Original article
Cardiovascular
Single Versus Bilateral Internal Mammary Artery for Isolated First Myocardial Revascularization in Multivessel Disease: Long-Term Clinical Results in Medically Treated Diabetic Patients

https://doi.org/10.1016/j.athoracsur.2005.03.077Get rights and content

Background

We evaluated our experience to investigate if the use of bilateral internal mammary artery (BIMA) grafting, with or without complementary saphenous vein grafts (SVG), increases the quality of the results of coronary bypass grafting in medically treated diabetic patients who undergo first myocardial revascularization, when compared with the use of a single left internal mammary artery (LIMA) and SVG.

Methods

From October 1991 to December 2001, 558 diabetic patients with multivessel coronary disease had first isolated myocardial revascularization using LIMA and SVG (group LIMA) in 217 cases and BIMA ± SVG (group BIMA) in 341. Propensity score analysis identified 400 patients, 200 for each group, with similar preoperative characteristics. Thirty-day outcome and 8-year freedom from death from any cause, cardiac death, acute myocardial infarction (AMI), AMI in a grafted area, redo/percutaneous transluminal coronary angioplasty (PTCA), redo/PTCA in a grafted area, target cardiac events, and any event were evaluated. Follow-up ranged from 2.0 to 12.2 years (mean 6.0 ± 2.0).

Results

There was no difference between groups except the cardiac deaths, which were significantly higher in the LIMA group (7 versus 0, p = 0.015). The BIMA group showed better 8-year freedom from death any cause (86.7 ± 3.2 versus 79.5 ± 4.1, p = 0.0274), cardiac death (96.3 ± 1.4 versus 88.4 ± 4.0, p = 0.0406), acute myocardial infarction (99.5 ± 0.5 versus 92.0 ± 3.9, p = 0.0092), and acute myocardial infarction in a grafted area (99.5 ± 0.5 versus 93.4 ± 3.7, p = 0.0204). Cox analysis confirmed that the use of LIMA and SVG was an independent predictor for lower freedom from death (hazard ratio [HR] = 1.8, p = 0.0310), cardiac death (HR = 1.9, p = 0.0426), AMI (HR = 9.7, p = 0.0033) and AMI in a grafted area (HR = 8.2, p = 0.0410).

Conclusions

In diabetic patients with multivessel disease who undergo first myocardial revascularization, BIMA ± SVG provides higher freedom from death, any cause, and cardiac-related death, if compared with LIMA + SVG. It plays a protective role in reducing the incidence of late AMI.

Section snippets

Material and Methods

From October 1991 to December 2001, 558 medically treated diabetic patients affected by multivessel coronary disease underwent coronary artery bypass grafting (CABG) using LIMA to the left anterior descending artery (LAD) and SVG (n = 217), or BIMA (one IMA always to the LAD) with or without SVG (n = 341). Propensity score analysis was used to select 400 patients (71.6%), matching each LIMA + SVG with a BIMA ± SVG with the nearest propensity score. Two groups of patients (LIMA group and BIMA

Results

The operative details are reported in Table 2. In the LIMA group, the internal mammary artery was anastomosed always to the LAD, in 39 cases sequentially with the diagonal. In the BIMA group, an IMA (the left in 115 cases [57.5%], and the right in 85 cases [42.5%]) was always anastomosed to the LAD, whereas the diagonal was sequentially grafted with an IMA in 28 cases (14.0%). The remaining IMA was grafted to the circumflex artery system in 173 patients (86.5%) and to the right coronary artery

Comment

The prevalence of diabetic patients referred to surgical or percutaneous coronary revascularization has remarkably increased, reaching 25% in the United States [13]. Diabetes mellitus represents one of the most important limitations for PTCA. Indeed, most of the previous studies comparing PTCA and CABG have fully demonstrated that diabetic patients, treated with PTCA, have lower survival [14, 15, 16, 17] and significantly higher restenosis and reintervention rate [16, 17, 18]. Therefore, most

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