Vol. 24 No. 4 (2020)
CORONARY ARTERY DISEASES

Bilateral internal mammary grafting: Are the advantages obvious?

PDF (Русский)
  • A. Semchenko,
  • I. Zaicev,
  • A. Schevchenko,
  • A. Semchenko
A. Semchenko
Federal Center for Cardiovascular Surgery of Healthcare Ministry of the Russian Federation, Khabarovsk
Bio
I. Zaicev
Federal Center for Cardiovascular Surgery of Healthcare Ministry of the Russian Federation, Khabarovsk
A. Schevchenko
Federal Center for Cardiovascular Surgery of Healthcare Ministry of the Russian Federation, Khabarovsk
A. Semchenko
Federal Center for Cardiovascular Surgery of Healthcare Ministry of the Russian Federation, Khabarovsk
DOI: https://doi.org/10.21688/1681-3472-2020-4-50-62

Published 2020-12-30

Keywords

  • bilateral internal mammary grafting,
  • coronary artery bypass grafting,
  • internal thoracic artery

How to Cite

Semchenko, A., Zaicev, I., Schevchenko, A., & Semchenko, A. (2020). Bilateral internal mammary grafting: Are the advantages obvious?. Patologiya Krovoobrashcheniya I Kardiokhirurgiya, 24(4), 50–62. https://doi.org/10.21688/1681-3472-2020-4-50-62

Copyright (c) 2020 Semchenko A.N., Zaicev I.V., Schevchenko A.M., Semchenko A.V.

Creative Commons License

This work is licensed under a Creative Commons Attribution 4.0 International License.

Abstract

Background. The use of one internal thoracic artery has long been considered a gold standard for coronary artery bypass grafting. However, despite the benefits, the frequency of using both internal mammary arteries remains low. The relationship between improving coronary artery bypass grafting results and the risk of complications after surgery using two internal thoracic arteries are yet to be resolved.
Aim. We compared immediate and mid-term outcomes of coronary artery bypass grafting using one and two mammary arteries.
Methods. Two hundred and thirty-one (231) patients with coronary artery disease, after microscope-assisted coronary artery bypass surgery, were categorised into two groups: group I — patients had received one internal mammary artery during surgery (n = 177), and group II — patients had received two internal mammary arteries during surgery (n = 54). Propensity-score matching was applied to reduce differences between groups, therefore two groups of 50 patients were obtained after matching.
Results. Operations with bilateral internal mammary grafting in comparison to single internal mammary grafting were associated with longer operating times (group I: 167.5 [150-190] min., group II: 205 [190–220] min., p < 0.001) and increased aortic cross-clamp times (group I: 37.5 [32–45] min., group II: 44 [39–48] min., p = 0.012), but cardiopulmonary bypass duration was similar (group I: 65.5 [56–78] min. and group II: 69 [58–78] min., p = 0.95). No differences were observed for adverse event frequencies (i.e. death, myocardial infarction, acute cerebrovascular accidents and repeated revascularisation) and sternal wound complications in the early- and long-term post-operation. The grafts patency in groups I and II before discharge was 98.0 vs. 92.5 % (p = 0.195) and 94.6 vs. 92.5 % (p = 0.582) for mammary and venous grafts, respectively. At follow-up time (29.5 ± 18.7 months), group I was associated with significantly improved actuarial overall survival (p = 0.021) and were composite survival free from cardiac-related mortality, myocardial infarction, repeat revascularisation and stroke (p = 0.008). Complete revascularisation was associated with a reduced risk of major cardiac events (OR, 0.41; 95% CI: 0.20–0.85).
Conclusion. Bilateral internal mammary artery coronary artery bypass grafting in comparison with single internal mammary grafting was associated with increased operation times, similar grafts patency, early and late outcomes, but no overall improved survival and composite freedom from major adverse cardiac events in the mid-term. Complete revascularisation may be considered an independent prognostic factor after coronary bypass surgery and may be more clinically relevant than both internal thoracic arteries.

Received 29 April 2020. Revised 8 September 2020. Accepted 9 September 2020.

