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• W2000349594 abstract "The internal thoracic artery has been the most reliable graft material used in coronary artery bypass grafting with an excellent long-term patency rate. Complete myocardial revascularization with internal thoracic arteries improves long-term survival and decreases the rate of repeat operations compared with vein grafts. Adequate length of the graft in coronary artery bypass graft surgery is essential for providing complete arterial revascularization. In the last decade or so, technique of skeletonization of internal thoracic artery has been proposed to achieve extra length. Skeletonization of the internal thoracic artery allows the preparation of longer conduits with a superior free flow and can reduce the incidence of postoperative pulmonary and sternal complications. However, concerns about vasoreactivity of skeletonized internal thoracic artery grafts, the functional consequences of surgical trauma, the possible loss of innervation, and vasa vasorum perfusion in the skeletonized conduits have prevented this technique from being universally accepted. Presently available evidence from retrospective studies (level 3 evidence) suggests that skeletonization is a safe and effective technique for myocardial revascularization. However, there is a need for conducting multicenter, randomized controlled trials comparing the skeletonized and pedicled internal thoracic arteries with special emphasis on long-term patency to conclusively validate the safety and efficacy of skeletonization technique. The internal thoracic artery has been the most reliable graft material used in coronary artery bypass grafting with an excellent long-term patency rate. Complete myocardial revascularization with internal thoracic arteries improves long-term survival and decreases the rate of repeat operations compared with vein grafts. Adequate length of the graft in coronary artery bypass graft surgery is essential for providing complete arterial revascularization. In the last decade or so, technique of skeletonization of internal thoracic artery has been proposed to achieve extra length. Skeletonization of the internal thoracic artery allows the preparation of longer conduits with a superior free flow and can reduce the incidence of postoperative pulmonary and sternal complications. However, concerns about vasoreactivity of skeletonized internal thoracic artery grafts, the functional consequences of surgical trauma, the possible loss of innervation, and vasa vasorum perfusion in the skeletonized conduits have prevented this technique from being universally accepted. Presently available evidence from retrospective studies (level 3 evidence) suggests that skeletonization is a safe and effective technique for myocardial revascularization. However, there is a need for conducting multicenter, randomized controlled trials comparing the skeletonized and pedicled internal thoracic arteries with special emphasis on long-term patency to conclusively validate the safety and efficacy of skeletonization technique. The effectiveness of the internal thoracic artery (ITA) for coronary artery bypass grafting (CABG) is well established [1Grondin C.M. Campeau L. Lesperance J. Enjalbert M. Bourassa M.G. Comparison of late changes in internal mammary artery and saphenous vein grafts in two consecutive series of patients 10 years after operation.Circulation. 1984; 70: I208-I212PubMed Google Scholar, 2Cameron A. Kemp Jr, H.G. Green G.E. Bypass surgery with the internal mammary artery graft 15 year follow-up.Circulation. 