In-Hospital Outcomes of Pedicled Bilateral Internal Mammary Artery Use in Diabetic and Nondiabetic Patients Undergoing Off-Pump Coronary Artery Bypass Grafting: Single-Surgeon, Single-Center Experience

Authors

  • Shahzad G. Raja
  • Kareem Salhiyyah
  • Muhammad Umar Rafiq
  • Manoraj Navaratnarajah
  • Dimple Chudasama
  • Christopher P. Walker
  • Fouad Amin
  • Mohamed Amrani

DOI:

https://doi.org/10.1532/HSF98.20121038

Abstract

Objective: A common perception is that use of pedicled bilateral internal mammary arteries (BIMA) increases the risk of sternal wound complications in diabetic patients undergoing coronary artery bypass grafting (CABG). The purpose of this study was to compare the in-hospital outcomes of CABG using pedicled BIMA in diabetic and nondiabetic patients.

Methods: From September 1998 to September 2010, 390 consecutive diabetic patients and 519 nondiabetic patients underwent isolated off-pump CABG using pedicled BIMA. The 2 groups had comparable preoperative demographics except for a higher prevalence of acute myocardial infarction (18.9% versus 6.1%, P = .01), peripheral vascular disease (17.2% versus 2.7%, P = .001), an ejection fraction <30% (17.7% versus 8.5%, P = .02), and chronic renal failure (4.5% versus 0.9%, P = .01) in the diabetic patients.

Results: The operative mortality rate of the diabetic patients was comparable to that of the nondiabetic patients (2.8% versus 2.1%, P = .87). The in-hospital outcomes, including occurrence of superficial and deep sternal wound infections, were similar except for an increased occurrence of wound infection at the vein harvest site (6.6% versus 1.1%, P = .04) and a need for hemofiltration (11.8% versus 2.1%, P = .02) in the diabetic patients.

Conclusions: Pedicled BIMA use is associated with comparable incidences of sternal wound complications and other outcomes in diabetic patients and nondiabetic patients. Strict perioperative glycemic control, adherence to meticulous closure technique, and postoperative management of surgical wounds can make pedicled BIMA use a default strategy for diabetic patients.

