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DOI: 10.1055/s-0040-1713662
Wound Infection after CABG Using Internal Mammary Artery Grafts: A Meta-Analysis
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Abstract
Background Internal mammary arteries show better long-term patency rates than venous grafts. The use of both mammary arteries is associated with a higher risk of sternal wound infections. This meta-analysis was designed to assess the incidence of a wound healing disorder after bilateral compared with single mammary artery bypass grafting. Compared with existing meta-analysis this paper includes more current literature and one randomized controlled trial.
Methods A literature search was performed using PubMed and the Cochrane Library. The quality of the articles was assessed by the Newcastle Ottawa Scale. The odds ratio was used as a measure of the chance of developing a wound healing disorder after bilateral internal mammary artery (BIMA) surgery. Meta-analyses were performed for different subgroups.
Results Twenty studies met the quality criteria, including one randomized controlled trial. The use of both mammary arteries significantly increased the risk of superficial (odds ratio [OR] 1.72) and deep (OR 1.75) wound healing disorder in the total population (OR 1.80) as well as in the diabetic subgroup (OR 1.38) and with both preparation techniques. The increased risk with BIMA grafting was present independently of the preparation technique (pedicled: OR 1.89, skeletonized: OR 1.37).
Conclusion Bilateral internal mammary artery grafting, especially in high-risk and diabetic patients, is associated with an increased risk of wound healing impairment. Skeletonized preparation does not eliminate the elevated wound healing disorder risk after BIMA use.
Publikationsverlauf
Eingereicht: 22. März 2020
Angenommen: 11. Mai 2020
Artikel online veröffentlicht:
13. August 2020
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References
- 1 Goldman S, Zadina K, Moritz T. et al; VA Cooperative Study Group #207/297/364. Long-term patency of saphenous vein and left internal mammary artery grafts after coronary artery bypass surgery: results from a Department of Veterans Affairs Cooperative Study. J Am Coll Cardiol 2004; 44 (11) 2149-2156
- 2 Gansera B, Schmidtler F, Angelis I, Kiask T, Kemkes BM, Botzenhardt F. Patency of internal thoracic artery compared to vein grafts—postoperative angiographic findings in 1189 symptomatic patients in 12 years. Thorac Cardiovasc Surg 2007; 55 (07) 412-417
- 3 Takagi H, Goto SN, Watanabe T, Mizuno Y, Kawai N, Umemoto T. A meta-analysis of adjusted hazard ratios from 20 observational studies of bilateral versus single internal thoracic artery coronary artery bypass grafting. J Thorac Cardiovasc Surg 2014; 148 (04) 1282-1290
- 4 Dai C, Lu Z, Zhu H, Xue S, Lian F. Bilateral internal mammary artery grafting and risk of sternal wound infection: evidence from observational studies. Ann Thorac Surg 2013; 95 (06) 1938-1945
- 5 Toumpoulis IK, Anagnostopoulos CE, Derose Jr JJ, Swistel DG. The impact of deep sternal wound infection on long-term survival after coronary artery bypass grafting. Chest 2005; 127 (02) 464-471
- 6 Deutschland C. Arbeitsgemeinschaft der Wissenschaftlichen medizinischen Fachgesellschaften—Institut für medizinisches Wissensmanagement. Bewertung des Biasrisikos (Risiko systematischer Fehler) in klinischen Studien: ein Manual für die Leitlinienerstellung.”. 2016 . Accessed December 6, 2018 at: http://www.cochrane.de/de/rob-manual
- 7 Higgins JPT, Green S. Cochrane Handbook for Systematic Reviews of Interventions. Version 5.1.0. Chapter 9.5.2; 2011. Accessed November 17, 2018 at: http://handbook.cochrane.org
- 8 Schwarzer G. Meta: an R package for meta-analysis. R News 2007; 7 (03) 40-45
- 9 Schwarzer G, Carpenter JR, Rücker G. Meta-Analysis with R. Springer International Publishing. 2015. (Use R!)