Funding: The study did not have sponsorship.

Conflict of interest: Authors declare no conflict of interest.

PDF (Русский)

References

  1. Loop F.D., Lytle B.W., Cosgrove D.M., Stewart R.W., Goormastic M., Williams G.W., Golding L.A., Gill C.C., Taylor P.C., Sheldon W.C., Proudfit W.L. Influence of the internal-mammary-artery graft on 10-year survival and other cardiac events. N Eng J Med. 1986;314(1):1-6. PMID: 3484393. https://doi.org/10.1056/NEJM198601023140101
  2. Neumann F.-J., Sousa-Uva M., Ahlsson A., Alfonso F., Banning A.P., Benedetto U., Byrne R.A., Collet J.-P., Falk V., Head S.J., Jüni P., Kastrati A., Koller A., Kristensen S.D., Niebauer J., Richter D.J., Seferovic P.M., Sibbing D., Stefanini G.G., Windecker S., Yadav R., Zembala M.O., ESC Scientific Document Group. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J. 2019;40(2):87-165. PMID: 30165437. https://doi.org/10.1093/eurheartj/ehy394
  3. Persson M., Sartipy U. Bilateral versus single internal thoracic artery grafts. Curr Cardiol Rep. PMID: 29362968, PMCID: PMC5780539. 2018;20(1):4. https://doi.org/10.1007/s11886-018-0947-1
  4. Bisleri G., Di Bacco L., Giroletti L., Muneretto C. Total arterial grafting is associated with improved clinical outcomes compared to conventional myocardial revascularization at 10 years follow-up. Heart Vessels. 2017;32(2):109-116. PMID: 27142066. https://doi.org/10.1007/s00380-016-0846-6
  5. Taggart D.P. Implications of the 10-year outcomes of the Arterial Revascularization Trial (ART) for multiple arterial grafts during coronary artery bypass graft. Eur J Cardiothorac Surg. 2019;56(3):427-428. PMID: 31168576. https://doi.org/10.1093/ejcts/ezz174
  6. Жбанов И.В., Мартиросян А.К., Урюжников В.В., Киладзе И.З., Галимов Н.М., Ревишвили Г.А., Шабалкин Б.В. Множественное коронарное шунтирование с использованием двух внутренних грудных артерий. Клиническая и экспериментальная хирургия. Журнал имени академика Б.В. Петровского. 2018;6(4(22)):66-74. [Zhbanov I.V., Martirosyan A.K., Uryuzhnikov V.V., Kiladze I.Z., Galimov N.M., Revishvili G.A., Shabalkin B.V. Multiple coronary artery bypass surgery using two internal thoracic arteries. Clinical and experimental surgery. Petrovsky Journal. 2018;6(4(22)):66-74. (In Russ.)]. https://doi.org/10.24411/2308-1198-2018-14010
  7. Бокерия Л.А., Милиевская Е.Б., Кудзоева З.Ф., Прянишников В.В., Скопин А.И., Юрлов И.А. Сердечно-сосудистая хирургия — 2018. М.: Национальный медицинский исследовательский центр сердечно-сосудистой хирургии имени А.Н. Бакулева; 2019. 270 с. [Bokeriya L.A., Milevskaya E.B., Kudzoeva Z.F., Pryanishnikov V.V., Scopin A.I., Yurlov I.A. Cardiovascular Surgery — 2017. Moscow: A.N. Bakoulev National Medical Research Center for Cardiovascular Surgery; 2019. 270 p. (In Russ.)]
  8. Mastrobuoni S., Gawad N., Price J., Chan V., Ruel M., Mesana T.G., Rubens F.D. Use of bilateral internal thoracic artery during coronary artery bypass graft surgery in Canada: The bilateral internal thoracic artery survey. J Thorac Cardiovasc Surg. 2012;144(4):874-879. PMID: 22342478. https://doi.org/10.1016/j.jtcvs.2012.01.022
