Is the era of bilateral internal thoracic artery grafting coming for diabetic patients? An updated meta-analysis

Abstract

Objective: Because of an increased risk of sternal wound complications, the use of bilateral internal thoracic artery grafting in diabetic patients remains controversial. The objective of the present meta-analysis is to compare the safety and efficacy of single internal thoracic artery and bilateral internal thoracic artery grafting in the diabetic population.

Methods: Four electronic databases, including PubMed, the Cochrane Library, Embase, and ISI Web of Knowledge, were comprehensively searched. Prospective randomized trials or observational studies comparing single internal thoracic artery and bilateral internal thoracic artery were considered eligible for the current study.

Results: A literature search yielded 1 randomized controlled trial and 17 observational studies (129,871 diabetic patients: 124,233 single internal thoracic arteries and 5638 bilateral internal thoracic arteries). Pooled analysis demonstrated overall incidence of deep sternal wound infection in the bilateral internal thoracic artery grafting group was significantly higher than in the single internal thoracic artery grafting group (3.26% for bilateral internal thoracic artery vs 1.70% for single internal thoracic artery). No significant difference was found between both groups in terms of risk of deep sternal wound infection when the skeletonized harvesting technique was adopted. Furthermore, in-hospital mortality was comparable between both groups (2.80% for bilateral internal thoracic artery vs 2.36% for single internal thoracic artery). However, compared with single internal thoracic artery grafting, bilateral internal thoracic artery grafting could confer a lower risk for long-term overall mortality (hazard ratio, 1.41; 95% confidence interval, 1.18-1.67; P < .001; I² = 63%) and cardiac mortality (hazard ratio, 3.15; 95% confidence interval, 2.23-4.46; P < .001; I² = 0%).

Conclusions: Compared with single internal thoracic artery grafting, bilateral internal thoracic artery grafting is associated with enhanced long-term survival among diabetic patients. Skeletonization of bilateral internal thoracic artery is not associated with an increased risk of deep sternal wound infection. Therefore, surgeons should be encouraged to adopt bilateral internal thoracic artery grafting in a skeletonized manner more routinely in diabetic patients.

Keywords: bilateral internal thoracic artery grafting; coronary artery bypass grafting; diabetes; skeletonization.