Why Did You Not Use Both Internal Thoracic Arteries?

Abstract

That is the question every cardiologist should ask if the patient he or she has referred for primary surgical coronary revascularization returns from the operating room with a single internal thoracic artery graft. There is a substantial body of evidence demonstrating that the majority of coronary bypass patients benefit more when coronary artery bypass graft (CABG) surgery is performed with both internal thoracic artery conduits rather than just one.1–4 However, only 4.4% of primary isolated CABG cases in the 2011 Society of Thoracic Surgeons National Adult Cardiac Surgery Database received bilateral internal thoracic artery (BITA) grafting.5 There are several putative reasons for this failure of adoption, but referring cardiologists and patients should demand better. Article see p 2935 Why are American surgeons doing so few BITA grafts? Fundamentally, U.S. surgeons are responding to their practice environment, especially to a fear of deep sternal wound infection in an increasingly obese, diabetic population of patients. The surgeon pays a large and immediate political price for a deep sternal wound infection and receives relatively little credit for the extra years that BITA grafting adds to a patient's life in the future. There is also a relative financial disincentive to perform BITA grafting: incremental payment for the second internal thoracic artery graft is small considering the extra time required in the operating room. Moreover, the Centers for Medicare and Medicaid Services no longer reimburse for extra care necessary for treatment of mediastinitis after cardiac surgery, because this is now deemed a never event. Thus, surgeons, who are increasingly employed by hospitals and hospital systems, are under intense pressure to perform CABG surgery that is safe and cost-effective according to short-term metrics. Any perceived tradeoff, however small or misinformed, between the long-term benefit of BITA grafting and short-term risk of mediastinitis, …