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Ann Thorac Surg 1996;62:1289-1294
© 1996 The Society of Thoracic Surgeons

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Original Article: Cardiovascular

Operation for Two-Vessel Coronary Artery Disease: Midterm Results of Bilateral ITA Grafting Versus Unilateral ITA and Saphenous Vein Grafting

Clinic for Cardiovascular Surgery, University Hospital, Zürich, Switzerland

	Abstract

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Background. Several studies have demonstrated that single internal thoracic artery (ITA) grafting achieves better results than the use of vein grafts alone, but it is less clear whether bilateral ITA grafting produces better long-term results than a single ITA graft to the left descending coronary artery does.

Methods. We analyzed the early and midterm results of the surgical treatment of two-vessel coronary artery disease (left anterior descending artery and right coronary artery) in two groups of 80 consecutive patients operated on between 1985 and 1989 who received either a bilateral ITA graft or a unilateral ITA graft combined with a saphenous vein graft. Patients were selected from a data base so as to be rigorously matched for demographic and clinical factors as well as angiographic variables, with the researcher being blinded to any additional intraoperative or postoperative data. Follow-up examination was performed after a mean postoperative interval of 8 years.

Results. Univariate analysis showed a somewhat higher incidence of sternal complications in the bilateral ITA group (4.8% versus 1.2%; p < 0.02) and a significantly lower reintervention-free survival at 8 years in the group of patients who received a unilateral ITA and saphenous vein graft (84% ± 5.5% versus 95% ± 1.5%; p < 0.02). The latter was predominantly due to the development of significant main stem lesions necessitating a redo procedure during the follow-up interval or to the need for percutaneous coronary angioplasty of circumflex artery lesions that were not critical at the time of the initial operation. Perioperative risk was similar in both groups of patients. Old age and a history of congestive heart failure were the most important predictors of perioperative mortality and morbidity for patients receiving bilateral ITAs. Multivariate analysis did not demonstrate any benefit from bilateral arterial grafting over unilateral ITA bypass combined with saphenous vein grafting in terms of overall survival and event-free and intervention-free survival.

Conclusions. Although bilateral ITA grafting can be performed with a perioperative risk comparable with that for unilateral ITA and saphenous vein grafting, long-term results (up to 8 years) of surgically treated two-vessel coronary artery disease are not improved by bilateral ITA grafting.

	Introduction

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
See also page 1294.

The internal thoracic artery (ITA) has become the conduit of choice for myocardial revascularization, because it has been proved that early mortality and morbidity are low, the long-term patency rate is superior to that of saphenous vein grafts (SVGs), and late atherosclerotic lesions rarely occur in this vessel [1–4]. With increasing experience, use of the ITA has expanded, including bilateral ITA, sequential anastomoses, and T grafts [5–7]. With more data available concerning the long-term patency of this graft conduit, virtually every patient is afforded the advantage of this surgical procedure.

Several studies have demonstrated that single ITA grafting yields better results than vein grafts alone, but it is less clear whether bilateral ITA grafting produces better long-term results than a single ITA graft to the left anterior descending coronary artery (LAD) does [3, 8–10].

We wanted to clarify whether an improvement in overall survival and in event-free and reintervention-free survival can be expected after myocardial revascularization using bilateral ITA grafts instead of a unilateral ITA graft and SVG in the special setting of two-vessel coronary artery disease. We also analyzed the incidence of recurrence of angina and of progression of the disease in the native coronary circulation in both groups of patients.

	Patients and Methods

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
We analyzed the early and long-term results of surgical myocardial revascularization in two groups of 80 consecutive patients operated on between 1985 and 1989. All patients presented originally with two-vessel coronary artery disease (LAD and right coronary artery [RCA]) and received either a bilateral ITA graft or unilateral ITA graft + SVG. Prerequisite conditions to enter this study were either occlusion or significant stenosis of the LAD branch and of the RCA, narrowing the cross-sectional diameter by at least 50%, with or without noncritical stenosis (<50%) in the circumflex artery. Patients with main stem lesions were excluded. The study was not randomized, and the choice of the graft material depended on surgeon preference. Patients were selected from a data base so as to be rigorously matched for demographic factors and preoperative clinical (incidence of cardiovascular risk factors, functional class, prior myocardial infarction, heart failure) and angiographic variables. The matching process used mainly preoperative data and either unilateral ITA + SVG or bilateral ITA as bypass graft material, with the researcher being blinded to any additional intraoperative or postoperative data.

