Coronary revascularization with a bilateral internal thoracic artery (ITA) approach was found to increase the risk for post-operative acute lower limb ischemia in patients with peripheral artery disease, according to a retrospective analysis published in the Journal of Cardiothoracic Surgery.

The data of 1961 patients with peripheral artery disease who underwent isolated coronary artery bypass grafting between 1997 and 2019 were examined. Patients were assessed for occurrence of ischemia of the lower limbs, 30-day mortality, cardiac death, stroke, and acute kidney disease. Coronary artery bypass surgery was conducted with a left ITA approach in 1768 patients and a bilateral ITA approach in 193 patients. Due to imbalance, propensity score matching was applied.

Before propensity matching, the highest standard effect size differences between the 2 groups were for 2-vessel disease (effect size, -0.17), 3-vessel disease (effect size, 0.13), previous percutaneous transluminal coronary angioplasty (effect size, 0.11), history of stroke (effect size, -0.11), dialysis (effect size, 0.11), left ventricular ejection fraction (effect size, 0.1), and carotid stenosis >50% (effect size, 0.1).

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Prior to weighting, lower limb ischemia was observed in 34.7% of patients undergoing bilateral ITA and in 19.3% of patients undergoing left ITA grafting (P <.001). Sternal wound infections occurred in 17% and 2.0% of patients undergoing bilateral and left ITA, respectively (P <.001).

After weighting, acute lower limb ischemia was 14% higher among those who received bilateral vs left ITA (95% CI, 7.0%-22.0%; P <.001).

Occurrences of cardiac death (1.4%; 95% CI, -0.9% to 3.7%; P =.23), all-cause mortality (1.3%; 95% CI, -1.6% to 4.2%; P =.37), postoperative acute kidney disease (1.4%; 95% CI, -3.0% to 6.0%; P =.57), and stroke (-0.3%; 95% CI, -3.7% to 2.9%; P =.81) were comparable in patients receiving bilateral or left ITA.

A major study limitation was the absence of stratification based on peripheral artery disease type.

“The usage of both ITAs increased the development of [acute lower limb ischemia] in patients with [peripheral artery disease],” noted the study authors. “Additional prospective trials are necessary in order to confirm our findings.”


Micali L R, Bonacchi M, Weigel D, et al. The use of both internal thoracic arteries for coronary revascularization increases the estimate of post-operative lower limb ischemia in patients with peripheral artery disease. J Cardiothorac Surg. 2020;15(1):266. doi:10.1186/s13019-020-01315-8