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The Journal of Cardiovascular Surgery 2000 April;41(2):165-70


language: English

Bilateral internal thoracic artery operations in the elderly

Jones J. W., Schmidt S. E., Miller C. C. III, Beall A. C. jr., Baldwin J. C.

From the Department of Surgery Baylor College of Medicine and Veterans Affairs Medical Center Houston, Texas, USA


Background. Elderly sur­gi­cal ­patients ­have high­er oper­a­tive mor­bid­ity and mor­tal­ity ­than young­er ­cohorts, par­tic­u­lar­ly ­when the pro­ce­dure is ­lengthy and com­plex. While use of bilat­er­al inte­rnal tho­rac­ic arter­ies (BITA) is ­often asso­ciat­ed ­with ­increased sur­gi­cal ­risk, we nev­er­the­less hypoth­e­sized ­that the use of ­BITA in eld­er­ly cor­o­nary ­artery ­bypass ­patients ­would not sig­nif­i­cant­ly ­increase ­their oper­a­tive ­risk ­beyond ­that encoun­tered ­using sin­gle inte­rnal tho­rac­ic arte­ri­al (­SITA) or saph­e­nous ­vein ­grafts (SVG). We main­tained ­that arte­ri­al ­grafts ­remain essen­tial­ly unaf­fect­ed by arte­rio­scle­ro­sis, and ­that exten­sion of a ­high-qual­ity ­life is a desir­able out­come regar­dless of age at oper­a­tion.
Methods. Experimental Design: We stud­ied myo­car­dial revas­cu­lar­iza­tion in 673 ­patients ­over 65 ­years of age at the ­time of oper­a­tion. All oper­a­tions ­were con­duct­ed or super­vised by a sin­gle sur­geon dur­ing a ten-­year peri­od ­from January 1986 to January 1996. Preoperative and oper­a­tive ­dates ­were record­ed pros­pec­tive­ly. Setting: All ­patients under­went cor­o­nary ­artery ­bypass graft­ing. Interventions: The ­study com­pared out­comes in ­patients hav­ing all ­veins, ­SITA or ­BITA oper­a­tions. For the ­first anal­y­sis, 673 ­patients ­were divid­ed ­into ­three ­groups: 163 ­patients (Group 1) had saph­e­nous ­vein ­used for all bypass­es; 338 ­patients had a ­SITA ­with sup­ple­men­tal ­vein ­grafts (Group 2); and 172 ­patients (Group 3) had BITAs ­with addi­tion­al ­vein ­grafts as need­ed. In the sec­ond anal­y­sis, Group 3 was sub­di­vid­ed and ­grouped by the cor­o­nary arter­ies ­which ­received the ITA ­grafts, and the anal­y­sis was repeat­ed. One hundred and six- teen ­patients (Group 3A) under­went tra­di­tion­al place­ment of ITA bypass­es (­left ITA to the LAD, ­right ITA to the RCA); in Group 3B, 56 ­patients ­received revas­cu­lar­iza­tion of branch­es of the ­left cor­o­nary ­artery (­left ITA to the cir­cum­flex ­system, ­right ITA to the LAD). Measures: We com­mu­ni­cat­ed direct­ly ­with 90.5% of the ­patients, ­their fam­i­lies, or ­their phy­si­cians. The sur­vi­val stat­us of the remain­der was deter­mined ­through the National Social Security Death Index Network. This ­allowed us to ­obtain fol­low-up lon­gev­ity ­data for 100% of the ­study sam­ple at a ­mean obser­va­tion peri­od of 5.03±3.1 ­years ­with vari­a­tion ­between 10.8 ­years to 2.4 ­years.
Results. A mul­ti­var­i­ate anal­y­sis ­showed ­that place­ment of ­both ITA ­grafts to ­left-sid­ed arter­ies in old­er ­patients inde­pen­dent­ly ­improved ­long-­term sur­vi­val (p=0.031).
Conclusions. The ­BITA pro­ce­dure ­does not ­have great­er oper­a­tive mor­bid­ity or mor­tal­ity in the eld­er­ly ­despite the ­length or com­plex­ity of the sur­gery. To real­ize ­improved ­long-­term sur­vi­val ­rates, how­ev­er, ­both ITAs ­must be graft­ed to the ­left cor­o­nary ­artery branch­es.

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