Preoperative selective angiography of both ITAs was performed routinely at the end of the cardiac catheterization in our institution; no anomalies of the ITA or significant side branches and significant obstructive lesions of the subclavian artery were observed in these patients.

All operations were performed through a median sternotomy. The left and right ITAs are prepared with low-power cautery after wide opening of the pleural cavity. The ITA is mobilized within a thin pedicle of surrounding muscle, fat tissue, and endothoracic fascia up to the subclavian vein. The pedicle is wrapped in a papaverine-soaked sponge and not touched again until implantation. Cardiopulmonary bypass is conducted under moderate hypothermia and revascularization performed during a single period of cardioplegic arrest. The ITA is divided distally and flow assessed visually. Hydrostatic dilation is not performed routinely in these patients, but if the flow is judged to be severely reduced, correction is obtained through the use of a very thin probe and the injection of diluted papaverine solution. Running suture is achieved with 7-0 polypropylene and each anastomosis tested with a 1.5- to 2.0-mm probe. In this series, the left ITA could always be used in situ, whereas the right ITA had to be used as a free graft in 5 patients because of inadequate length. The site of distal anastomosis was the RCA in the vertical segment in 55 patients and the posterior descending branch in 35 patients, depending on the size of the vessel and the presence of disease in the bifurcation area. The standard postoperative drug treatment in most patients includes low-dose salicylic acid combined with either calcium-channel blockers or ß-blockers.

Perioperative data were obtained from the patient's hospital record. Follow-up information was collected yearly from the patient's cardiologist and from responses to mailed questionnaires. End-point follow-up examination was performed after a mean postoperative interval of 8 years. All subsequent interventions (percutaneous coronary angioplasty or redo operation) were performed in the same institution. Cardiac-related events included in the calculation of event-free survival were sudden death, reoperation, percutaneous coronary angioplasty, heart failure, and myocardial infarction. Recurrence of angina was defined as the finding of New York Heart Association functional class II or more during the follow-up interval. Survival analysis included all causes of death.

The functional status of all survivors was evaluated with a questionnaire. Results of the last ambulatory examination, including stress electrocardiography and echocardiography, were available for 85% of the operative survivors.

Statistical analysis of preoperative, intraoperative, and postoperative data consisted of a comparison of the mean values in each group of patients and a Wilcoxon paired-rank test for the comparison of each matched, paired group. Mean values and standard deviations were calculated. Univariate analysis with ² testing for proportions or analysis of variance for means was used to compare the characteristics of both groups of patients (unilateral ITA + SVG and bilateral ITA). These variables were selected in part from a review of publications dealing with the use of unilateral and bilateral ITA in coronary operations:

• Age
  
• Sex
  
• Angina class
  
• Heart failure
  
• Prior myocardial infarction
  
• Smoking
  
• Hypertension
  
• Hyperlipidemia
  
• Diabetes
  
• Positive exercise electrocardiogram
  
• Diseased circumflex artery (<50%)
  
• Left ventricular dysfunction (continuous)
  
• Left ventricular end-diastolic pressure (continuous)
  
• Unilateral internal thoracic artery and saphenous vein grafts
  
• Bilateral internal thoracic artery graft
  
• Date of last follow-up
  
• Late angina class
  
• Late antianginal medication
  
• Late myocardial infarction
  
• Late reintervention (percutaneous coronary angioplasty or coronary artery bypass grafting)
  

Multivariate logistic regression was used to select the independent predictors of event-free survival, reintervention-free survival, and recurrence of angina for both groups of patients combined and then for each group separately. The regression analysis was performed with backward elimination and was continued until all nonsignificant predictors were removed. Survival curves were calculated with the Kaplan-Meier method. Differences in the survival rates between the two treatment groups were analyzed by the log rank test. In all statistical tests, a p value of less than 0.05 was considered significant.

	Results

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Both groups were similar in terms of demographic factors. The main preoperative coronary angiographic findings are summarized on Table 1. Although only two-vessel coronary artery disease was considered, the circumflex area was more often diseased (<50% stenosis) at the time of initial operation in the unilateral ITA + SVG group than in the bilateral ITA group (20 patients versus 8 patients; p < 0.01).