  9. Фролов А.В. Тотальная артериальная реваскуляризация миокарда. Комплексные проблемы сердечно-сосудистых заболеваний. 2018;7(4S):108-117. [Frolov A.V. Total arterial myocardial revascularization. Complex Issues of Cardiovascular Diseases. 2018;7(4S):108-117. (In Russ.)]. https://doi.org/10.17802/2306-1278-2018-7-4S-108-117
  10. Кузнецов Д.В., Геворгян А.А., Новокшенов В.В., Михайлов К.М., Крюков А.В., Хохлунов С.М. Коронарное шунтирование с использованием двух внутренних грудных артерий. Вестник хирургии им. И.И. Грекова. 2019;178(3):10-15. [Kuznetsov D.V., Gevorgyan A.A., Novokshenov V.V., Mikhailov K.M., Kryukov A.V., Khokhlunov S.M. Bilateral internal thoracic artery coronary bypass grafting. Grekov’s Bulletin of Surgery. 2019;178(3):10-15. (In Russ.)]. https://doi.org/10.24884/0042-4625-2019-178-3-10-15
  11. Gaudino M., Bakaeen F., Benedetto U., Rahouma M., Di Franco A., Tam D.Y., Iannaccone M., Schwann T.A., Habib R., Ruel M., Puskas J.D., Sabik J., Girardi L.N., Taggart D.P., Fremes S.E. Use rate and outcome in bilateral internal thoracic artery grafting: insights from a systematic review and meta-analysis. J Am Heart Assoc. 2018;7(11):e009361. PMID: 29773579, PMCID: PMC6015367. https://doi.org/10.1161/JAHA.118.009361
  12. Ruka E., Dagenais F., Mohammadi S., Chauvette V., Poirier P., Voisine P. Bilateral mammary artery grafting increases postoperative mediastinitis without survival benefit in obese patients. Eur J Cardiothorac Surg. 2016;50(6):1188-1195. PMID: 27229669. https://doi.org/10.1093/ejcts/ezw164
  13. Taggart D.P., Altman D.G., Gray A.M., Lees B., Nugara F., Yu L.-M., Campbell H., Flather M., ART Investigators. Randomized trial to compare bilateral vs. single internal mammary coronary artery bypass grafting: 1-year results of the Arterial Revascularisation Trial (ART). Eur Heart J. 2010;31(20):2470-2481. PMID: 20805116. https://doi.org/10.1093/eurheartj/ehq318
  14. Benedetto U., Altman D.G., Gerry S., Gray A., Lees B., Pawlaczyk R., Flather M., Taggart D.P., Arterial Revascularization Trial investigators. Pedicled and skeletonized single and bilateral internal thoracic artery grafts and the incidence of sternal wound complications: Insights from the Arterial Revascularization Trial. J Thorac Cardiovasc Surg. 2016;152(1):270-276. PMID: 27112712. http://dx.doi.org/10.1016/j.jtcvs.2016.03.056
  15. Lytle B.W., Blackstone E.H., Loop F.D., Houghtaling P.L., Arnold J.H., Akhrass R., McCarthy P.M., Cosgrove D.M. Two internal thoracic artery grafts are better than one. J Thorac Cardiovasc Surg. 1999;117(5):855-872. PMID: 10220677. https://doi.org/10.1016/S0022-5223(99)70365-X
  16. Taggart D.P., D'Amico R., Altman D.G. Effect of arterial revascularisation on survival: a systematic review of studies comparing bilateral and single internal mammary arteries. Lancet. 2001;358(9285):870-875. PMID: 11567701. https://doi.org/10.1016/S0140-6736(01)06069-X
  17. Yi G., Shine B., Rehman S.M., Altman D.G., Taggart D.P. Effect of bilateral internal mammary artery grafts on long-term survival: a meta-analysis approach. Circulation. 2014;130(7):539-545. PMID: 24916209. https://doi.org/10.1161/CIRCULATIONAHA.113.004255
  18. Morris J.J., Smith L.R., Glower D.D., Muhlbaier L.H., Reves J.G., Wechsler A.S., Rankin J.S. Clinical evaluation of single versus multiple mammary artery bypass. Circulation. 1990;82(5 Suppl):IV214-223. PMID: 2225407.
