Clinical outcome of arterial myocardial revascularization using bilateral internal thoracic arteries in diabetic patients: a single centre experience

Bilateral versus single internal mammary artery in diabetic patients: systematic review and meta-analysis

OBJECTIVES

Data on bilateral internal mammary artery (BIMA) versus single internal mammary artery (SIMA) on diabetics were analyzed; This is the only meta-analysis, the last 7 years.

METHODS

Medline through PubMed/EMBASE/CINHAL and the Cochrane Central Register of Controlled Trials; 179 articles were studied; 19 studies deemed suitable and were included in the analysis.

RESULTS

The mortality was 2.41% for BIMA versus 1.71% for SIMA (odds ratio [OR] =  0.95; 95% confidence interval [CI]: 0.74-1.22). Postoperative reopening for bleeding was higher at 3.75% for BIMA versus 2.91% for SIMA (OR =  1.49; 95% CI: 1.15-1.93). The incidence of MI was 0.87% for BIMA versus 0.83% for SIMA (OR =  0.73; 95% CI: 0.37-1.44). Deep sternal wound infection was 3.02% for BIMA and 1.95% for SIMA (OR =  1.57; 95% CI: 1.26-1.95). When skeletonized, the incidence of DSWI was 2.5% for BIMA versus 2.41% for SIMA. There was a significant difference at 5-year survival favoring the BIMA, 85.15% BIMA versus 80.77% SIMA (OR =  1.79; 95% CI: 1.60-2.01). The 10-year overall survival was 74.04% BIMA versus 61.57% SIMA (OR =  1.79; 95% CI: 1.61-1.98). The 15-year survival was 47.08% for BIMA versus 37.06% for SIMA (OR =  1.69; 95% CI: 1.52-1.88).

CONCLUSIONS

Postoperative bleeding was higher in BIMA group. Bilateral internal mammary artery in diabetic patients should be carried out in a skeletonize fashion, to reduce DSWI. There is a survival benefit of using BIMA in diabetics within 5 years of surgery; it remains significant up to 15 years.

Total Arterial Revascularization in Diabetic Patients Undergoing Coronary Artery Bypass Graft Surgery: A Systematic Review and Meta-Analysis

Background

Total arterial revascularization (TAR) has gradually become accepted and recognized, but its effect and safety in diabetic patients are not clear. We performed a systematic review and meta-analysis to summarize the safety and efficacy of TAR and additionally evaluated the clinical outcomes of arterial revascularization using different arterial deployments in patients with diabetes.

Methods

PubMed, Embase, and the Cochrane Library databases from inception to July 2022 for studies that studied the effect of arterial revascularization in diabetic patients undergoing isolated coronary artery bypass graft (CABG) were searched. The primary outcome was long-term ( ≥ 12 months of follow-up) death by any cause. The secondary efficacy endpoints were long-term ( ≥ 12 months) cardiovascular death, early sternal wound infection (SWI) and death ( ≤ 30 days or in hospital). Risk ratios (RRs), hazard ratios (HRs), and their corresponding 95% confidence intervals (CIs) were calculated to describe short-term results and long-term survival outcomes. Two different ways were used to analyze the effect of TAR and the impact of diabetes on the clinical outcomes of TAR.

Results

Thirty-five studies were included in the study, covering 178,274 diabetic patients. Compared to conventional surgery with saphenous veins, TAR was not associated with increased early mortality (RR 0.77, 95% CI 0.48-1.23) and risk of SWI (RR 0.77, 95% CI 0.46-1.28). The overall Kaplan-Meier survival curves based on reconstructed patient data indicated a significant association between TAR and reduced late mortality (HR 0.52, 95% CI 0.48-0.67) and the curves based on the propensity-score matched (PSM) analyses suggested a similar result (HR 0.74, 95% CI 0.66-0.85). TAR could also effectively decrease the risk of cardiovascular death (HR 0.42, 95% CI 0.24-0.75). Through comparing the effect of TAR in patients with and without diabetes, we found that the presence of diabetes did not elevate the risk of early adverse events (death: RR 1.50, 95% CI 0.64-3.49; SWI: RR 2.52, 95% CI 0.91-7.00). Although diabetes increased long-term mortality (HR 1.06; 95% CI 1.35-2.03), the cardiovascular death rate was similar in patients with diabetes and patients without diabetes (HR 1.09; 95% CI 0.49-2.45). Regarding the selection of arterial conduits, grafting via the bilateral internal mammary artery (BIMA) decreased the risk of overall death (HR 0.67, 95% CI 0.52-0.85) and cardiovascular death (HR 0.55, 95% CI 0.35-0.87) without resulting in a significantly elevated rate of early death (RR 0.95, 95% CI 0.82-1.11). However, the evidence from PSM studies indicated no difference between the long-term mortality of the BIMA group and that of the single internal mammary arteries (SIMA) groups (HR 0.76, 95% CI 0.52-1.11), and the risk of SWI was significantly increased by BIMA in diabetes (RR 1.65, 95% CI 1.42-1.91). The sub-analysis indicated the consistent benefit of the radial artery (RA) application in diabetic patients (HR 0.71, 95% CI 0.63-0.79) compared to saphenous vein graft. In two propensity-score-matched studies, the evidence showed that the survival outcomes of the BIMA group were similar to that of the SIMA plus RA group but that grafting via the RA reduced the risk of sternal wound infection.

