Surgical Outcomes of in situ Internal Thoracic Artery Grafting in Patients with Ipsilateral Upper-Extremity Arteriovenous Fistulas

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OBJECTIVES: The use of in situ internal thoracic artery (ITA) grafts ipsilateral to upper extremity arterio-venous fistulas (UE-AVFs) during coronary artery bypass grafting (CABG) in dialysis-dependent patients raises concerns of coronary steal and compromised graft perfusion. However, the clinical significance of ITA-AVF laterality remains uncertain. METHODS: We retrospectively analysed dialysis-dependent patients who underwent CABG between February 2015 and December 2023 at 2 institutions. Patients with non-UE-AVF access, total vein grafting, or composite vein-artery configurations were excluded. The final cohort (N = 122) was divided into 2 groups: ipsilateral in situ ITA grafts (N = 66) and contralateral in situ or free ITA grafts (N = 56). The primary outcome was the incidence of major adverse cardiovascular and cerebrovascular events (MACCE); secondary outcomes included perioperative complications, haemodialysis-induced ischaemia, and 3-year survival. RESULTS: Baseline and operative characteristics were largely comparable between groups. Perioperative outcomes, including surgical site infection, 30-day mortality, and prolonged ventilation, showed no significant differences. Over a median follow-up of 2.4 years, MACCE occurred in 44% of patients (39% ipsilateral vs 50% contralateral/free ITA; P = .24), with no significant differences in 3-year mortality (29% vs 21%; P = .352). Multivariable analyses showed no association between ITA-AVF laterality and MACCE (adjusted odds ratio 0.68, P = .31) or 3-year mortality (adjusted hazard ratio 1.56, P = .291). CONCLUSIONS: In this modestly sized retrospective cohort, ipsilateral in situ ITA grafting was not associated with significantly worse perioperative or long-term outcomes. Our findings should be interpreted as hypothesis-generating, and larger multicentre studies are needed to more definitively evaluate the safety of this grafting strategy in dialysis-dependent patients with UE-AVFs.

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