Bilateral Internal Thoracic Artery Grafting: Does Graft Configuration Affect Outcome?
The Hopkins group reviewed differential outcomes in close to 800 patients who had undergone bilateral IMA revascularization during CABG. The compared configurations included:
- IS LITA-LAD and IS RITA-left coronary circulation
- IS LITA-LAD and IS RITA-right coronary circulation
- IS RITA-LAD and IS LITA-left coronary circulation
- IS LITA-LAD and Composite RITA to anywhere
Outcomes analysis failed to detect a difference in outcome endpoints consisting of long-term survival or repeat revascularization among the four configurations.
Is this enough evidence to say that it does not matter which of the techniques you use?
This is an analysis of a highly selected group of patients who underwent BITA grafting by various configurations selected on indeterminate criteria but were generally based on coronary anatomy favorable to a particular configuration. The criteria varied over time and presumably between surgeons allowing overlap between groups but the criteria were not included in the analyses.
In a highly select group of patients in whom appropriate graft configuration selection criteria are followed, there appears to be no substantial difference in outcomes between groups.
The data from the composite graft group were limited to the extent that a statement of similar outcomes (non inferiority) cannot be considered to be valid.
Most importantly, the favorable outcomes of all configurations should not be assumed if the importance of favorable coronary anatomy is ignored, as stated by Tatoulis et al. (Tatoulis J, Buxton BF, Fuller JA. The right internal thoracic artery: the forgotten conduit–5,766 patients and 991 angiograms. Ann Thorac Surg. 2011 Jul;92(1):9-15)
The disease severity and the the degree of stenosis affecting the choice f conduit has not been reflected properly in inclusion / eclusion criteria