Skeletonized <i>versus</i> pedicled harvesting of bilateral internal mammary artery in coronary artery bypass graft: A case control study _Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

ZHONG Zhaoji , HOU Jianfeng , FAN Hongguang , LI Haojie , XIE Yanbo ,  WANG Xiaoqi , ZHENG Zhe , GAO Ge

Department of Cardiovascular Surgery, Fuwai Hospital, Chinese Academy of Medical Science, Beijing, 100037, P.R.China;

Corresponding?author：

WANG Xiaoqi, Email: wxqfwn@163.com

Keywords：

Coronary artery bypass graft; internal mammary artery; skeletonized harvesting

DOI：

10.7507/1007-4848.201707035

Video：

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Objective To evaluate the safety and efficacy of skeletonized and pedicled harvesting of bilateral internal mammary artery (BIMA) in coronary artery bypass graft (CABG) surgery. Methods From December 2015 to May 2017, 152 patients (128 males, 24 females, age of 56.5±6.8 years) underwent CABG using either skeletonized BIMA (s-BIMA group, n=73) or pedicled BIMA(p-BIMA group, n=79). The operative data and post-operative outcomes were analyzed in the s-BIMA group (61 males, 12 females, age of 56.6±7.0 years) and the p-BIMA group (67 males, 12 females, age of 56.3±6.7 years). Results There was no peri-operative mortality. There was no statistical difference in operative time, cardiopulmonary bypass time, aortic cross-clamp time or internal mammary artery graft flow between the two groups. One patient(1.4%) in the s-BIMA group suffered from severe sternal wound complication, which was major sternal wound complication. Five patients (6.3%) in the p-BIMA group suffered from sternal wound complications, including 1(1.3%) with severe complication and 4(5.1%) with minor complication. One(1.4%) patient in the s-BIMA group and 7 (8.9%) patients in the p-BIMA group suffered from chylothorax. The chest tube drainage significantly reduced in the s-BIMA group, both in postoperative day 1(P=0.000) and postoperative day 1-3 (P=0.001). CT angiography showed no stenosis of BIMA in both groups. Conclusion The use of skeletonized BIMA for CABG is safe and efficacious, with less sternal wound complications, chylothorax and chest tube drainage. Skeletonization should be suggested if BIMA is harvested in CABG.

Citation： ZHONG Zhaoji, HOU Jianfeng, FAN Hongguang, LI Haojie, XIE Yanbo, WANG Xiaoqi, ZHENG Zhe, GAO Ge. Skeletonized versus pedicled harvesting of bilateral internal mammary artery in coronary artery bypass graft: A case control study . Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2018, 25(2): 128-132. doi: 10.7507/1007-4848.201707035 Copy