Conclusions

Compared with conventional surgery using SVG, TAR was associated with an enhanced survival benefit in diabetes and this long-term gain did not increase the risk of early mortality or SWI. Given the increased infection risk and controversial long-term survival gains of grafting via the BIMA in diabetes, its wide use for grafting in this cohort should be seriously considered. Compared to using the right internal mammary artery (RIMA), RA might be a similarly effective but safer option for patients with diabetes.

Effect of bilateral internal thoracic artery harvesting on deep sternal wound infection in diabetic patients: Review of literature

Instead of its documented superiority of patency and long-term outcomes, the bilateral internal thoracic artery grafts are underused in the general population, and its use is controversial and debatable in diabetic patients due to long surgery duration, post-surgical bleeding, and sternal wound complications such as sternal wound infection, mediastinitis, and sternal wound dehiscence. This review article is particularly focused on deep sternal wound infection (DSWI) of bilateral internal thoracic artery (BITA) grafts in diabetic patients with comparison to single internal thoracic artery (SITA) graft.

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Bilateral internal thoracic artery grafting is superior to single internal thoracic artery grafting in terms of outcomes.

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Bilateral internal thoracic artery grafting is underused, especially in diabetic patients.

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The risk of DSWI in skeletonized BITA grafting in diabetic patients is almost similar to SITA grafting.

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Skeletonized BITA grafting should be encouraged in selected diabetic patients.

Does Bilateral Internal Mammary Artery Grafting Better Suit Patients With Diabetes? - Two Different Ways to Explore Outcomes

BACKGROUND

This analysis compared short-term mortality, sternal wound infection (SWI), and long-term survival outcomes in diabetic patients who underwent coronary artery bypass grafting (CABG) with bilateral (BIMA) vs. single (SIMA) internal mammary artery, as well as in diabetic vs. non-diabetic patients undergoing BIMA grafting.

METHODS AND RESULTS

Nineteen studies were included in the study, covering 21,143 different patients. Of these patients, 6,464 underwent CABG with BIMA, 10,264 underwent CAGB with SIMA, 11,584 had diabetes, and 6,717 did not. Compared with SIMA, BIMA had a significantly lower risk of in-hospital mortality (odds ratio [OR] 0.73, P=0.02), but a significantly higher risk of SWI (OR 1.30, P=0.04). However, compared with non-diabetic patients who underwent CABG with BIMA, diabetic patients with BIMA grafting did not have significantly higher risks of either mortality (OR 1.22, P=0.53) or SWI (OR 1.10, P=0.72). No significant differences were detected with different harvesting techniques. Longer term, BIMA was associated with a significantly higher rate of survival than SIMA (hazard ratio [HR] 0.76, P<0.001).

CONCLUSIONS

Results from the 2 types of comparisons indicate that BIMA is a preferable option for diabetic patients, even though it has a higher risk of infection. CABG with BIMA is also associated with a long-term survival benefit.

Vasodilatory Efficacy and Impact of Papaverine on Endothelium in Radial Artery Predilatation for CABG Surgery: in Search for Optimal Concentration

OBJECTIVE

The aim of this study was to compare the efficacy of two different papaverine concentrations (0.5 mg/ml and 2 mg/ml) for vasospasm prevention and their impact on endothelium integrity.

METHODS

We have studied distal segments of radial arteries obtained by no-touch technique from coronary artery bypass graft (CABG) patients (n=10). The vasodilatory effect of papaverine (concentrations of 0.5 mg/ml and 2 mg/ml) was assessed in vitro, in isometric tension studies using ex vivo myography (organ bath technique) and arterial rings precontracted with potassium chloride (KCl) and phenylephrine. The impact of papaverine on endothelial integrity was studied by measurement of the percentage of vessel's circumference revealing CD34 endothelial marker.

