BILATERAL INTERNAL THORACIC ARTERY GRAFTING: FIFTEEN YEARS OF EXPERIENCE

Highlights

• Bilateral internal thoracic artery (BITA) grafting is one of the most effective methods of direct myocardial revascularization. However, its results are still contradictory, despite the worldwide trend to use more autogenous arterial conduits.
• This study involves more than fifteen years of data in the use of BITA in Kuzbass in coronary artery disease surgery. The findings presented in the course of the analysis confirm the need to use both internal mammary arteries more actively.

Aim. To analyze long-term results of BITA grafting in terms of more than 15 years follow-up.

Methods. The study included 232 patients who were admitted at the Cardiac Surgery Department for coronary artery bypass grafting (CABG). All patients were divided into 2 groups depending on usage of single or bilateral internal thoracic artery conduits. Both groups included an equal number of patients 116 (50%). Long-term results were assessed in terms of more than 15 years follow-up.

Results. BITA grafting is comparable with CABG in such major adverse cardiac and cerebrovascular events as repeated myocardial revascularization, stroke, and in combined endpoint such as myocardial infarction (MI), stroke, repeated myocardial revascularization, or patient’s death within 15 years. However, the BITA group is superior to the CABG group in freedom from MI, all-cause deaths, showing a higher life expectancy after surgery (p = 0.011), and improved left ventricular ejection fraction and decreased functional class of angina. Moreover, in the present research it was confirmed that the severity of atherosclerosis in the coronary arteries is lower after bypassing with autogenous arterial conduits.

Conclusion. BITA is safe procedure comparable with CABG, however, it has more advantageous long-term clinical and angiographic results.

1. Bonatti J., Wallner S., Crailsheim I., Grabenwöger M., Winkler B. Minimally invasive and robotic coronary artery bypass grafting-a 25-year review. J Thorac Dis. 2021;13(3):1922-1944. doi: 10.21037/jtd-20-1535.

2. Gomes W.J., Gomes E.N., Bertini A.Jr., Reis P.H., Hossne N.A.Jr. The Anaortic Technique with Bilateral Internal Thoracic Artery Grafting - Filling the Gap in Coronary Artery Bypass Surgery. Braz J Cardiovasc Surg. 2021;36(3):397-405. doi: 10.21470/1678-9741-2020-0451.

3. Dimitrova K.R., Hoffman D.M., Geller C.M., Dincheva G., Ko W., Tranbaugh R.F. Arterial grafts protect the native coronary vessels from atherosclerotic disease progression. Ann Thorac Surg. 2012;94(2):475-81. doi: 10.1016/j.athoracsur.2012.04.035.

4. Frolov A.V. Morphological and functional system of graft-artery junctions. Complex Issues of Cardiovascular Diseases. 2019;8(1):112-122. doi: 10.17802/2306-1278-2019-8-1-112-122 (In Russian)

5. Frolov A.V., Nishonov A.B., Zagorodnikov N.I., Ivanov S.V., Barbarash L.S. Long-term results of bilateral internal mammary artery grafting. Russ Jour Card and Cardiovasc Surg=Kard i serd-sosud khir. 2019;12(2):110-115. doi:10.17116/kardio201912021110 (In Russian)

6. 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. doi: 10.1056/NEJMoa1808783.

7. Al Smady M.N., Zaki M.N., Alataywi E., Jegaden O. Impact of Bilateral versus Single Internal Thoracic Artery Grafting on the Long-Term Survival in Adults: A Systematic Review. Vasc Health Risk Manag. 2021;17:509-518. doi: 10.2147/VHRM.S320848

8. Bayer N., Hart W.M., Arulampalam T., Hamilton C., Schmoeckel M. Is the Use of BIMA in CABG Sub-Optimal? A Review of the Current Clinical and Economic Evidence Including Innovative Approaches to the Management of Mediastinitis. Ann Thorac Cardiovasc Surg. 2020;26(5):229-239. doi: 10.5761/atcs.ra.19-00310.

9. 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. doi: 10.24884/0042-4625-2019-178-3-10-15 (In Russian)

10. Sef D., Raja S.G. Bilateral internal thoracic artery use in coronary artery bypass grafting in the post-ART era - Perspective. Int J Surg. 2021;86:1-4. doi: 10.1016/j.ijsu.2020.12.007.

11. Rampidis G..P., Benetos G., Benz D.C., Giannopoulos A.A., Buechel R.R. A guide for Gensini Score calculation. Atherosclerosis. 2019;287:181-183. doi: 10.1016/j.atherosclerosis.2019.05.012.

12. Gharibeh L., Ferrari G., Ouimet M., Grau J.B. Conduits' Biology Regulates the Outcomes of Coronary Artery Bypass Grafting. JACC Basic Transl Sci. 2021;6(4):388-396. doi: 10.1016/j.jacbts.2020.11.015.

13. Spadaccio C., Antoniades C., Nenna A., Chung C., Will R., Chello M., Gaudino M.F.L. Preventing treatment failures in coronary artery disease: what can we learn from the biology of in-stent restenosis, vein graft failure, and internal thoracic arteries? Cardiovasc Res. 2020;116(3):505-519. doi: 10.1093/cvr/cvz214.

14. Eikelboom R., Amir T., Gupta S., Whitlock R.P. Optimal medical therapy after coronary artery bypass grafting: a primer for surgeons. Curr Opin Cardiol. 2021;36(5):609-615. doi: 10.1097/HCO.0000000000000889.

15. Ngu J.M.C., Ruel M., Sun L.Y. Left ventricular function recovery after revascularization: comparative effects of percutaneous coronary intervention and coronary artery bypass grafting. Curr Opin Cardiol. 2018;33(6):633-637. doi: 10.1097/HCO.0000000000000566.

16. 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):2005-12; discussion 2012-4. doi: 10.1016/j.athoracsur.2004.05.070.

17. Doenst T., Sigusch H. Surgical collateralization: The hidden mechanism for improving prognosis in chronic coronary syndromes. J Thorac Cardiovasc Surg. 2022;163(2):703-708.e2. doi: 10.1016/j.jtcvs.2020.10.121.