Bilateral internal thoracic artery grafts for myocardial revascularization in insulin-dependent diabetic patients: time for wide clinical practice?

Cite this article as: Jatene FB, Kolh P. Bilateral internal thoracic artery grafts for myocardial revascularization in insulin-dependent diabetic patients: time for wide clinical practice?. In this issue of the European Journal of Cardiothoracic Surgery, Gatti et al. [1] analysed early and long-term outcomes of routine use of bilateral internal thoracic artery (BITA) grafts for left-sided myocardial revascularization in a consecutive cohort of 188 insulin-dependent diabetic patients. In addition to low in-hospital mortality, they reported that a higher incidence of deep sternal wound infection (DSWI), when compared with non-diabetic patients receiving BITA grafts, did not impact long-term outcome. While, these results are welcome in the cardiac surgical community, concern remains regarding the use of BITA grafting, possibly associated with an increased incidence of early complications , such as DSWI, particularly in diabetic patients. To stimulate change in clinical practice and encourage more widespread use of BITA grafting, in particular in diabetic patients, two questions should be addressed: (i) Is the use of BITA grafts important for all patients? (ii) Do all diabetic patients share a similar profile? Since the 1980s, it has been known that the internal thoracic artery (ITA) graft to the left anterior descending coronary artery significantly improves survival and is associated with lower incidence of late cardiac events and better quality of life over a 10-year period. These benefits result from greater long-term patency of ITA grafts when compared with saphenous vein grafts [2]. With increasing evidence, studies have shown that using two ITAs might be better than one [3]. However, not all patients benefit equally from BITA grafting, while the advantage at follow-up occurs at different time points for different patient subsets. Patients without abnormal left ventricular (LV) function or co-morbidities are ideal patients for BITA grafting. For patients with LV dysfunction or non-cardiac risk factors, BITA grafting still carries better survival [4]. However, for patients having LV dysfunction and non-cardiac risk factors, the overall prognosis appears poor, and the benefit of BITA grafting to improve late survival is controversial [5, 6]. Overall, survival curves of patients with BITA grafting versus single ITA (SITA) grafting begin to diverge about 10 years after surgery, possibly related to saphenous vein graft progressive disease [3, 4]. The arterial revascularization trial randomized 3102 patients between BITA grafting and SITA grafting, with a primary outcome of 10-year survival [7]. Preliminary published data reported similar 30-day and 1-year outcomes in terms of …