RESULTS

2 mg/ml papaverine concentration showed stronger vasodilatatory effect than 0.5 mg/ml, but it caused significantly higher endothelial damage. Response to KCl was 7.35±3.33 mN for vessels protected with papaverine 0.5 mg/ml and 2.66±1.96 mN when papaverine in concentration of 2 mg/ml was used. The histological examination revealed a significant difference in the presence of undamaged endothelium between vessels incubated in papaverine 0.5 mg/ml (72.86±9.3%) and 2 mg/ml (50.23±13.42%), P=0.002.

CONCLUSION

Papaverine 2 mg/ml caused the higher endothelial damage. Concentration of 0.5 mg/ml caused better preservation of the endothelial lining.

The use of stem cells in ischemic heart disease treatment

Ischemic heart disease is a major cause of death and disabilities worldwide. Unfortunately, not all patients are suitable for direct revascularization. Cell-based therapies may be alternative options because of their potential to promote neovascularisation and endothelial repair, improving myocardial perfusion. The success of cell-based therapies depends on the type of implanted stem cells, delivery method and underlying disease. Several different cell populations including bone marrow-derived mononuclear cells (MNCs), mesenchymal stromal cells (MSCs), CD34+, CD133+, endothelial progenitor cells, adipose-derived mesenchymal stromal cells (ASCs) and stem cells from placenta and umbilical cord have been investigated. Presently, no consensus exists about the best cell type for clinical regenerative therapy. Because the system of coronary arteries in the ischemic area is poor and most of the coronary artery is significantly narrowed or closed, direct implantation of stem cells in the ischemic area of the heart muscle appears an attractive method.

Use Rate and Outcome in Bilateral Internal Thoracic Artery Grafting: Insights From a Systematic Review and Meta-Analysis

Background

This meta‐analysis was designed to assess whether center experience affects the short‐ and long‐term results and the relative benefits of bilateral internal thoracic artery grafting (BITA) for coronary artery bypass grafting.

Methods and Results

MEDLINE and EMBASE were searched to identify all articles reporting the outcome of BITA in patients undergoing coronary artery bypass grafting. The BITA center experience was gauged according to the percentage use of BITA in the institutional overall coronary artery bypass grafting population (%BITA). The primary outcome was long‐term all‐cause mortality. Secondary outcomes were operative mortality, perioperative myocardial infarction, perioperative stroke, deep sternal wound infections (DSWIs), and major postoperative adverse event. The rates of the primary and secondary outcomes were calculated after adjusting for %BITA. Primary and secondary outcomes were also compared between the BITA and the single internal thoracic artery arms in the adjusted studies. Meta‐regression was used to evaluate the effect of %BITA on the primary and secondary outcomes. Thirty‐four studies (27 894 patients undergoing BITA) were included. In the pooled analysis, the incidence rate for long‐term mortality was 2.83% (95% confidence interval, 2.21%–3.61%). %BITA was significantly and inversely associated with long‐term mortality and the rate of DSWI. In the pairwise comparison, %BITA was significantly and inversely associated with the risk of long‐term mortality and DSWI in the group undergoing BITA.

Conclusions

BITA series with higher %BITA report significantly lower long‐term mortality and DSWI rate as well as higher long‐term survival advantage and lower relative risk of DSWI in their BITA cohort. These findings suggest that a specific volume‐outcome relationship exists for BITA grafting.

Incidence of Deep Sternal Wound Infection in Diabetic Patients Undergoing Off-Pump Skeletonized Internal Thoracic Artery Grafting

OBJECTIVES

To evaluate the impact of skeletonized bilateral or single internal thoracic artery (ITA) grafting on the risk of deep sternal wound infection (DSWI) in diabetic patients undergoing off-pump coronary artery bypass grafting (OPCAB).

MATERIALS AND METHODS

A total of 803 diabetic patients undergoing OPCAB surgery from January 2010 to December 2014 were enrolled into this study and assigned to the pSITA group (patients undergoing pedicled single ITA grafting, n = 362), the sSITA group (skeletonized single ITA grafting, n = 295), or the sBITA group (skeletonized bilateral ITA grafting, n = 146). The primary end point was the diagnosis of a DSWI.

RESULTS

Eighteen patients developed postoperative DSWI, with an incidence of 2.2%. Patients in the sSITA group had a significantly lower incidence of DSWI than those in the pSITA group (1.0 vs. 3.6%, p = 0.0408). In multivariate logistic regression analysis, the risk of DSWI in the sSITA group was 0.41 times that in the pSITA group.

CONCLUSIONS

sSITA grafting lowered the risk of DSWI in diabetic patients undergoing OPCAB surgery compared to pSITA grafting. Multicenter clinical trials involving larger sample sizes are needed to determine the merit of pSITA grafting in reducing the risk of DSWI following OPCAB surgery.