Hospital mortality was 1.2% in the unilateral ITA + SVG group and 2.4% in the bilateral ITA group (p = not significant). The cause of death was perioperative myocardial infarction in 2 patients and multiorgan failure subsequent to septicemia in 1 patient. There was no statistically significant difference in the incidence of perioperative myocardial infarction and low cardiac output between the two groups. No patient was lost to follow-up. The median duration of follow-up was similar for both groups. At 8 years, the overall survival was not different between the ITA + SVG group and bilateral ITA group (94% ± 2.5% versus 92% ± 3.3%). The number of late deaths was too small to permit reliable multivariate analysis of independent predictors for late mortality.

The perioperative risk factors and the most important findings during long-term follow-up are summarized in Table 2. Only the incidence of sternal dehiscence was somewhat higher in the bilateral ITA group (p < 0.02).

A total of 14 patients underwent 18 reinterventions. The reason for reintervention was progression of disease in the native circulation in 13 patients and the development of a severe atherosclerotic lesion in an SVG in 1 patient. Reinterventions were necessary after a mean follow-up of 5.7 years in the unilateral ITA + SVG group and of 6.3 years in the bilateral ITA group.

Three patients underwent coronary reoperation (2 patients had undergone prior bilateral ITA grafting and needed a redo operation because of main stem disease; 1 of them also received a venous graft to the RCA because of occlusion of the right ITA, despite good quality of the distal native artery). The third patient had had a unilateral ITA + SVG previously and required a new venous graft to the RCA because of occlusion of the previously grafted saphenous vein in addition to a graft to the circumflex branch. Eleven patients underwent coronary angioplasty late after prior myocardial revascularization; all had shown significant progression of nonsignificant lesions of the circumflex artery or of the marginal or diagonal branches, or both, at the time of initial presentation.

Univariate analysis showed a significantly lower reintervention-free survival for the unilateral ITA + SVG group; this was predominantly due to the need for percutaneous coronary angioplasty of circumflex lesions that were not critical at the time of the initial operation (Table 4).

	Comment

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Previous studies did not conclusively demonstrate that bilateral ITA grafting provides additional benefit over the unilateral ITA graft in a well-defined subgroup of patients, namely, those suffering from two-vessel coronary artery disease who have undergone myocardial revascularization with two grafts only. Most studies focusing on perioperative morbidity and mortality have shown that myocardial revascularization using either single or bilateral ITA grafts does not increase the perioperative risk [11–18], despite the fact that immediate blood flow through this arterial conduit is generally less than that through an SVG, and thus it may not be adequate to meet requirements during peak myocardial demand [19].

With the exception of sternal dehiscence, the overall incidence of perioperative complications evaluated in this study was not higher in patients receiving unilateral or bilateral ITA grafts. In agreement with the findings reported by other authors, old age and preoperative congestive heart failure as well as female sex were also identified in our study as significant predictors for perioperative risk in the bilateral ITA group. In the unilateral ITA + SVG group, none of the variables tested reached the level of statistical significance in the logistic regression analysis.

The late results of surgical myocardial revascularization are affected by the preoperative status of the patient, the progression of coronary artery disease, and the long-term patency of the grafts used. In most studies that have evaluated the long-term effectiveness of ITA and venous grafts, a substantial proportion of the patients have received unilateral ITA grafts only, and several studies were performed in patients with three-vessel coronary artery disease in whom several venous anastomoses were performed in addition to the placement of one or two ITA grafts [2, 8, 9, 17].

Few studies have demonstrated that systematic use of both ITAs results in a better cardiac event–free survival than the use of unilateral ITA to revascularize the LAD only [8,20–22]. Our study design is somewhat equivalent to that of Fiore and Naunheim in terms of the strategy of anastomosis (left ITA to LAD, right ITA to RCA). That group failed to demonstrate a significant benefit in terms of survival over a 15-year period. Fiore and colleagues [8, 21] showed a significantly better recurrent angina–free survival in patients who had had bilateral ITA grafting (36%) than in those who had had unilateral ITA grafting (27%), although no difference in late incidence of myocardial infarction was detected.

Our 8-year survival rates of 94% after unilateral ITA + SVG and 92% after bilateral ITA are very satisfactory and do not show a benefit of bilateral ITA over unilateral ITA + SVG. The univariate analysis showed a trend toward a higher reintervention-free survival in patients who received bilateral ITAs. However, logistic regression did not confirm this trend. In the present follow-up interval of up to 8 years, the main reason for reinterventions has been progression of disease in the native coronary arteries, the latter being responsible for necessitating angioplasty and redo operation for the treatment of lesions in the posterolateral area and for the manage ment of significant main stem lesions that had developed. No reintervention was strictly necessitated by occlusion of either the SVG or the ITA graft.