References

Agrifoglio M, Trezzi M, Barili F, et al. 2008. Double vs single internal thoracic artery harvesting in diabetic patients: role in perioperative infection rate. J Cardiothorac Surg 3:35.nAllen KB, Heimansohn DA, Robison RJ, et al. 2000. Risk factors for leg wound complications following endoscopic versus traditional saphenous vein harvesting. Heart Surg Forum 3:325-30.nBerreklouw E, Rademakers PP, Koster JM, van Leur L, van der Wielen BJ, Westers P. 2001. Better ischemic event-free survival after two internal thoracic artery grafts: 13 years of follow-up. Ann Thorac Surg 72:1535-41.nBoodhwani M, Lam BK, Nathan HJ, et al. 2006. Skeletonized internal thoracic artery harvest reduces pain and dysesthesia and improves sternal perfusion after coronary artery bypass surgery: a randomized, double-blind, within-patient comparison. Circulation 114:766-73.nBorger MA, Rao V, Weisel RD, et al. 1998. Deep sternal wound infection: risk factors and outcomes. Ann Thorac Surg 65:1050-6.nBottio T, Rizzoli G, Vida V, Casarotto D, Gerosa G. 2003. Double crisscross sternal wiring and chest wound infections: a prospective randomized study. J Thorac Cardiovasc Surg 126:1352-6.nBurfeind WR Jr, Glower DD, Wechsler AS, et al. 2004. Single versus multiple internal mammary artery grafting for coronary artery bypass: 15-year follow-up of a clinical practice trial. Circulation 110:II27-35.nChoo SJ, Lee SK, Chung SW, et al. 2009. Does bilateral pedicle internal thoracic artery harvest increase the risk of mediastinitis? Yonsei Med J 50:78-82.nDe Paulis R, de Notaris S, Scaffa R, et al. 2005. The effect of bilateral internal thoracic artery harvesting on superficial and deep sternal infection: the role of skeletonization. J Thorac Cardiovasc Surg 129:536-43.nEklund A, Valtonen M, Werkkala K. 2005. Prophylaxis of sternal wound infections with gentamicin-collagen implant: randomized controlled study in cardiac surgery. J Hosp Infect 59:108-12.nEl Oakley RM, Wright JE. 1996. Post-operative mediastinitis: classification and management. Ann Thorac Surg 61:1030-6.nFokin AA, Robicsek F, Fokin A Jr, Anderson JE Jr. 2004. Changes in sternal blood flow after different methods of internal thoracic artery harvesting. Thorac Cardiovasc Surg 52:334-7.nFriberg O, Svedjeholm R, Söderquist B, Granfeldt H, Vikerfors T, Källman J. 2005. Local gentamicin reduces sternal would infections after cardiac surgery: a randomized controlled trial. Ann Thorac Surg 79:153-61.nFurnary AP, Zerr KJ, Grunkemeier GL, Starr A. 1999. Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures. Ann Thorac Surg 67:352-60.nGrossi EA, Esposito R, Harris LJ, et al. 1991. Sternal wound infections and use of internal mammary artery grafts. J Thorac Cardiovasc Surg 102:342-6.nIoannidis JP, Galanos O, Katritsis D, et al. 2001. Early mortality and morbidity of bilateral versus single internal thoracic artery revascularization: propensity and risk modeling. J Am Coll Cardiol 37:521-8.nKappetein AP. 2010. Bilateral mammary artery vs. single mammary artery grafting: promising early results: but will the match finish with enough players? Eur Heart J 31:2444-6.nLattouf OM, Thourani VH, Kilgo PD, et al. 2008. Influence of on-pump versus off-pump techniques and completeness of revascularization on long-term survival after coronary artery bypass. Ann Thorac Surg 86:797-805.nLytle BW, Blackstone EH, Loop FD, et al. 1999. Two internal thoracic artery grafts are better than one. J Thorac Cardiovasc Surg 117:855-72.nMalinowski M, Deja MA, Go?ba KS, Roleder T, Biernat J, Wo S. 2008. Perivascular tissue of internal thoracic artery releases potent nitric oxide and prostacyclin-independent anticontractile factor. Eur J Cardiothorac Surg 33:225-31.nNakano J, Okabayashi H, Hanyu M, et al. 2008. Risk factors for wound infection after off-pump coronary artery bypass grafting: should bilateral internal thoracic arteries be harvested in patients with diabetes? J Thorac Cardiovasc Surg 135:540-5.nNishi H, Mitsuno M, Tanaka H, Ryomoto M, Fukui S, Miyamoto Y. 2011. Decreasing sternum microcirculation after harvesting the internal thoracic artery. Eur J Cardiothorac Surg 40:240-4.nParish MA, Asai T, Grossi EA, et al. 1992. The effects of different techniques of internal mammary artery harvesting on sternal blood flow. J Thorac Cardiovasc Surg 104:1303-7.nPeterson MD, Borger MA, Rao V, Peniston CM, Feindel CM. 2003. Skeletonization of bilateral internal thoracic artery grafts lowers the risk of sternal infection in patients with diabetes. J Thorac Cardiovasc Surg 126:1314-9.nRaja SG. 2004. Skeletonized bilateral internal thoracic arteries in patients with diabetes: additional advantages and concerns. J Thorac Cardiovasc Surg 127:1856-7.nRaja SG, Dreyfus GD. 2005. Internal thoracic artery: to skeletonize or not to skeletonize? Ann Thorac Surg 79:1805-11.nRaja SG, Siddiqui H, Ilsley CD, Amrani M. 2009. In-hospital outcomes of off-pump multivessel total arterial and conventional coronary artery bypass grafting: single surgeon, single center experience. Ann Thorac Surg 88:47-52nSavage EB, Grab JD, O'Brien SM, et al. 2007. Use of both internal thoracic arteries in diabetic patients increases deep sternal wound infection. Ann Thorac Surg 83:1002-6.nSchmeltz LR, DeSantis AJ, Thiyagarajan V, et al. 2007. Reduction of surgical mortality and morbidity in diabetic patients undergoing cardiac surgery with a combined intravenous and subcutaneous insulin glucose management strategy. Diabetes Care 30:823-8.nTaggart DP, D'Amico R, Altman DG. 2001. Effect of arterial revascularisation on survival: a systematic review of studies comparing bilateral and single internal mammary arteries. Lancet 358:870-5.n

Published

2013-02-25

How to Cite

Raja, S. G., Salhiyyah, K., Rafiq, M. U., Navaratnarajah, M., Chudasama, D., Walker, C. P., Amin, F., & Amrani, M. (2013). In-Hospital Outcomes of Pedicled Bilateral Internal Mammary Artery Use in Diabetic and Nondiabetic Patients Undergoing Off-Pump Coronary Artery Bypass Grafting: Single-Surgeon, Single-Center Experience. The Heart Surgery Forum, 16(1), E1-E7. https://doi.org/10.1532/HSF98.20121038

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