1.	Lytle BW. Bilateral internal thoracic artery grafting. Ann Cardiothorac Surg, 2013, 2(4): 485-492.
2.	Lytle BW, Blackstone EH, Sabik JF, et al. The effect of bilateral internal thoracic artery grafting on survival during 20 postoperative years. Ann Thorac Surg, 2004, 78(6): 2005-2014.
3.	Kurlansky PA, Traad EA, Dorman MJ, et al. Thirty-year follow-up defines survival benefit for second internal mammary artery in propensity-matched groups. Ann Thorac Surg, 2010, 90(1): 101-108.
4.	Weiss AJ, Zhao S, Tian DH, et al. A meta-analysis comparing bilateral internal mammary artery with left internal mammary artery for coronary artery bypass grafting. Ann Cardiothorac Surg, 2013, 2(4): 390-400.
5.	Shi WY, Hayward PA, Tatoulis J, et al. Are all forms of total arterial revascularization equal? A comparison of single versus bilateral internal thoracic artery grafting strategies. J Thorac Cardiovasc Surg, 2015, 150(6): 1526-1534.
6.	Di Mauro M, Iaco AL, Allam A, et al. Bilateral internal mammary artery grafting: in situ versus Y-graft. Similar 20-year outcome. Eur J Cardiothorac Surg, 2016, 50(4): 729-734.
7.	暢怡, 王小啟, 鄭哲, 等. 使用雙側乳內動脈行冠狀動脈旁路移植術早期結果分析. 中國胸心血管外科臨床雜志, 2017, 24(3): 206-210.
8.	Athanasiou T, Crossman MC, Asimakopoulos G, et al. Should the internal thoracic artery be skeletonized?. Ann Thorac Surg, 2004, 77(6): 2238-2246.
9.	Raja SG, Dreyfus GD. Internal thoracic artery: to skeletonize or not to skeletonize?. Ann Thorac Surg, 2005, 79(5): 1805-1811.
10.	Keeley SB. The skeletonized internal mammary artery. Ann Thorac Surg, 1987, 44(3): 324-325.
11.	Kamiya H, Akhyari P, Martens A, et al. Sternal microcirculation after skeletonized versus pedicled harvesting of the internal thoracic artery: a randomized study. J Thorac Cardiovasc Surg, 2008, 135(1): 32-37.
12.	Onorati F, Esposito A, Pezzo F, et al. Hospital outcome analysis after different techniques of left internal mammary grafts harvesting. Ann Thorac Surg, 2007, 84(6): 1912-1919.
13.	張爾永, 石應康, 蒙煒, 等. 骨骼化乳內動脈在冠狀動脈旁路移植術中的應用. 中國胸心血管外科臨床雜志, 2007, 14(6): 415-417.
14.	房勤, 谷天祥, 劉波, 等. 冠狀動脈旁路移植術中應用骨骼化與帶蒂左乳內動脈的隨機對照試驗. 中國胸心血管外科臨床雜志, 2015, 22(4): 332-336.
15.	Sun X, Huang J, Wang W, et al. Off-pump skeletonized versus pedicled left internal mammary artery grafting: mid-term results. J Card Surg, 2015, 30(6): 494-499.
16.	Peterson MD, Borger MA, Rao V, et al. Skeletonization of bilateral internal thoracic artery grafts lowers the risk of sternal infection in patients with diabetes. J Thorac Cardiovasc Surg, 2003, 126(5): 1314-1319.
17.	Boodhwani M, Lam BK, Nathan HJ, et al. Skeletonized internal thoracic artery harvest reduces pain and dysesthesia and improves sternal perfusion after coronary artery bypass surgery: a randomized, double-blind, within-patient comparison. Circulation, 2006, 114(8): 766-773.
18.	Sajja LR, Mannam G, Dandu SB, et al. Reduction of sternal wound infections in diabetic patients undergoing off-pump coronary artery bypass surgery and using modified pedicle bilateral internal thoracic artery harvest technique. J Thorac Cardiovasc Surg, 2012, 144(2): 480-485.
19.	Dai C, Lu Z, Zhu H, et al. Bilateral internal mammary artery grafting and risk of sternal wound infection: evidence from observational studies. Ann Thorac Surg, 2013, 95(6): 1938-1945.
20.	Deo SV, Shah IK, Dunlay SM, et al. Bilateral internal thoracic artery harvest and deep sternal wound infection in diabetic patients. Ann Thorac Surg, 2013, 95(3): 862-869.
21.	Sa MP, Ferraz PE, Escobar RR, et al. Skeletonized versus pedicled internal thoracic artery and risk of sternal wound infection after coronary bypass surgery: meta-analysis and meta-regression of 4817 patients. Interact Cardiovasc Thorac Surg, 2013, 16(6): 849-857.
22.	Sa MP, Cavalcanti PE, de Andrade CSH, et al. Skeletonized versus pedicled bilateral internal mammary artery grafting: outcomes and concerns analyzed through a meta-analytical approach. Int J Surg, 2015, 16(Pt B): 146-152.
23.	Benedetto U, Altman DG, Gerry S, et al. Pedicled and skeletonized single and bilateral internal thoracic artery grafts and the incidence of sternal wound complications: Insights from the arterial revascularization trial. J Thorac Cardiovasc Surg, 2016, 152(1): 270-276.
24.	Deutsch O, Gansera L, Wunderlich M, et al. Does bilateral ita grafting increase perioperative complications? outcome of 6,476 patients with bilateral versus 5,020 patients with single ita bypass. Thorac Cardiovasc Surg, 2016, 64(3): 188-194.
25.	Hillis LD, Smith PK, Anderson JL, et al. 2011 ACCF/AHA guideline for coronary artery bypass graft surgery: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation, 2011, 124(23): e652-e735.
26.	Kolh P, Windecker S, Alfonso F, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: the task force on myocardial revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur J Cardiothorac Surg, 2014, 46(4): 517-592.
27.	Aldea GS, Bakaeen FG, Pal J, et al. The Society of Thoracic Surgeons Clinical Practice Guidelines on arterial conduits for coronary artery bypass grafting. Ann Thorac Surg, 2016, 101(2): 801-809.
28.	Toumpoulis IK, Anagnostopoulos CE, Derose JJ, et al. The impact of deep sternal wound infection on long-term survival after coronary artery bypass grafting. Chest, 2005, 27(2): 464-471.
29.	Gatti G, Soso P, Dell'Angela L, et al. Routine use of bilateral internal thoracic artery grafts for left-sided myocardial revascularization in insulin-dependent diabetic patients: early and long-term outcomes. Eur J Cardiothorac Surg, 2015, 48(1): 115-120.
30.	Hashimoto M, Fukui T, Takanashi S. Bilateral Internal Thoracic Artery Grafting: Is It Reasonable in Octogenarians?. Ann Thorac Cardiovasc Surg, 2015, 21(5): 452-458.
31.	Gatti G, Maschietto L, Morosin M, et al. Routine use of bilateral internal thoracic artery grafting in women: A risk factor analysis for poor outcomes. Cardiovasc Revasc Med, 2017, 18(1): 40-46.
32.	孫宏濤, 孫立忠, 閻軍, 等. 經胸骨正中切口心臟手術后并發乳糜胸的治療. 中國胸心血管外科臨床雜志, 2010, 17(2): 163-164.

