Meta-Analysis of Bilateral Versus Single Internal Thoracic Artery Grafting in Patients ≥70 Years of Age

Multiarterial grafting in redo coronary artery bypass grafting: Type of arterial conduit and patient sex determine benefit

OBJECTIVE

To evaluate whether multiarterial grafting provides an incremental benefit above single arterial grafting in isolated redo coronary artery bypass grafting (CABG).

METHODS

From January 1980 to July 2020, 6559 adults underwent a total of 6693 isolated CABG reoperations. Patients undergoing multiarterial grafting were propensity score-matched with those undergoing single arterial grafting with or without additional vein grafts, yielding 2005 well-matched pairs. Endpoints were in-hospital postoperative complications, hospital mortality, and long-term mortality. The median follow-up was 10 years, with 25% of patients followed for >17 years. Multivariable multiphase hazard models and nonparametric random survival forest models for survival were used to identify patients for whom multiarterial grafting was most beneficial.

RESULTS

Among propensity score-matched patients, postoperative complications in multiarterial versus single arterial grafting included any reoperation (50 [2.5%] vs 65 [3.2%]); renal failure (73 [3.6%] vs 55 [2.7%]), stroke (44 [2.2%] vs 38 [1.9%]), and deep sternal infection (36 [1.8%] vs 25 [1.2%]). In-hospital mortality was 1.7% (n = 35) in multiarterial grafting versus 2.8% (n = 56) in single arterial grafting (P = .03). Comparing multiarterial to single arterial grafting, overall survival was 95% versus 94% at 1 year, 92% versus 88% at 3 years, 87% versus 82% at 5 years, 49% versus 42% at 15 years, and 31% versus 25% at 20 years. Better survival after multiarterial grafting was confined to males with 2 patent internal thoracic artery grafts (P < .0001).

CONCLUSIONS

Redo CABG with multiarterial grafting can be performed with lower in-hospital mortality and similar major morbidity to single arterial grafting. It is associated with better long-term survival, particularly in males when 2 internal thoracic artery grafts are used.

Predominant Use of Bilateral Internal Mammary Arteries in Off-Pump Coronary Artery Bypass Surgery

Bilateral internal mammary artery (BIMA) in coronary artery bypass grafting (CABG) has been shown to provide long-term clinical benefits over single internal mammary artery (SIMA) grafting. Nevertheless, the perceived technical complexity of the procedure and concerns about potential early postoperative complications, particularly, sternal wound infections, have led to a utilization rate of BIMA grafting of less than 5% in the United States. We systematically compared early (30-day) postoperative outcomes between the BIMA and SIMA cohorts in patients with similar baseline characteristics. A retrospective single-center study was conducted on matched patients, using stabilized inverse probability treatment weighting to mitigate bias between the 2 study cohorts. From 546 patients who underwent off-pump CABG initially identified, we examined 328 BIMA and 213 SIMA grafts from the matched samples. Despite using 60.4% BIMA grafts, we observed similar rates of 30-day overall and cardiac mortality between the BIMA and SIMA groups. The rates of 30-day postoperative complications, including superficial and deep sternal wound infections, stroke, sepsis, acute kidney injury, and cardiac arrest, were similar between the 2 groups. The rates of 30-day overall and cardiac readmission were also similar. In addition, the median length of hospital stays, intensive care unit stay, and ventilation times were similar between the 2 groups. In conclusion, our data suggest that a BIMA utilization rate of 60.4% in off-pump CABG procedures is achievable without causing any significant increment in early postoperative complications, including deep sternal wound infection.

Sternal wound infections following internal mammary artery grafts for a coronary bypass: A meta-analysis

The meta-analysis aims to evaluate and compare the sternal wound infections following internal mammary artery grafts for a coronary bypass. Examinations comparing bilateral internal mammary artery to single internal mammary artery for coronary artery bypass grafting were among the meta-analyses from various languages that met the inclusion criteria. Using dichotomous random- or fixed-effect models, the results of these investigations were examined, and the Odd Ratio (OR) with 95% confidence intervals (CIs) was computed. A total of 31 examinations from 2001 to 2023 were recruited for the current analysis including 181 503 personals with coronary artery bypass grafting. Bilateral internal mammary artery had significantly higher sternal wound infection (OR, 1.51; 95% CI, 1.37-1.68, p < 0.001), superficial sternal wound infection (OR, 1.72; 95% CI, 1.16-2.56, p = 0.007), deep sternal wound infection (OR, 1.62; 95% CI, 1.41-1.86, p < 0.001), sternal wound infection in diabetics (OR, 1.48; 95% CI, 1.16-1.90, p = 0.002), sternal wound infection in elderly (OR, 1.38; 95% CI, 1.22-1.57, p < 0.001), sternal wound infection in pedicled preparation (OR, 1.70; 95% CI, 1.30-2.23, p < 0.001) and sternal wound infection in skeletonized preparation (OR, 1.40; 95% CI, 1.09-1.81, p = 0.009) compared to single internal mammary artery in personals with coronary artery bypass grafting. Bilateral internal mammary artery grafting is linked to a higher risk of impaired wound healing, particularly in diabetic individuals, elderly, pedicled preparation, and skeletonized preparation. Nevertheless, caution should be exercised while interacting with its values since examinations were performed by different surgeons with different skills on different types of personals.