Are two really always better than one? Results, concerns and controversies in the use of bilateral internal thoracic arteries for coronary artery bypass grafting in the elderly

A systematic review and meta-analysis

Salil V. Deo, Salah E. Altarabsheh, Ishan K. Shah, Yang Hyun Cho, Michael McGraw, Basar Sarayyepoglu, Benjamin Medalion, Alan H. Markowitz, Soon J. Park

Research output: Contribution to journalArticle

12 Citations (Scopus)

Abstract

Introduction: Bilateral internal thoracic artery grafting appears to be the preferred method to achieve durable long-term coronary artery revascularization. However, data reporting the benefit of this technique in the elderly is very conflicting. Method: We performed a systematic review of available literature (till November 2014) using multiple databases to identify studies comparing clinical events in patients undergoing coronary artery bypass grafting using either a single or double internal thoracic artery in the elderly. While early mortality was the primary end-point of inclusion, other adverse events compared were sternal wound infection (deep and superficial), stroke and peri-operative myocardial infarction. Individual and pooled odd's ratios were calculated using the Mantel-Haenzel method (random effect model); sensitivity analysis was performed. Results are presented using 95% confidence intervals. Result: Nine retrospective studies (4479 BITA, 7733 LITA patients) fulfilled search criteria. Deep sternal wound infection was significantly higher after BITA harvest [OR 1.86 (1.3-2.5); I<sup>2</sup>=0%; p<0.01]. Early mortality (BITA 3.6% vs SITA 3.1%; p=0.86), stroke [OR 0.7(0.4-1.1); p=0.1], and peri-operative myocardial infarction (BITA 4.3% vs SITA 2.3%; p=0.1) were comparable in both cohorts. Long-term survival favored the BITA cohort in two propensity matched studies. Conclusion: The incidence of deep sternal wound infection may be significantly higher after the harvest of both internal thoracic arteries in the elderly. While other post-operative adverse events are comparable, data regarding the long-term survival advantage in this cohort is conflicting. Hence, the use of both internal thoracic arteries in this age group needs to be invidualized.

Original languageEnglish (US)
Pages (from-to)163-170
Number of pages8
JournalInternational Journal of Surgery
Volume16
Issue numberPB
DOIs
StatePublished - Apr 1 2015
Externally publishedYes

Fingerprint

Mammary Arteries
Coronary Artery Bypass
Meta-Analysis
Wound Infection
Stroke
Myocardial Infarction
Survival
Mortality
Coronary Vessels
Research Design
Retrospective Studies
Age Groups
Odds Ratio
Databases
Confidence Intervals
Incidence

Keywords

  • Coronary artery bypass grafting
  • Coronary artery disease
  • Internal thoracic artery
  • Sternal wound infection
  • Survival

ASJC Scopus subject areas

  • Surgery

Cite this

Are two really always better than one? Results, concerns and controversies in the use of bilateral internal thoracic arteries for coronary artery bypass grafting in the elderly : A systematic review and meta-analysis. / Deo, Salil V.; Altarabsheh, Salah E.; Shah, Ishan K.; Cho, Yang Hyun; McGraw, Michael; Sarayyepoglu, Basar; Medalion, Benjamin; Markowitz, Alan H.; Park, Soon J.

In: International Journal of Surgery, Vol. 16, No. PB, 01.04.2015, p. 163-170.

Research output: Contribution to journalArticle

Deo, Salil V. ; Altarabsheh, Salah E. ; Shah, Ishan K. ; Cho, Yang Hyun ; McGraw, Michael ; Sarayyepoglu, Basar ; Medalion, Benjamin ; Markowitz, Alan H. ; Park, Soon J. / Are two really always better than one? Results, concerns and controversies in the use of bilateral internal thoracic arteries for coronary artery bypass grafting in the elderly : A systematic review and meta-analysis. In: International Journal of Surgery. 2015 ; Vol. 16, No. PB. pp. 163-170.
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abstract = "Introduction: Bilateral internal thoracic artery grafting appears to be the preferred method to achieve durable long-term coronary artery revascularization. However, data reporting the benefit of this technique in the elderly is very conflicting. Method: We performed a systematic review of available literature (till November 2014) using multiple databases to identify studies comparing clinical events in patients undergoing coronary artery bypass grafting using either a single or double internal thoracic artery in the elderly. While early mortality was the primary end-point of inclusion, other adverse events compared were sternal wound infection (deep and superficial), stroke and peri-operative myocardial infarction. Individual and pooled odd's ratios were calculated using the Mantel-Haenzel method (random effect model); sensitivity analysis was performed. Results are presented using 95{\%} confidence intervals. Result: Nine retrospective studies (4479 BITA, 7733 LITA patients) fulfilled search criteria. Deep sternal wound infection was significantly higher after BITA harvest [OR 1.86 (1.3-2.5); I2=0{\%}; p<0.01]. Early mortality (BITA 3.6{\%} vs SITA 3.1{\%}; p=0.86), stroke [OR 0.7(0.4-1.1); p=0.1], and peri-operative myocardial infarction (BITA 4.3{\%} vs SITA 2.3{\%}; p=0.1) were comparable in both cohorts. Long-term survival favored the BITA cohort in two propensity matched studies. Conclusion: The incidence of deep sternal wound infection may be significantly higher after the harvest of both internal thoracic arteries in the elderly. While other post-operative adverse events are comparable, data regarding the long-term survival advantage in this cohort is conflicting. Hence, the use of both internal thoracic arteries in this age group needs to be invidualized.",
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T2 - A systematic review and meta-analysis

