Surgical revascularization techniques that minimize surgical risk and maximize late survival after coronary artery bypass grafting in patients with diabetes mellitus

doi:10.1016/j.jtcvs.2014.06.058

The Journal of Thoracic and Cardiovascular Surgery

Volume 148, Issue 4, October 2014, Pages 1257-1266.e9

Read at the 94th Annual Meeting of The American Association for Thoracic Surgery, Toronto, Ontario, Canada, April 26-30, 2014.

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Objective

To identify surgical revascularization techniques that minimize surgical risk and maximize late survival in patients with diabetes undergoing coronary artery bypass grafting (CABG).

Methods

From January 1972 to January 2011, 11,922 patients with diabetes underwent primary isolated CABG. The revascularization techniques investigated included bilateral internal thoracic artery (BITA) grafting (n = 938; 7.9%) versus single ITA (SITA) grafting, off-pump (n = 602; 5.0%) versus on-pump CABG, and incomplete (n = 2109; 18%) versus complete revascularization. The median follow-up was 7.8 years and total follow-up, 104,516 patient-years. Multivariable analyses were performed to assess the effects of surgical techniques on hospital outcomes and long-term mortality.

Results

After adjusting for patient characteristics, BITA versus SITA grafting was associated with a 21% lower late mortality (68% confidence limits, 16%-26%). However, BITA grafting was also associated with more deep sternal wound infections (DSWIs), but the considerable mortality from DSWI minimally affected overall survival because of its rare occurrence. The risk factors for DSWI were female sex (80% increased risk), higher body mass index (7% increased risk per kg/m²), medically treated diabetes (73% increased risk), previous myocardial infarction (58% increased risk), and peripheral arterial disease (73% increased risk). Off-pump and on-pump CABG had similar results. Complete versus incomplete revascularization had similar hospital outcomes; however, complete revascularization was associated with 10% lower late mortality (68% confidence limits, 7.0%-13%).

Conclusions

BITA grafting with complete revascularization maximizes long-term survival and is recommended for patients with diabetes undergoing CABG. BITA grafting should be used in all patients with diabetes whose risk of DSWI is low. It might be best avoided in obese diabetic women with diffuse atherosclerotic burden—those at greatest risk of developing these infections.

CTSNet classification

Abbreviations and Acronyms

BITA

bilateral internal thoracic artery

BMI

body mass index

CABG

coronary artery bypass grafting

CAD

coronary artery disease

DSWI

deep sternal wound infection

ITA

internal thoracic artery

SITA

single internal thoracic artery

STS

Society of Thoracic Surgeons

SVG

saphenous vein grafting

Cited by (0)

: The present study was supported in part by the Sheikh Hamdan bin Rashid Al Maktoum Distinguished Chair in Thoracic and Cardiovascular Surgery, held by Dr Sabik, and the Kenneth Gee and Paula Shaw, PhD, Chair in Heart Research, held by Dr Blackstone.

: Disclosures: Dr Sabik is the North American principal investigator for the Abbott Laboratories–sponsored left main coronary disease randomized trial (EXCEL) and is on the Society for Thoracic Surgeons board of directors and the scientific advisory board of Medtronic. All other authors have nothing to disclose with regard to commercial support.