Contributor: Faisal Bakaeen, MD
Sometimes, two arteries are better than one.
For people with diabetes who have multivessel or extensive coronary artery disease, we have learned that bypass surgery to give blood a new pathway to the heart is better than angioplasty, which involves using a tiny device to open up narrowed blood vessels.
Various studies, such as FREEDOM and ASCERT support the use of bypass surgery. However, these studies did not look at what specific type of bypass surgery is best. For diabetic patients who need coronary bypass surgery, we’ve learned that one technique works particularly well that uses two arteries from the chest instead of the saphenous vein from the leg.
This technique is called bilateral internal thoracic artery (BITA) grafting. Our research confirms what we have observed in our patients: BITA grafting and complete restoration in blood flow improve surgical outcomes for our heart patients who also have diabetes.
One reason why surgeons have tended not to use the BITA is because of concerns about wound infection involving the breast bone. Diabetics, in general, are at higher risk for infection. So there has been some anxiety about using two arteries for the procedure.
However, the risk for wound infection is rare except in very overweight patients who were diabetic with widespread hardening of the arteries and in patients with poorly controlled diabetes.
For those patients, the risks of infection need to be weighed against the longer survival expected with BITA grafting. In addition, the use of meticulous harvesting techniques can reduce the risk of infection and allow our surgeons to offer BITA to more patients who may benefit from it.
Over the past decade, surgeons observed that the traditional leg vein grafts we used developed problems. The grafts started to narrow or close about a decade after surgery.
The use of an artery from the chest, the internal thoracic artery, greatly improved long-term results. Patients do better for longer and need fewer repeat surgeries.
There are two internal thoracic arteries, one on the left side, and one on the right side of the chest area. Ordinarily, only the left artery is rerouted in CABG surgery. In certain cases, both left and right arteries are used to restore blood flow to the heart.
We now know that using both chest arteries improves outcomes for heart patients, and we conducted a study to confirm this benefit for diabetic patients in particular.
Our research shows that using both the left and right internal thoracic arteries can make the most of restoring blood flow and yield the best short- and long-term outcomes for diabetic patients.
We looked at the surgical records from just under 12,000 diabetic patients who underwent CABG surgery. Some patients had traditional leg vein graft surgery. Others had surgery involving grafting of one artery. And some underwent BITA graft surgery.
We found that those diabetic patients who underwent BITA grafts had better short- and long-term survival than those who had the other types of surgery.