.7 (1.3 to 2.4); (6) carotid disease, RR = 1.7 (1.2 to 2.4); and (7) single ITA (versus bilateral ITA), RR = 1.4 (1.1 to 1.8). Number of vessels diseased, surgical status (i.e., urgent versus elective), hypertension, and sex were not significant predictors. Unadjusted actuarial survival rates at 10 years were 86 +/- 3% (mean +/- 95% CI) for bilateral ITA group and 71 +/- 5% for single ITA. Single ITA was also a predictor of all-cause mortality, late myocardial infarction, or late reoperation (RR = 1.3 [1.1 to 1.6]).

Conclusions: Bilateral ITA grafting may improve long-term survival and freedom from late myocardial infarction or reoperation after coronary artery surgery. Mathematical modeling may assist in developing a strategy for use of bilateral ITA grafts.