Patency data from the Cleveland Clinic Foundation Cardiovascular Information Registry regarding postoperative angiographic findings for ITA grafts, according to the coronary vessel grafted and postoperative interval, have shown that the patency rate of an in situ ITA graft to the LAD was 95% at 10 years, whereas, for the same interval, the patency rate for an in situ ITA graft to the RCA was only 76%. Similar results have been found for the free ITA graft (92% patency rate for graft to LAD versus 69% for graft to RCA) [13]. It is unclear why right ITA grafts seem to fail earlier and more often than left ITA grafts; the lower patency rate was thought to be caused by an unfavorable ITA–coronary flow matching, which developed most probably in the early postoperative period. This slightly lower patency rate for the right ITA was confirmed by Huddleston and associates [23], who noted patency rates of 90% for left ITA grafts and 79% for right ITA grafts at 5 years postoperatively.

On the basis of findings in several studies, it does appear that patients who receive bilateral ITAs are less likely to need reoperation [8, 9, 13], but we were not able to confirm this observation, mainly because of the low number of redo operations.

Postoperative recurrence of angina may be caused either by progression of the disease or by occlusion of the bypass graft. Multivariate analysis revealed no common predictor of the recurrence of angina for either group of patients; there was also no difference between the two groups in the time until the recurrence of angina. Left ventricular dysfunction, female sex, and diabetes were identified as independent predictors of recurrent angina after bilateral ITA grafting only. This information should be considered with caution, however, because the level of significance was borderline. As stated by Boylan and associates [3, 9], it seems that the most important principle of the surgical treatment of one- and two-vessel coronary artery disease is that the LAD revascularization be secure, because preservation of the anterior wall may be sufficient for extending longevity. Our observations confirm this statement: the development of main stem disease and the appearance of circumflex lesions were the most important factors predisposing to the recurrence of disease, whereas the outcome for the graft to the RCA did not significantly influence the overall survival nor the event-free survival for up to 8 years.

Limitations
Like every nonrandomized study, there is a danger of bias in this retrospective analysis, particularly from the standpoint of differences in preoperative patient-related variables that might confound the comparison of different strategies. To diminish the potential negative influence introduced by such bias, the researcher who matched the patients was blinded to all intraoperative and postoperative variables, except the number of diseased and grafted arteries. Another limitation is the length of the follow-up, which does not exceed 8 years. A significant difference in survival, the incidence of late cardiac events, and reinterventions may reasonably appear after this time. In this series, noncritical lesions in the circumflex area were more prevalent in the unilateral ITA + SVG group. However, because this variable affected mainly the unilateral ITA group, the results of bilateral ITA should have been much more impressive.

Conclusions
Bilateral ITA grafting can be performed with a perioperative risk comparable with that for unilateral ITA and SVG, but the long-term results (up to 8 years) of surgical revascularization for two-vessel disease are not improved by bilateral ITA grafting. The outcome is mainly influenced by progression of the disease in the native coronary circulation. However, young patients (with hyperlipidemia) should not be denied bilateral ITA, because it has been proved that the ITA graft is more resistant to atherosclerosis than the SVG. Despite the results of this study (ie, length of follow-up), we still believe that extended use of the right ITA is justified in patients with a severely stenosed or occluded RCA. We consider patients with moderate stenosis of the RCA as well as insulin-dependent, older diabetic patients to have a relative contraindication to bilateral ITA grafting. Potential indications for using an SVG to the RCA are moderate stenosis of the RCA, severe left ventricular dysfunction, simultaneous mitral valve operation, and multiple anastomoses to a dominant right coronary system.

	Acknowledgments

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
We thank Osmund Bertel, MD, Clinic for Cardiology, Stadtspital Triemli Zürich, and Franz Ammann, MD, Department of Cardiology, University Hospital Zürich, and their teams for the critical review of preoperative angiograms.

We acknowledge the secretarial assistance of Andrea Mätzener, from the Clinic of Thoracic and Cardiovascular Surgery, University of Berne, Switzerland.

	Footnotes

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Presented at the Thirty-second Annual Meeting of The Society of Thoracic Surgeons, Orlando, FL, Jan 29-31, 1996.

Address reprint requests to Dr Carrel, Clinic for Thoracic and Cardiovascular Surgery, University Hospital, CH-3010 Berne, Switzerland.

	References

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 

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