Bilateral Internal Thoracic Artery Configuration for Coronary Artery Bypass Surgery: A Prospective Randomized Trial

David Glineur, Munir Boodhwani, Claude Hanet, Laurent de Kerchove, Emiliano Navarra, Parla Astarci, Philippe Noirhomme, Gebrine El Khoury, David Glineur, Munir Boodhwani, Claude Hanet, Laurent de Kerchove, Emiliano Navarra, Parla Astarci, Philippe Noirhomme, Gebrine El Khoury

Abstract

Background: Bilateral internal thoracic arteries (BITA) have demonstrated superior patency and improved survival in patients undergoing coronary artery bypass grafting. However, the optimal configuration for BITA utilization and its effect on long-term outcome remains uncertain.

Methods and results: We randomly assigned 304 patients undergoing coronary artery bypass grafting using BITA to either in situ or Y grafting configurations. The primary end point was 3-year angiographic patency. Secondary end points included major adverse cardiac and cerebrovascular events (ie, death from any cause, stroke, myocardial infarction, or repeat revascularization) at 7 years. More coronary targets were able to be revascularized using internal thoracic arteries in patients randomized to Y grafting versus in situ group (3.2±0.8 versus 2.4±0.5 arteries/patient; P<0.01). The primary end point did not show significant differences in graft patency between groups. Secondary end points occurred more frequently in the in situ group (P=0.03), with 7-year rates of 34±10% in the in situ and 25±12% in the Y grafting groups, driven largely by a higher incidence of repeat revascularization in the in situ group (14±4.5% versus 7.4±3.2% at 7 years; P=0.009). There were no significant differences in hospital mortality or morbidity or in late survival, myocardial infarction, or stroke between groups.

Conclusions: Three-year systematic angiographic follow-up revealed no significant difference in graft patency between the 2 BITA configurations. However, compared with in situ configuration, the use of BITA in a Y grafting configuration results in lower rates of major adverse cardiovascular and cerebrovascular events at 7 years.

Clinical trial registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01666366.

Keywords: arteriosclerosis; cohort studies; coronary artery bypass; coronary vessel; incidence.

© 2016 The Authors.

Figures

Figure 1.
Figure 1.
Advantages and disadvantages of the 2 bilateral internal thoracic artery (BITA) configurations. CABG indicates coronary artery bypass grafting; ITA, internal thoracic artery; LAD, left anterior descending; LCX, left circumflex artery; LITA, left internal thoracic artery; RITA, right internal thoracic artery; and TS, transverse sinus.
Figure 2.
Figure 2.
Consort flow chart of the trial. BITA indicates bilateral internal thoracic artery; and CABG, coronary artery bypass grafting.
Figure 3.
Figure 3.
Kaplan–Meier major adverse cardiac cerebrovascular event long-term comparison. A, Overall death event rate (P=0.3). B, Myocardial infarction and percutaneous coronary intervention event rate (P=0.02). C, Stroke event rate (P=0.9). D, Revascularization event rate (P<0.01). E, Major adverse cardiac and cerebrovascular event rates (0.04). *Significant P value. The small dotted lines indicate 1.5 SE.

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