AU - Deo, Salil V.

AU - Altarabsheh, Salah E.

AU - Shah, Ishan K.

AU - Cho, Yang Hyun

AU - McGraw, Michael

AU - Sarayyepoglu, Basar

AU - Medalion, Benjamin

AU - Markowitz, Alan H.

AU - Park, Soon J.

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N2 - Introduction: Bilateral internal thoracic artery grafting appears to be the preferred method to achieve durable long-term coronary artery revascularization. However, data reporting the benefit of this technique in the elderly is very conflicting. Method: We performed a systematic review of available literature (till November 2014) using multiple databases to identify studies comparing clinical events in patients undergoing coronary artery bypass grafting using either a single or double internal thoracic artery in the elderly. While early mortality was the primary end-point of inclusion, other adverse events compared were sternal wound infection (deep and superficial), stroke and peri-operative myocardial infarction. Individual and pooled odd's ratios were calculated using the Mantel-Haenzel method (random effect model); sensitivity analysis was performed. Results are presented using 95% confidence intervals. Result: Nine retrospective studies (4479 BITA, 7733 LITA patients) fulfilled search criteria. Deep sternal wound infection was significantly higher after BITA harvest [OR 1.86 (1.3-2.5); I2=0%; p<0.01]. Early mortality (BITA 3.6% vs SITA 3.1%; p=0.86), stroke [OR 0.7(0.4-1.1); p=0.1], and peri-operative myocardial infarction (BITA 4.3% vs SITA 2.3%; p=0.1) were comparable in both cohorts. Long-term survival favored the BITA cohort in two propensity matched studies. Conclusion: The incidence of deep sternal wound infection may be significantly higher after the harvest of both internal thoracic arteries in the elderly. While other post-operative adverse events are comparable, data regarding the long-term survival advantage in this cohort is conflicting. Hence, the use of both internal thoracic arteries in this age group needs to be invidualized.

AB - Introduction: Bilateral internal thoracic artery grafting appears to be the preferred method to achieve durable long-term coronary artery revascularization. However, data reporting the benefit of this technique in the elderly is very conflicting. Method: We performed a systematic review of available literature (till November 2014) using multiple databases to identify studies comparing clinical events in patients undergoing coronary artery bypass grafting using either a single or double internal thoracic artery in the elderly. While early mortality was the primary end-point of inclusion, other adverse events compared were sternal wound infection (deep and superficial), stroke and peri-operative myocardial infarction. Individual and pooled odd's ratios were calculated using the Mantel-Haenzel method (random effect model); sensitivity analysis was performed. Results are presented using 95% confidence intervals. Result: Nine retrospective studies (4479 BITA, 7733 LITA patients) fulfilled search criteria. Deep sternal wound infection was significantly higher after BITA harvest [OR 1.86 (1.3-2.5); I2=0%; p<0.01]. Early mortality (BITA 3.6% vs SITA 3.1%; p=0.86), stroke [OR 0.7(0.4-1.1); p=0.1], and peri-operative myocardial infarction (BITA 4.3% vs SITA 2.3%; p=0.1) were comparable in both cohorts. Long-term survival favored the BITA cohort in two propensity matched studies. Conclusion: The incidence of deep sternal wound infection may be significantly higher after the harvest of both internal thoracic arteries in the elderly. While other post-operative adverse events are comparable, data regarding the long-term survival advantage in this cohort is conflicting. Hence, the use of both internal thoracic arteries in this age group needs to be invidualized.

KW - Coronary artery bypass grafting

KW - Coronary artery disease

KW - Internal thoracic artery

KW - Sternal wound infection

KW - Survival

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