1. Lytle BW. Bilateral internal thoracic artery grafting. Ann Cardiothorac Surg, 2013, 2(4): 485-492.
2. Lytle BW, Blackstone EH, Sabik JF, et al. The effect of bilateral internal thoracic artery grafting on survival during 20 postoperative years. Ann Thorac Surg, 2004, 78(6): 2005-2014.
3. Kurlansky PA, Traad EA, Dorman MJ, et al. Thirty-year follow-up defines survival benefit for second internal mammary artery in propensity-matched groups. Ann Thorac Surg, 2010, 90(1): 101-108.
4. Weiss AJ, Zhao S, Tian DH, et al. A meta-analysis comparing bilateral internal mammary artery with left internal mammary artery for coronary artery bypass grafting. Ann Cardiothorac Surg, 2013, 2(4): 390-400.
5. Shi WY, Hayward PA, Tatoulis J, et al. Are all forms of total arterial revascularization equal? A comparison of single versus bilateral internal thoracic artery grafting strategies. J Thorac Cardiovasc Surg, 2015, 150(6): 1526-1534.
6. Di Mauro M, Iaco AL, Allam A, et al. Bilateral internal mammary artery grafting: in situ versus Y-graft. Similar 20-year outcome. Eur J Cardiothorac Surg, 2016, 50(4): 729-734.
7. 暢怡, 王小啟, 鄭哲, 等. 使用雙側乳內動脈行冠狀動脈旁路移植術早期結果分析. 中國胸心血管外科臨床雜志, 2017, 24(3): 206-210.
8. Athanasiou T, Crossman MC, Asimakopoulos G, et al. Should the internal thoracic artery be skeletonized?. Ann Thorac Surg, 2004, 77(6): 2238-2246.
9. Raja SG, Dreyfus GD. Internal thoracic artery: to skeletonize or not to skeletonize?. Ann Thorac Surg, 2005, 79(5): 1805-1811.
10. Keeley SB. The skeletonized internal mammary artery. Ann Thorac Surg, 1987, 44(3): 324-325.
11. Kamiya H, Akhyari P, Martens A, et al. Sternal microcirculation after skeletonized versus pedicled harvesting of the internal thoracic artery: a randomized study. J Thorac Cardiovasc Surg, 2008, 135(1): 32-37.
12. Onorati F, Esposito A, Pezzo F, et al. Hospital outcome analysis after different techniques of left internal mammary grafts harvesting. Ann Thorac Surg, 2007, 84(6): 1912-1919.
13. 張爾永, 石應康, 蒙煒, 等. 骨骼化乳內動脈在冠狀動脈旁路移植術中的應用. 中國胸心血管外科臨床雜志, 2007, 14(6): 415-417.
14. 房勤, 谷天祥, 劉波, 等. 冠狀動脈旁路移植術中應用骨骼化與帶蒂左乳內動脈的隨機對照試驗. 中國胸心血管外科臨床雜志, 2015, 22(4): 332-336.
15. Sun X, Huang J, Wang W, et al. Off-pump skeletonized versus pedicled left internal mammary artery grafting: mid-term results. J Card Surg, 2015, 30(6): 494-499.
16. Peterson MD, Borger MA, Rao V, et al. Skeletonization of bilateral internal thoracic artery grafts lowers the risk of sternal infection in patients with diabetes. J Thorac Cardiovasc Surg, 2003, 126(5): 1314-1319.
17. Boodhwani M, Lam BK, Nathan HJ, et al. Skeletonized internal thoracic artery harvest reduces pain and dysesthesia and improves sternal perfusion after coronary artery bypass surgery: a randomized, double-blind, within-patient comparison. Circulation, 2006, 114(8): 766-773.
18. Sajja LR, Mannam G, Dandu SB, et al. Reduction of sternal wound infections in diabetic patients undergoing off-pump coronary artery bypass surgery and using modified pedicle bilateral internal thoracic artery harvest technique. J Thorac Cardiovasc Surg, 2012, 144(2): 480-485.
