Are two really always better than one? Results, concerns and controversies in the use of bilateral internal thoracic arteries for coronary artery bypass grafting in the elderly: A systematic review and meta-analysis

•Data discussing benefit of bilateral internal thoracic artery grafting in elderly is limited.•These patients are at higher risk of deep sternal wound infection.•It is unclear whether this technique improves long-term survival in the elderly patient cohort.

IntroductionBilateral internal thoracic artery grafting appears to be the preferred method to achieve durable long-term coronary artery revascularization. However, data reporting the benefit of this technique in the elderly is very conflicting.MethodWe performed a systematic review of available literature (till November 2014) using multiple databases to identify studies comparing clinical events in patients undergoing coronary artery bypass grafting using either a single or double internal thoracic artery in the elderly. While early mortality was the primary end-point of inclusion, other adverse events compared were sternal wound infection (deep and superficial), stroke and peri-operative myocardial infarction. Individual and pooled odd's ratios were calculated using the Mantel–Haenzel method (random effect model); sensitivity analysis was performed. Results are presented using 95% confidence intervals.ResultNine retrospective studies (4479 BITA, 7733 LITA patients) fulfilled search criteria. Deep sternal wound infection was significantly higher after BITA harvest [OR 1.86 (1.3–2.5); I2 = 0%; p < 0.01]. Early mortality (BITA 3.6% vs SITA 3.1%; p = 0.86), stroke [OR 0.7(0.4–1.1); p = 0.1], and peri-operative myocardial infarction (BITA 4.3% vs SITA 2.3%; p = 0.1) were comparable in both cohorts. Long-term survival favored the BITA cohort in two propensity matched studies.ConclusionThe incidence of deep sternal wound infection may be significantly higher after the harvest of both internal thoracic arteries in the elderly. While other post-operative adverse events are comparable, data regarding the long-term survival advantage in this cohort is conflicting. Hence, the use of both internal thoracic arteries in this age group needs to be invidualized.