  19. Dewar L.R., Jamieson W.R., Janusz M.T., Adeli-Sardo M., Germann E., MacNab J.S., Tyers G.F. Unilateral versus bilateral internal mammary revascularization. Survival and event-free performance. Circulation. 1995;92(9 Suppl):II8-13. PMID: 7586466. https://doi.org/10.1161/01.CIR.92.9.8
  20. Carrel T., Horber P., Turina M.I. Operation for two-vessel coronary artery disease: midterm results of bilateral ITA grafting versus unilateral ITA and saphenous vein grafting. Ann Thorac Surg. 1996;62(5):1289-1294. PMID: 8893559. https://doi.org/10.1016/0003-4975(96)00627-3
  21. Dalén M., Ivert T., Holzmann M.J., Sartipy U. Bilateral versus single internal mammary coronary artery bypass grafting in Sweden from 1997-2008. PLoS One. 2014;9(1):e86929. PMID: 24466293, PMCID: PMC3897769. https://doi.org/10.1371/journal.pone.0086929
  22. Taggart D.P., Benedetto U., Gerry S., Altman D.G., Gray A.M., Lees B., Gaudino M., Zamvar V., Bochenek A., Buxton B., Choong C., Clark S., Deja M., Desai J., Hasan R., Jasinski M., O'Keefe P., Moraes F., Pepper J., Seevanayagam S., Sudarshan C., Trivedi U., Wos S., Puskas J., Flather M., Arterial Revascularization Trial Investigators. Bilateral versus single internal-thoracic-artery grafts at 10 years. N Engl J Med. 2019;380(5):437-446. PMID: 30699314. https://doi.org/10.1056/NEJMoa1808783
  23. Gaudino M., Rahouma M., Hameed I., Khan F.M., Taggart D.P., Flather M., Biondi-Zoccai G., Fremes S.E. Disagreement between randomized and observational evidence on the use of bilateral internal thoracic artery grafting: a meta-analytic approach. J Am Heart Assoc. 2019;8(23):e014638. PMID: 31752642, PMCID: PMC6912987. https://doi.org/10.1161/JAHA.119.014638
  24. Gaudino M., Alexander J.H., Bakaeen F.G., Ballman K., Barili F., Calafiore A.M., Davierwala P., Goldman S., Kappetein P., Lorusso R., Mylotte D., Pagano D., Ruel M., Schwann T., Suma H., Taggart D.P., Tranbaugh R.F., Fremes S. Randomized comparison of the clinical outcome of single versus multiple arterial grafts: the ROMA trial-rationale and study protocol. Eur J Cardiothorac Surg. 2017;52(6):1031-1040. PMID: 29059371. https://doi.org/10.1093/ejcts/ezx358
  25. Lytle B.W., Blackstone E.H., Sabik J.F., Houghtaling P., Loop F.D., Cosgrove D.M. The effect of bilateral internal thoracic artery grafting on survival during 20 postoperative years. Ann Thorac Surg. 2004;78(6):2005-2012. PMID: 15561021. https://doi.org/10.1016/j.athoracsur.2004.05.070
  26. Samadashvili Z., Sundt T.M. 3rd, Wechsler A., Chikwe J., Adams D.H., Smith C.R., Jordan D., Girardi L., Lahey S.J., Gold J.P., Ashraf M.H., Hannan E.L. Multiple versus single arterial coronary bypass graft surgery for multivessel disease. J Am Coll Cardiol. 2019;74(10):1275-1285. PMID: 31488263. https://doi.org/10.1016/j.jacc.2019.06.067
  27. Семченко А.Н. Микрохирургическая техника в коронарной хирургии: возможности, перспективы и ограничения. Хирургия. Журнал им. Н.И. Пирогова. 2019;6:80-87. [Semchenko A.N. Microsurgical technique in coronary bypass surgery: possibilities, perspectives and limitations. Pirogov Russian Journal of Surgery = Khirurgiya. Zhurnal imeni N.I. Pirogova. 2019;6:80-87. (In Russ.)]. https://doi.org/10.17116/hirurgia201906180
