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J Thorac Cardiovasc Surg 2004;127:1145-1150
© 2004 The American Association for Thoracic Surgery

Surgery for acquired cardiovascular disease

Bilateral internal thoracic artery grafting in diabetic patients: Short-term and long-term results of a 515-patient series

^a Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel,
^b Statistical Service, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel

Received for publication June 11, 2003; revisions received September 18, 2003; revisions received October 3, 2003; accepted for publication October 7, 2003.

^* Address for reprints: Oren Lev-Ran, MD, Department of Cardiac and Thoracic Surgery, The Tel Aviv Sourasky Medical Center, 6 Weizman St, Tel Aviv 64239, Israel
orenlevran{at}hotmail.com

BACKGROUND: Despite potential long-term benefits, bilateral internal thoracic artery grafting in diabetics remains controversial because of the risk of sternal infection. We sought to assess the short- and long-term outcome after left-sided bilateral internal thoracic artery grafting and to determine the configuration of choice in diabetic subsets.

METHODS: Between 1996 and 2001, 515 diabetics underwent isolated left-sided skeletonized bilateral internal thoracic artery grafting. The outcome of 468 consecutive oral-treated diabetics and 47 selective insulin-treated patients was analyzed. Patients undergoing T-grafting were compared with those undergoing in situ bilateral internal thoracic artery arrangements.

RESULTS: The respective rates for early mortality and sternal infections were 2.4% and 1.9% in oral-treated diabetics and 6.3% and 4.3% in insulin-treated diabetics. Multivariate correlates of sternal infection were chronic lung disease (odds ratio, 10), obesity (odds ratio, 7), reoperation (odds ratio, 22), and a creatinine level of 2 mg/dL or more (odds ratio, 8). Five-year survival was 82%. The T-graft (n = 437) and in situ (n = 162) subgroups had comparable baseline profiles. Freedom from cardiac mortality at 6.5 years was 95.6% and 87.6% (P = .277), and freedom from repeat revascularization was 91.5% and 92.7% (P = .860), respectively. The choice of bilateral internal thoracic artery configuration did not appear as a correlate of mortality, cardiac mortality, or major adverse cardiac events. Complementary right-sided gastroepiploic artery (hazard ratio, 0.36) and sequential (hazard ratio, 0.55) grafting were identified as protective factors against the occurrence of major adverse cardiac events.

CONCLUSIONS: Routine skeletonized bilateral internal thoracic artery grafting can be implemented safely in oral-treated diabetics. This strategy is associated with a favorable late cardiac outcome and is thus recommended. Both left-sided bilateral internal thoracic artery configurations provide comparable short- and long-term outcomes.

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