1. Department of cardiovascular surgery Kumamoto Central Hospital Taro Nakatsu, Nobushige Tamura, Takuya Nomoto, Koji Hagio, Masanosuke Ishigami, Shouichi Kyo

2. Bilateral internal thoracic artery (BITA) grafting is known to improve the long-term survival after coronary artery bypass grafting (CABG). However, there are few reports regarding the efficacy of BITA grafting in end-stage renal disease (ESRD) patients.

3. 1988.10 ~ 2009. 8 154 ESRD patients underwent CABG. 130 patients had CABG with ITAs. SITA 81 patients BITA 49 patients Operation Arrest90 patients VF9 patients On Pump Beating12 patients OPCAB19 patients

4. Follow up duration 5.2±3.8 years 83 patients (63.8%) : Dead Survival Cardiac death Hospital death Cardiogenic death Sudden death Cardiac event Cardiac death Myocardial infarction Reccurent angina Repeated CABGs Repeated PCIs

5. Characteristic SITA (n = 81) BITA (n = 49) P value Age63.8±8.663.7±7.4NS Male 64 (79.0%) 41 (83.7%) NS HT 70 (86.4%) 40 (81.6%) NS HL 23 (28.4%) 20 (40.8%) NS DM 49 (60.5%) 20 (40.8%) 0.0294 Insulin 27 (33.3%) 11 (22.4%) NS CVD 14 (17.3%) 9 (18.4%) NS PVD 22 (27.2%) 10 (20.4%) NS OMI 28 (34.6%) 15 (30.6%) NS Characteristic SITA (n = 81) BITA (n = 49) P value Obesity (BMI>26) 7 (8.6%) 5 (10.2%) NS HD duration5.8±5.09.1±7.2 0.0068 EF64±1465±14NS LMT disease 24 (29.6%) 21 (42.9%) NS 3VD 55 (67.9%) 38 (77.6%) NS 2VD 22 (27.2%) 7 (14.3%) NS 1VD 4 (4.9%) 0NS

6. Variable LITARITA SITA LAD 73 (90%)3 (3.7%) Diag or HL 1 (1.2%)- LCx 4 (4.9%)- BITA LAD 36 (73%)11(22%) Diag or HL 2 (4.1%)6(12%) LCx 11 (22%)32 (65%)

7. SITABITAP value n14145 SVG98.6%93.3%0.0581 n1617 GEA93.8%100%0.2952 n343 RITA100% 1 n6943 LITA98.6%100%0.3974

8. SITA (n = 81) BITA (n = 49) P value Emergent case11(13.5%)1(2.0%)0.0276 Anastomosis3.1±1.13.5±1.00.0433 Use of GEA16 (19.8%) 19 （ 38.8%) 0.0178 Off pump9 (11.1%)10(20.4%)0.1459 Operation time310±67368±71<0.0001 CPB time133±42120±310.083 Cross-clamp time85±2775±280.0934

9. SITA (n = 81) BITA (n = 49) P value In hospital Mortality4 (4.9%)2(4.1%)0.8215 Rethoracotomy1 (1.1%)1 (2.0%)0.7174 Mediastinitis2 (2.5%)2(4.1%)0.605 Perioperative myocardial infarction 4 (4.9%)00.1141 Stroke1 (1.1%)2(4.1%)0.2948 Intestinal complication4 (4.9%)1 (2.0%)0.4051 Multiple organ failure2 (2.5%)2(4.1%)0.605

10. survival Time(years) No. at risk SITA77645334151162 BITA4730242014700 0246810121416 BITA SITA P = 0.1636 0 20% 40% 60% 80% 100% 3 years5 years7 years10 years SITA79.6%62.5%43.6%22.6% BITA76.0%61.9%58.8%33.2%

11. No. at risk SITA77645334151162 BITA4730242014700 0 20% 40% 60% 80% 100% 0246810121416 BITA SITA Time(years) Cumulative Freedom from Cardiac death P = 0.3205 3 years5 years7 years10 years SITA87.1 %80.6%70.7%43.4% BITA85.1%75.3% 60.8%

12. No. at risk SITA77564125863 BITA472719141140 0 20% 40% 60% 80% 100% 02468101214 Time(years) Cumulative Freedom from Cardiac event BITA SITA P = 0.4071 3 years5 years7 years10 years SITA73.9%64.2%51.1%24.6% BITA77.7%60.9%49.6%39.1%

