Urgent Coronary Revascularization with Bilateral Internal Thoracic Artery Grafting: Is the Risk Justified?

Abstract

Background The frequent need of immediate institution of cardiopulmonary bypass because of ischemia and increased risk of bleeding and longer duration of surgery limit the use of bilateral internal thoracic artery (BITA) grafting in urgency.

Patients and Methods Of 4,525 consecutive patients with multivessel coronary artery disease who underwent isolated coronary bypass surgery at the authors' institution (1999–September 2015), 121 (2.7%) patients had an operation before the beginning of the next working day after decision to operate, which is the definition for emergency according to the European System for Cardiac Operative Risk Evaluation II. BITA and single internal thoracic artery (SITA) grafting were used in 52 and 46 of these patients, respectively; venous grafts alone were used in the remaining cases. BITA and SITA patients were compared as risk profiles, operative data, and outcomes. A propensity score (PS)-matched analysis was also performed.

Results Between BITA and SITA patients, there was no significant difference as hospital mortality, both in the overall (3.8 vs. 6.5%; p = 0.66) and the PS-matched series (0 vs. 4.3%; p = 1). Among the postoperative complications, only bleeding (but not blood transfusion nor mediastinal re-exploration) was increased both in the overall (p = 0.037) and the PS-matched series of BITA patients (p = 0.092); duration of surgery was increased but not quite significantly (p = 0.12). Freedom from cardiac and cerebrovascular deaths, and major adverse cardiac and cerebrovascular events were higher in PS-matched BITA patients, even though not quite significantly (p = 0.11 for both).

Conclusion BITA grafting may be performed even in urgency. With respect to SITA grafting, hospital mortality and postoperative complications other than bleeding are not increased; late outcomes seem to be better.

Keywords

blood transfusion - coronary artery bypass grafting - CABG - outcomes - wound infection

• References

• 1 Popovic B, Voillot D, Maureira P , et al. Bilateral internal mammary artery bypass grafting: long-term clinical benefits in a series of 1000 patients. Heart 2013; 99 (12) 854-859
• 2 Deo SV, Shah IK, Dunlay SM , et al. Bilateral internal thoracic artery harvest and deep sternal wound infection in diabetic patients. Ann Thorac Surg 2013; 95 (3) 862-869
• 3 Dorman MJ, Kurlansky PA, Traad EA, Galbut DL, Zucker M, Ebra G. Bilateral internal mammary artery grafting enhances survival in diabetic patients: a 30-year follow-up of propensity score-matched cohorts. Circulation 2012; 126 (25) 2935-2942
• 4 Taggart DP, Lees B, Gray A , et al. A randomized trial to compare survival following bilateral versus single internal mammary grafting in coronary revascularization. Trials 2006; 7: 7-17
• 5 LaPar DJ, Crosby IK, Rich JB , et al; Investigators for the Virginia Cardiac Surgery Quality Initiative. Bilateral internal mammary artery use for coronary artery bypass grafting remains underutilized: a propensity-matched multi-institution analysis. Ann Thorac Surg 2015; 100 (1) 8-14 , discussion 14–15
• 6 Mastrobuoni S, Gawad N, Price J , et al. Use of bilateral internal thoracic artery during coronary artery bypass graft surgery in Canada: the bilateral internal thoracic artery survey. J Thorac Cardiovasc Surg 2012; 144 (4) 874-879
• 7 Gatti G, Dell'Angela L, Benussi B , et al. Bilateral internal thoracic artery grafting in octogenarians: where are the benefits?. Heart Vessels 2016; 31 (5) 702-712
• 8 Kai M, Okabayashi H, Hanyu M , et al. Long-term results of bilateral internal thoracic artery grafting in dialysis patients. Ann Thorac Surg 2007; 83 (5) 1666-1671
• 9 Bonacchi M, Prifti E, Maiani M, Giunti G, Leacche M. Skeletonized bilateral internal mammary arteries for non-elective surgical revascularization in unstable angina. Eur J Cardiothorac Surg 2005; 28 (1) 120-126
• 10 Gansera B, Schmidtler F, Spiliopoulos K, Angelis I, Neumaier-Prauser P, Kemkes BM. Urgent or emergent coronary revascularization using bilateral internal thoracic artery after previous clopidogrel antiplatelet therapy. Thorac Cardiovasc Surg 2003; 51 (4) 185-189
• 11 Nashef SA, Roques F, Sharples LD , et al. EuroSCORE II. Eur J Cardiothorac Surg 2012; 41 (4) 734-744 , discussion 744–745
• 12 Gatti G, Soso P, Dell'Angela L , et al. Routine use of bilateral internal thoracic artery grafts for left-sided myocardial revascularization in insulin-dependent diabetic patients: early and long-term outcomes. Eur J Cardiothorac Surg 2015; 48 (1) 115-120
• 13 Gatti G, Dell'Angela L, Barbati G , et al. A predictive scoring system for deep sternal wound infection after bilateral internal thoracic artery grafting. Eur J Cardiothorac Surg 2016; 49 (3) 910-917
• 14 Gatti G, Pappalardo A, Gon L, Zingone B. Protecting the crossover right internal thoracic artery bypass graft with a pedicled thymus flap. Ann Thorac Surg 2006; 82 (5) 1919-1921
• 15 Zingone B, Rauber E, Gatti G , et al. The impact of epiaortic ultrasonographic scanning on the risk of perioperative stroke. Eur J Cardiothorac Surg 2006; 29 (5) 720-728
• 16 Santarpino G, Ruggieri VG, Mariscalco G , et al. Outcome in patients having salvage coronary artery bypass grafting. Am J Cardiol 2015; 116 (8) 1193-1198
• 17 Biancari F, Onorati F, Rubino AS , et al. Outcome of emergency coronary artery bypass grafting. J Cardiothorac Vasc Anesth 2015; 29 (2) 275-282
• 18 Ben-Gal Y, Stone GW, Smith CR , et al. On-pump versus off-pump surgical revascularization in patients with acute coronary syndromes: analysis from the Acute Catheterization and Urgent Intervention Triage Strategy trial. J Thorac Cardiovasc Surg 2011; 142 (2) e33-e39
• 19 Harling L, Moscarelli M, Kidher E, Fattouch K, Ashrafian H, Athanasiou T. The effect of off-pump coronary artery bypass on mortality after acute coronary syndrome: a meta-analysis. Int J Cardiol 2013; 169 (5) 339-348