What are the best graft options for a diabetic patient with peripheral vascular disease (PVD) undergoing open heart surgery, considering poor circulation in the legs?

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Optimal Graft Selection for Diabetic Patients with Peripheral Vascular Disease Undergoing CABG

For your diabetic patient with peripheral vascular disease requiring coronary artery bypass surgery, the surgical team should prioritize bilateral internal thoracic artery (BITA) grafting or single internal thoracic artery (ITA) plus radial artery grafting, avoiding leg vein harvest entirely given the compromised lower extremity circulation.

Primary Graft Conduit Hierarchy

First-Line: Internal Thoracic Arteries

  • The left internal thoracic artery (LITA) to the left anterior descending artery is mandatory and provides superior long-term patency compared to any other conduit, with particular benefit in diabetic patients 1, 2.
  • Bilateral internal thoracic artery grafting significantly improves survival and reduces coronary reoperation in diabetic patients compared to single ITA plus saphenous vein grafts (10-year survival 80% vs 68%, hazard ratio 0.72) 1.
  • BITA grafting does not increase deep sternal wound infection risk beyond acceptable levels in diabetic patients when skeletonized harvesting technique is used (3.1% BITA vs 3.9% single ITA) 3.

Second-Line: Radial Artery

  • If BITA is not feasible, single ITA plus radial artery grafting yields equivalent outcomes to BITA in diabetic patients, with similar in-hospital mortality (0.35% vs 0.35%) and comparable 14-year survival (58% vs 64%, p=0.2) 4.
  • The radial artery provides superior long-term patency compared to saphenous vein grafts and should be the preferred second conduit when BITA cannot be performed 4, 5.

Avoid: Leg Vein Harvest in PVD Patients

  • Saphenous vein harvest from legs with poor circulation risks wound complications, delayed healing, and potential limb-threatening ischemia in patients with existing peripheral vascular disease 6.
  • Alternative vein sources if arterial conduits are exhausted include: lesser saphenous vein, contralateral greater saphenous vein (if that leg has adequate circulation), or arm veins 6.

Specific Surgical Request Algorithm

Request to Cardiac Surgery Team:

  1. Primary strategy: BITA grafting using skeletonized harvesting technique to minimize sternal infection risk while maximizing long-term survival benefit 1, 2, 3.

  2. Alternative strategy if BITA contraindicated: Single LITA plus radial artery grafting, which provides equivalent outcomes without requiring leg vein harvest 4.

  3. Only if both ITAs and radial artery are unsuitable: Consider arm veins or lesser saphenous vein from the leg with better circulation, but explicitly request the surgical team avoid harvesting from the leg with documented poor circulation 6.

Evidence Supporting Arterial Grafting in Diabetic Patients

Survival Benefit

  • BITA grafting reduces long-term mortality risk by 28% (HR 0.72) and coronary reoperation by 62% (HR 0.38) in diabetic patients compared to single ITA plus vein grafts 1.
  • Even insulin-dependent diabetic patients benefit from BITA grafting, with improved cardiac event-free survival (69% vs 23% at 6 years, p<0.0001) and reduced return of angina (4% vs 20%, p=0.025) 2.

Infection Risk Mitigation

  • Modern skeletonized BITA harvesting technique maintains acceptable sternal infection rates (1.4-4%) even in diabetic patients, comparable to single ITA grafting 4, 2, 3.
  • The long-term survival advantage of BITA grafting substantially outweighs the minimal incremental infection risk 3.

Critical Pitfalls to Avoid

  • Do not automatically default to single ITA plus vein grafts in diabetic patients based on outdated concerns about sternal infection—contemporary evidence demonstrates BITA safety and superior outcomes 1, 3.
  • Do not harvest saphenous vein from legs with documented peripheral vascular disease without first confirming adequate circulation and discussing alternative conduit strategies 6.
  • Do not accept "complete arterial revascularization is too risky" as justification for inferior conduit selection—the evidence shows arterial grafting is both safe and superior in diabetic patients 1, 4, 2.

Practical Communication with Surgical Team

Explicitly state in your consultation request: "Patient has documented peripheral vascular disease with poor lower extremity circulation. Request BITA grafting with skeletonized harvesting technique as first-line strategy, or single LITA plus radial artery if BITA not feasible. Please avoid saphenous vein harvest from legs given compromised circulation. If additional conduits required beyond arterial grafts, consider arm veins or alternative sources."

This approach maximizes long-term cardiac outcomes while protecting already compromised lower extremity circulation 1, 4, 2, 3.

References

1
Research

Influence of diabetes and bilateral internal thoracic artery grafts on long-term outcome for multivessel coronary artery bypass grafting.

European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery, 2005

6
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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