- 10 Momin AU, Deshpande R, Potts J. et al. Incidence of sternal infection in diabetic patients undergoing bilateral internal thoracic artery grafting. Ann Thorac Surg 2005; 80 (05) 1765-1772 , discussion 1772
- 11 Puskas JD, Sadiq A, Vassiliades TA, Kilgo PD, Lattouf OM. Bilateral internal thoracic artery grafting is associated with significantly improved long-term survival, even among diabetic patients. Ann Thorac Surg 2012; 94 (03) 710-715 , discussion 715–716
- 12 Galbut DL, Kurlansky PA, Traad EA, Dorman MJ, Zucker M, Ebra G. Bilateral internal thoracic artery grafting improves long-term survival in patients with reduced ejection fraction: a propensity-matched study with 30-year follow-up. J Thorac Cardiovasc Surg 2012; 143 (04) 844-853.e4
- 13 Benedetto U, Amrani M, Gaer J. et al; Harefield Cardiac Outcomes Research Group. The influence of bilateral internal mammary arteries on short- and long-term outcomes: a propensity score matching in accordance with current recommendations. J Thorac Cardiovasc Surg 2014; 148 (06) 2699-2705
- 14 Benedetto U, Altman DG, Gerry S. et al; Arterial Revascularization Trial investigators. Pedicled and skeletonized single and bilateral internal thoracic artery grafts and the incidence of sternal wound complications: insights from the Arterial Revascularization Trial. J Thorac Cardiovasc Surg 2016; 152 (01) 270-276
- 15 Taggart DP, Altman DG, Gray AM. et al; ART Investigators. Randomized trial of bilateral versus single internal-thoracic-artery grafts. N Engl J Med 2016; 375 (26) 2540-2549
- 16 Ioannidis JPA, Galanos O, Katritsis D. et al. Early mortality and morbidity of bilateral versus single internal thoracic artery revascularization: propensity and risk modeling. J Am Coll Cardiol 2001; 37 (02) 521-528
- 17 Grau JB, Ferrari G, Mak AWC. et al. Propensity matched analysis of bilateral internal mammary artery versus single left internal mammary artery grafting at 17-year follow-up: validation of a contemporary surgical experience. Eur J Cardiothorac Surg 2012; 41 (04) 770-775 , discussion 776
- 18 Raza S, Sabik III JF, Masabni K, Ainkaran P, Lytle BW, Blackstone EH. Surgical revascularization techniques that minimize surgical risk and maximize late survival after coronary artery bypass grafting in patients with diabetes mellitus. J Thorac Cardiovasc Surg 2014; 148 (04) 1257-1264 , discussion 1264–1266
- 19 Agrifoglio M, Trezzi M, Barili F. et al. Double vs single internal thoracic artery harvesting in diabetic patients: role in perioperative infection rate. J Cardiothorac Surg 2008; 3: 35
- 20 Elmistekawy EM, Gawad N, Bourke M, Mesana T, Boodhwani M, Rubens FD. Is bilateral internal thoracic artery use safe in the elderly?. J Card Surg 2012; 27 (01) 1-5
- 21 Kinoshita T, Asai T, Suzuki T, Kuroyanagi S, Hosoba S, Takashima N. Off-pump bilateral skeletonized internal thoracic artery grafting in elderly patients. Ann Thorac Surg 2012; 93 (02) 531-536
- 22 Gideon S, Meir A, Battler A, Shapira Y, Vidne BA, Ben-Dor I. Bilateral skeletonized internal mammary versus single-pedicled internal mammary grafting in the elderly. Card Surg. 2007; 9: 294-298
- 23 Hassanein W, Hegazy YY, Albert A. et al. Short term outcomes of total arterial coronary revascularization in patients above 65 years: a propensity score analysis. J Cardiothorac Surg 2010; 5: 25
- 24 Itoh S, Kimura N, Adachi H, Yamaguchi A. Is bilateral internal mammary arterial grafting beneficial for patients aged 75 years or older?. Circ J 2016; 80 (08) 1756-1763
- 25 Benedetto U, Montecalvo A, Kattach H, Amrani M, Raja SG. ; Harefield Cardiac Outcomes Research Group. Impact of the second internal thoracic artery on short- and long-term outcomes in obese patients: a propensity score matched analysis. J Thorac Cardiovasc Surg 2015; 149 (03) 841-847.e1 , 2
