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CLINICAL STUDY: BYPASS SURGERY

Early mortality and morbidity of bilateral versus single internal thoracic artery revascularization: propensity and risk modeling

John P. A. Ioannidis, MD^* , Othon Galanos, MD , Demosthenes Katritsis, MD, PhD, FACC^||, Cliff P. Connery, MD, George E. Drossos, MD, Daniel G. Swistel, MD and Constantine E. Anagnostopoulos, MD

^* Division of Clinical Care Research, Department of Medicine, New England Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
Department of Cardiothoracic Surgery, St. Luke’s–Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, New York, New York, USA
Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece
Department of Cardiothoracic Surgery, University of Ioannina School of Medicine, Ioannina, Greece
^|| Department of Cardiology, St. Thomas’s Hospital, London, United Kingdom

Manuscript received April 27, 2000; revised manuscript received August 24, 2000, accepted October 4, 2000.

Reprint requests and correspondence: Dr. Constantine E. Anagnostopoulos, Professor of Surgery and Senior Attending, Cardiothoracic Surgery, St. Luke’s–Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, 1111 Amsterdam Ave., New York, New York 10025
cea8{at}columbia.edu

OBJECTIVES

We examined whether bilateral internal thoracic artery (BITA) revascularization is associated with any increased in-hospital mortality and complications compared with single internal thoracic artery (SITA) revascularization.

BACKGROUND

Despite proven long-term benefits, BITA revascularization has been slow to be adopted because of fear of increased early morbidity.

METHODS

We evaluated 1,697 consecutive patients undergoing BITA (n = 867) or SITA (n = 830) revascularization. We used propensity score analyses and adjusted risk models to address differences between arms.

RESULTS

There were 20 (2.3%) deaths in the BITA group versus 26 (3.1%) in the SITA group (odds ratio 0.73, p = 0.30). Propensity analysis identified several parameters that affected the decision to use BITA. Adjusting for propensity score and all potential risk factors, the odds ratio for death with BITA versus SITA was practically 1. Bilateral internal thoracic artery revascularization did not increase the number of in-hospital complications with the possible exception of deep sternal wound infections (11 [1.3%] vs. 3 [0.4%], p = 0.057). In multivariate modeling BITA increased the risk of deep sternal wound infections only in emergent cases and in older patients; the excess risk was negligible among 1,206 patients (71.1% of total) who did not have emergent revascularization and were 70 years old (risk difference 0.3%, p = 0.74). There was no difference in length of stay after adjustment for propensity factors (mean 11.3 vs. 11.7 days, p = 0.66).

CONCLUSIONS

Bilateral internal thoracic artery revascularization grafting confers no increased risk for early death and does not prolong hospital stay. The small increase in the risk of deep sternal wound infections does not affect the majority of patients.

Abbreviations and Acronyms   BITA = bilateral internal thoracic artery   CABG = coronary artery bypass graft   CI = confidence interval   IABP = intraaortic balloon pump   MI = myocardial infarction   LVAD = left ventricular assist device   OR = odds ratio   PTCA = percutaneous transluminal coronary angiography   PVD = peripheral vascular disease   SITA = single internal thoracic artery

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