Objective: To identify surgical revascularization techniques that minimize surgical risk and maximize late survival in patients with diabetes undergoing coronary artery bypass grafting (CABG).
Methods: From January 1972 to January 2011, 11,922 patients with diabetes underwent primary isolated CABG. The revascularization techniques investigated included bilateral internal thoracic artery (BITA) grafting (n = 938; 7.9%) versus single ITA (SITA) grafting, off-pump (n = 602; 5.0%) versus on-pump CABG, and incomplete (n = 2109; 18%) versus complete revascularization. The median follow-up was 7.8 years and total follow-up, 104,516 patient-years. Multivariable analyses were performed to assess the effects of surgical techniques on hospital outcomes and long-term mortality.
Results: After adjusting for patient characteristics, BITAversus SITA grafting was associated with a 21%lower late mortality (68%confidence limits, 16%-26%). However, BITA grafting was also associated with more deep sternal wound infections (DSWIs), but the considerable mortality fromDSWI minimally affected overall survival because of its rare occurrence. The risk factors for DSWI were female sex (80%increased risk), higher body mass index (7%increased risk per kg/m2), medically treated diabetes (73%increased risk), previous myocardial infarction (58% increased risk), and peripheral arterial disease (73% increased risk). Off-pump and on-pump CABG had similar results. Complete versus incomplete revascularization had similar hospital outcomes; however, complete revascularization was associated with 10% lower late mortality (68% confidence limits, 7.0%-13%).
Conclusions: BITA grafting with complete revascularization maximizes long-term survival and is recommended for patients with diabetes undergoing CABG. BITA grafting should be used in all patients with diabetes whose risk of DSWI is low. It might be best avoided in obese diabetic women with diffuse atherosclerotic burden-those at greatest risk of developing these infections.