  28. Ali E., Saso S., Ashrafian H., Athanasiou T. Does a skeletonized or pedicled left internal thoracic artery give the best graft patency? Interact Cardiovasc Thorac Surg. 2010;10(1):97-104. PMID: 19854791. https://doi.org/10.1510/icvts.2009.221242
  29. Sá M.P., Ferraz P.E., Escobar R.R., Nunes E.O., Lustosa P., Vasconcelos F.P., Lima R.C. Patency of skeletonized versus pedicled internal thoracic artery in coronary bypass graft surgery: A systematic review, meta-analysis and meta-regression. Int J Surg. 2014;12(7):666-672. PMID: 24880018. https://doi.org/10.1016/j.ijsu.2014.05.071
  30. Sasajima T., Wu M.H., Shi Q., Hayashida N., Sauvage L.R. Effect of skeletonizing dissection on the internal thoracic artery. Ann Thorac Surg. 1998;65(4):1009-1013. PMID: 9564919. https://doi.org/10.1016/s0003-4975(98)00080-0
  31. Bakaeen F.G., Ravichandren K., Blackstone E.H., Houghtaling P.L., Soltesz E.G., Johnston D.R., Mick S.L., Navia J.L., Tong M.-Z., McCurry K.R., Akhrass R., Abdallah M., Pettersson G.B., Smedira N.M., Roselli E.E., Gillinov A.M., Svensson L.G. Coronary artery target selection and survival after bilateral internal thoracic artery grafting. J Am Coll Cardiol. 2020;75(3):258-268. PMID: 31976863. https://doi.org/10.1016/j.jacc.2019.11.026
  32. Schmidt S.E., Jones J.W., Thornby J.I., Miller C.C. 3rd, Beall A.C. Jr. Improved survival with multiple left-sided bilateral internal thoracic artery grafts. Ann Thorac Surg. 1997;64(1):9-14. PMID: 9236328. https://doi.org/10.1016/s0003-4975(97)00473-6
  33. Kurlansky P.A., Traad E.A., Dorman M.J., Galbut D.L., Zucker M., Ebra G. Location of the second internal mammary artery graft does not influence outcome of coronary artery bypass grafting. Ann Thorac Surg. 2011;91(5):1378-1383. PMID: 21435631. https://doi.org/10.1016/j.athoracsur.2011.01.055
  34. Sabik J.F. 3rd, Stockins A., Nowicki E.R., Blackstone E.H., Houghtaling P.L., Lytle B.W., Loop F.D. Does location of the second internal thoracic artery graft influence outcome of coronary artery bypass grafting? Circulation. 2008;118(14 Suppl):S210-215. PMID: 18824756. https://doi.org/10.1161/CIRCULATIONAHA.107.760827
  35. Shah P.J., Durairaj M., Gordon I., Fuller J., Rosalion A., Seevanayagam S., Tatoulis J., Buxton B.F. Factors affecting patency of internal thoracic artery graft: clinical and angiographic study in 1434 symptomatic patients operated between 1982 and 2002. Eur J Cardiothorac Surg. 2004;26(1):118-124. PMID: 15200989. https://doi.org/10.1016/j.ejcts.2004.02.037
  36. Ogawa S., Tsunekawa T., Hosoba S., Goto Y., Kato T., Kitamura H., Tomita S., Okawa Y. Bilateral internal thoracic artery grafting: propensity analysis of the left internal thoracic artery versus the right internal thoracic artery as a bypass graft to the left anterior descending artery. Eur J Cardiothorac Surg. 2020;57(4):701-708. PMID: 31638700. https://doi.org/10.1093/ejcts/ezz290
  37. Leviner D.B., Torregrossa G., Puskas J.D. Incomplete revascularization: what the surgeon needs to know. Ann Cardiothorac Surg. 2018;7(4):463-469. PMID: 30094210, PMCID: PMC6082780. https://doi.org/10.21037/acs.2018.06.07