- 26 Ruka E, Dagenais F, Mohammadi S, Chauvette V, Poirier P, Voisine P. Bilateral mammary artery grafting increases postoperative mediastinitis without survival benefit in obese patients. Eur J Cardiothorac Surg 2016; 50 (06) 1188-1195
- 27 Nakahara Y, Yoshida S, Kanemura T, Yamagishi S, Tochigi S, Osaka S. Bilateral internal thoracic artery grafts in hemodialysis: a single-center propensity score analysis. Ann Thorac Surg 2018; 105 (01) 153-159
- 28 Mohammadi S, Kalavrouziotis D, Cresce G. et al. Bilateral internal thoracic artery use in patients with low ejection fraction: is there any additional long-term benefit?. Eur J Cardiothorac Surg 2014; 46 (03) 425-431 , discussion 431
- 29 Calafiore AM, Di Mauro M, Di Giammarco G. et al. Single versus bilateral internal mammary artery for isolated first myocardial revascularization in multivessel disease: long-term clinical results in medically treated diabetic patients. Ann Thorac Surg 2005; 80 (03) 888-895
- 30 Kuroczynski W, Peivandi A, Pruefer D, Dahm M, Oelert H. Präoperative Risikofaktoren und sternale Wundheilungsstörungen nach Herzoperationen mit Sternotomie im Erwachsenenalter. Z Für Herz-Thorax- Gefäßchirurgie 2005; 19 (01) 32-36
- 31 Hauser J, Steinau HU, Ring A, Lehnhardt M, Tilkorn DJ. Sternal osteomyelitis. Etiology, diagnostics and operative therapy concepts [in German]. Chirurg 2014; 85 (04) 357-365 , quiz 366–367
- 32 Taggart DP, D'Amico R, Altman DG. Effect of arterial revascularisation on survival: a systematic review of studies comparing bilateral and single internal mammary arteries. Lancet 2001; 358 (9285): 870-875
- 33 Sousa-Uva M, Neumann F-J, Ahlsson A. et al. 2018 ESC/EACTS guidelines on myocardial revascularization. Eur J Cardiothorac Surg 2019; 55 (01) 4-90
- 34 Sajja LR. Strategies to reduce deep sternal wound infection after bilateral internal mammary artery grafting. Int J Surg 2015; 16 (Pt B): 171-178
- 35 Kurlansky PA, Traad EA, Dorman MJ, Galbut DL, Zucker M, Ebra G. Thirty-year follow-up defines survival benefit for second internal mammary artery in propensity-matched groups. Ann Thorac Surg 2010; 90 (01) 101-108
- 36 Gaudino M, Alexander JH, Bakaeen FG. et al. Randomized comparison of the clinical outcome of single versus multiple arterial grafts: the ROMA trial-rationale and study protocol. Eur J Cardiothorac Surg 2017; 52 (06) 1031-1040
- 37 Gatti G, Dell'Angela L, Barbati G. et al. A predictive scoring system for deep sternal wound infection after bilateral internal thoracic artery grafting. Eur J Cardiothorac Surg 2016; 49 (03) 910-917
- 38 Buja A, Zampieron A, Cavalet S. et al. An update review on risk factors and scales for prediction of deep sternal wound infections. Int Wound J 2012; 9 (04) 372-386
- 39 Raja SG, Rochon M, Jarman JWE. Brompton Harefield Infection Score (BHIS): development and validation of a stratification tool for predicting risk of surgical site infection after coronary artery bypass grafting. Int J Surg 2015; 16 (Pt A): 69-73
- 40 Sá MPBO, Ferraz PE, Soares AF. et al. Development and validation of a stratification tool for predicting risk of deep sternal wound infection after coronary artery bypass grafting at a Brazilian hospital. Rev Bras Cir Cardiovasc 2017; 32 (01) 1-7
- 41 Raja SG, Benedetto U. Scoring system to guide decision making for the use of bilateral internal mammary arteries: The BIMA score. Int J Surg 2018; 51: 89-96
- 42 Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM. CDC definitions for nosocomial infections, 1988. Am J Infect Control 1988; 16 (03) 128-140