13. DM patients 69 patients (SITA 49 patients, BITA 20 patients) Non DM patients 61 patients (SITA 32 patients, BITA 29 patients)

14. Characteristic SITA (n = 49) BITA (n = 20) P value Age64.4±8.863.6±7.0NS Male 38 (77.6%) 15 (75.0%) NS HT 13 (26.5%) 8 (40.0%) NS HL 23 (28.4%) 20 (40.8%) NS Insulin 27 (55.1%) 11 (55.0%) NS Hb A1c6.9±1.16.4±0.87NS CVD 10 (20.4%) 3 (15.0%) NS PVD 18 (36.7%) 7 (35.0%) NS OMI 18 (36.7%) 4 (20.0%) NS Characteristic SITA (n = 49) BITA (n = 20) P value Obesity (BMI>26) 6 (12.2%) 1 (5.0%) NS HD duration4.5±3.96.1±4.7 NS EF65±1464±15NS LMT disease 15 (30.6%) 10 (50.0%) NS 3VD 36 (73.5%) 14 (70.0%) NS 2VD 9 (27.2%) 6 (30.0%) NS 1VD 2 (4.1%) 0NS

15. 0246810121416 No. at risk SITA493831168531 BITA2010864100 P = 0.8449 BITA SITA years survival 0 20% 40% 60% 80% 100% 3 years5 years7 years10 years SITA82.4%63.8%45.9%17.9% BITA82.5%56.6% 9.4%

16. No. at risk SITA493831168531 BITA2010864100 P = 0.6366 BITA SITA 0246810121416 years Cumulative Freedom from Cardiac Death 20% 40% 60% 80% 100% 0 3 years5 years7 years10 years SITA93.3%87.1%72.0%42.3% BITA86.8%77.2% 34.3%

17. No. at risk SITA493528146420 BITA207533000 P = 0.0899 BITA SITA years Cumulative Freedom from Cardiac Event 20% 40% 60% 80% 100% 0 02468101214 3 years5 years7 years10 years SITA85.1%79.1%68.4%35.3% BITA62.9%52.4%39.3%0

18. Characteristic SITA (n = 32) BITA (n = 29) P value Age62.8±8.563.7±7.8NS Male 26 (81.3%) 26 (89.7%) NS HT 27 (84.4%) 24 (82.8%) NS HL 10 (31.3%) 12 (41.4%) NS CVD 4 (12.5%) 6 (20.7%) NS PVD 4 (12.5%) 3 (10.3%) NS OMI 10 (31.3%) 11 (37.9%) NS Characteristic SITA (n = 32) BITA (n = 29) P value Obesity (BMI>26) 1 (3.1%) 4 (13.8%) NS HD duration7.7±5.711.1±8.0 NS EF62±1465±14NS LMT disease 9 (28.1%) 11 (37.9%) NS 3VD 18 (56.3%) 23 (79.3%) 0.0554 2VD 11 (34.3%) 5 (17.2%) NS 1VD 1 (3.1%) 0NS

19. No. at risk SITA292522187631 BITA2720161410600 0 20% 40% 60% 80% 100% 0246810121416 P = 0.0889 BITA SITA years survival 3 years5 years7 years10 years SITA75.0%59.4%40.4%28.3% BITA73.1%64.5%59.9%47.9%

20. 0246810121416 P = 0.0895 BITA SITA No. at risk SITA292522187631 BITA2720161410600 years Cumulative Freedom from Cardiac Death 20% 40% 60% 80% 100% 0 3 years5 years7 years10 years SITA77.7%70.9%61.8%43.3% BITA84.2%74.3%

21. 02468101214 BITA SITA P = 0.0075 No. at risk SITA292115112210 BITA272014118400 20% 40% 60% 80% 100% 0 Time(years) Cumulative Freedom from Cardiac event 3 years5 years7 years10 years SITA58.4%44.7%35.5%11.8% BITA84.0%64.2%53.4%

22. Bilateral internal thoracic artery grafting produces improved survival compared with single internal thoracic artery grafting during the second postoperative decade.

23. ESRD patients with diabetes mellitus have a increased risk of death 10 years survival BITA:17.9% SITA: 9.4%. Therefore, BITA grafting might confer few advantages for long term survivals.

24. After a long-term follow-up, CABG with BITA grafts showed no advantages in the long-term outcomes among ESRD patients. For ESRD patients without diabetes mellitus, BITA grafting may provide more promising long-term freedom from cardiac events ratio.