Bilateral Internal Thoracic Artery and Optimal Revascularization Strategy in Insulin-Dependent Diabetic Patients

Brazilian Journal of Cardiovascular Surgery Coronary artery disease (CAD) is a leading cause of mortality and morbidity in diabetic patients. Four among 10 patients undergoing coronary artery bypass graft surgery (CABG) are diabetic in the United States . Furthermore, insulindependent diabetics undergoing CABG reaches 20% in São Paulo Registry of Cardiovascular Surgery (REPLICCAR) . Currently, there is a progressive increase in the prevalence of diabetes in patients referred for CABG. This is mainly in response to FREDOOM trial that showed that diabetic patients have a higher survival rate when they undergo surgical myocardial revascularization. Over time, one of the reasons that made the CABG overlap percutaneous techniques was the anastomosis of the internal thoracic artery (ITA) on the left anterior descending artery. Long-term benefits would be related to higher patency of the ITA graft compared to the saphenous vein graft. Later studies in large databases were able to show that the use of bilateral internal thoracic artery (BITA) increased further patient survival. In this respect, only one prospective and randomized study showed no difference in one year and awaited long term outcomes. Therefore, which could make us desist from using BITA? Demand for technical dissection of BITA and risk of deep sternal infection especially in diabetic patients would be the most frequent reasons. Gatti et al. showed that even in insulindependent diabetic patient advantagens with BITA is over. This means that the longer survival achieved with BITA is not affected by a higher incidence of deep sternal wound infection (DSWI) in the short term. In order to justify the risk of this complication, patients should have a life expectancy of >10 years. Therefore, they are contraindicated for the most part of the time in diabetic individuals. CABG to insulin-dependent diabetic patient comprises various quality parameters. This begins with the classification in controlled and uncontrolled diabetics by glycosylated hemoglobin (HbA1c). It has been demonstrated that poorly controlled diabetes patients EDITORIAL