19. Dai C, Lu Z, Zhu H, et al. Bilateral internal mammary artery grafting and risk of sternal wound infection: evidence from observational studies. Ann Thorac Surg, 2013, 95(6): 1938-1945.
20. Deo SV, Shah IK, Dunlay SM, et al. Bilateral internal thoracic artery harvest and deep sternal wound infection in diabetic patients. Ann Thorac Surg, 2013, 95(3): 862-869.
21. Sa MP, Ferraz PE, Escobar RR, et al. Skeletonized versus pedicled internal thoracic artery and risk of sternal wound infection after coronary bypass surgery: meta-analysis and meta-regression of 4817 patients. Interact Cardiovasc Thorac Surg, 2013, 16(6): 849-857.
22. Sa MP, Cavalcanti PE, de Andrade CSH, et al. Skeletonized versus pedicled bilateral internal mammary artery grafting: outcomes and concerns analyzed through a meta-analytical approach. Int J Surg, 2015, 16(Pt B): 146-152.
23. Benedetto U, Altman DG, Gerry S, et al. Pedicled and skeletonized single and bilateral internal thoracic artery grafts and the incidence of sternal wound complications: Insights from the arterial revascularization trial. J Thorac Cardiovasc Surg, 2016, 152(1): 270-276.
24. Deutsch O, Gansera L, Wunderlich M, et al. Does bilateral ita grafting increase perioperative complications? outcome of 6,476 patients with bilateral versus 5,020 patients with single ita bypass. Thorac Cardiovasc Surg, 2016, 64(3): 188-194.
25. Hillis LD, Smith PK, Anderson JL, et al. 2011 ACCF/AHA guideline for coronary artery bypass graft surgery: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation, 2011, 124(23): e652-e735.
26. Kolh P, Windecker S, Alfonso F, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: the task force on myocardial revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur J Cardiothorac Surg, 2014, 46(4): 517-592.
27. Aldea GS, Bakaeen FG, Pal J, et al. The Society of Thoracic Surgeons Clinical Practice Guidelines on arterial conduits for coronary artery bypass grafting. Ann Thorac Surg, 2016, 101(2): 801-809.
28. Toumpoulis IK, Anagnostopoulos CE, Derose JJ, et al. The impact of deep sternal wound infection on long-term survival after coronary artery bypass grafting. Chest, 2005, 27(2): 464-471.
29. Gatti G, Soso P, Dell'Angela L, et al. Routine use of bilateral internal thoracic artery grafts for left-sided myocardial revascularization in insulin-dependent diabetic patients: early and long-term outcomes. Eur J Cardiothorac Surg, 2015, 48(1): 115-120.
30. Hashimoto M, Fukui T, Takanashi S. Bilateral Internal Thoracic Artery Grafting: Is It Reasonable in Octogenarians?. Ann Thorac Cardiovasc Surg, 2015, 21(5): 452-458.
31. Gatti G, Maschietto L, Morosin M, et al. Routine use of bilateral internal thoracic artery grafting in women: A risk factor analysis for poor outcomes. Cardiovasc Revasc Med, 2017, 18(1): 40-46.
32. 孫宏濤, 孫立忠, 閻軍, 等. 經胸骨正中切口心臟手術后并發乳糜胸的治療. 中國胸心血管外科臨床雜志, 2010, 17(2): 163-164.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Skeletonized versus pedicled harvesting of bilateral internal mammary artery in coronary artery bypass graft: A case control study

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