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Ann Thorac Surg 2001;72:1541
© 2001 The Society of Thoracic Surgeons
a Director of Cardiac Surgery, Austin & Repatriation Medical Centre, Level 5, Studley Rd, Heidelberg, Victoria 3084, Australia
e-mail: brianbuxton{at}armc.org.au
Based on the excellent late graft patency data using either the right or left internal thoracic artery (ITA) in situ internal artery grafts, one would expect the clinical outcome should improve using two rather than a single ITA. A difference in the clinical outcome between double compared with single ITA grafting has been difficult to demonstrate. In the absence of a prospective randomized study, observational studies with retrospective clinical matching and multivariable analytic techniques have not convincingly demonstrated a survival advantage. The number of major clinical events, eg, death, myocardial infarction, reintervention are relatively uncommon in young patients and a longer period of follow-up, even up to 20 or 30 years, may be required to demonstrate a difference between those having single or bilateral ITA grafting [1].
A large series of nonrandomized patients with bilateral or single ITA graft, studied at the Cleveland Clinic [2] demonstrated that death, reoperation and percutaneous transluminal coronary angioplasty were more frequent in patients undergoing single rather than bilateral ITA grafting. The authors concluded that the major difference was the frequency of reoperation. However many surgeons are loathe to perform a reoperation in patients with bilateral ITA graft, particularly if they are patent.
Doctor Berreklouw and his colleagues provide information suggesting that there may be benefits from bilateral [1] compared with single ITA grafting. The Kaplan-Meier estimates (Figures 1 through 5) are univariable comparisons and are not adjusted for confounding predictors, which may have been introduced by patient selection. The strongest part of this paper is the results of the multivariable analyses. The Cox proportional hazard models (Table 5), adjusted for potentially important variables, suggest that the use of bilateral ITAs reduces the incidence of angina and improves angina-free survival and ischemic-event-free survival. Angina itself is a weak endpoint and when used either alone, or as part of a composite endpoint reduces the validity of the conclusion. The scientific evidence supporting the benefits of bilateral ITA compared with single ITA grafting is weak. All analyses have the same trend, suggesting that there may be a benefit using bilateral compared with single ITA grafts in preventing ischemic events rather than improving survival. A longer follow-up and analysis of patient subsets may clarify any difference between single and bilateral ITA grafting.
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