1986; 74: III30-III36PubMed Google Scholar, 3Loop F.D. Lytle B.W. Cosgrove D.M. et al.Influence of the internal-mammary-artery graft on 10-year survival and other cardiac events.N Engl J Med. 1986; 314: 1-6Crossref PubMed Scopus (2262) Google Scholar, 4Barner H.B. Standeven J.W. Reese J. Twelve-year experience with internal mammary artery for coronary artery bypass.J Thorac Cardiovasc Surg. 1985; 90 (668–75)PubMed Google Scholar]. It has been postulated that long-term cardiac protection is provided only by arterial grafts, whereas venous conduits undergo pathophysiologic and clinical deterioration that is similar to that from the native coronary disease [3Loop F.D. Lytle B.W. Cosgrove D.M. et al.Influence of the internal-mammary-artery graft on 10-year survival and other cardiac events.N Engl J Med. 1986; 314: 1-6Crossref PubMed Scopus (2262) Google Scholar]. Comparative studies have demonstrated that internal thoracic arteries possess improved resistance to the development of arteriosclerosis, intimal hyperplasia, and medial calcification [5Kaufer E. Factor S.M. Frame R. Brodman R.F. Pathology of radial artery and internal thoracic arteries used as coronary artery bypass grafts.Ann Thorac Surg. 1997; 63: 1118-1122Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar, 6Ruengsakulrach P. Sinclair R. Komeda M. Raman J. Gordon I. Buxton B. Comparative histopathology of radial artery versus internal thoracic artery and risk factors for development of intimal hyperplasia and atherosclerosis.Circulation. 1999; 100: II139-II144PubMed Google Scholar]. Recent evidence indicates that bilateral ITA grafting further improves survival and reduces the need for repeat revascularization [7Lytle B.W. Blackstone E.H. Loop F.D. et al.Two internal thoracic artery grafts are better than one.J Thorac Cardiovasc Surg. 1999; 117: 855-872Abstract Full Text Full Text PDF PubMed Scopus (750) Google Scholar, 8Endo M. Nishida H. Tomizawa Y. Kasanuki H. Benefit of bilateral over single internal mammary artery grafts for multiple coronary artery bypass grafting.Circulation. 2001; 104: 2164-2170Crossref PubMed Scopus (151) Google Scholar]. Internal thoracic artery grafting is particularly important for patients with diabetes because survival is significantly higher in patients with diabetes after CABG compared with percutaneous transluminal angioplasty [9The Bypass Angioplasty Revascularization Investigation (BARI) InvestigatorsComparison of coronary bypass surgery with angioplasty in patients with multivessel disease.N Engl J Med. 1996; 335: 217-225Crossref PubMed Scopus (1545) Google Scholar]. Furthermore, the higher survival in the patients with diabetes after CABG was limited to patients who received ITA grafts. Patients with diabetes represent a subgroup of those who could potentially derive the greatest benefit from bilateral ITA grafting. Unfortunately this technique is limited by the increased risk of deep sternal wound infection associated with conventional pedicled ITA harvesting [10Grossi E.A. Esposito R. Harris L.J. et al.Sternal wound infections and use of internal mammary artery grafts.J Thorac Cardiovasc Surg. 1991; 102: 342-346PubMed Google Scholar]. Indeed, diabetes is a well-recognized risk factor for sternal infection even in patients receiving a single ITA graft [10Grossi E.A. Esposito R. Harris L.J. et al.Sternal wound infections and use of internal mammary artery grafts.J Thorac Cardiovasc Surg. 1991; 102: 342-346PubMed Google Scholar, 11Borger M.A. Rao V. Weisel R.D. et al.Deep sternal wound infection risk factors and outcomes.Ann Thorac Surg. 1998; 65: 1050-1056Abstract Full Text Full Text PDF PubMed Scopus (279) Google Scholar]. Pedicled harvesting of both ITA grafts may impair sternal wound healing by decreasing sternal blood flow, resulting in an increased risk of sternal wound infection and dehiscence [12Arnold M. The surgical anatomy of sternal blood supply.J Thorac Cardiovasc Surg. 1972; 64: 596-610PubMed Google Scholar, 13Lorberboym M. Medalion B. Bder O. et al.99mTc-MDP bone SPECT for the evaluation of sternal ischemia following internal mammary artery dissection.Nucl Med Commun. 2002; 23: 47-52Crossref PubMed Scopus (39) Google Scholar].Recently skeletonization of the internal thoracic artery (a technique pioneered by Sauvage and colleagues [14Sauvage L.R. Wu H.D. Kowalsky T.E. et al.Healing basis and surgical techniques for complete revascularization of the left ventricle using only the internal mammary arteries.Ann Thorac Surg. 1986; 42: 449-465Abstract Full Text PDF PubMed Scopus (100) Google Scholar]) has been advocated to decrease the occurrence of sternal wound infections and increase the number of arterial anastomoses [13Lorberboym M. Medalion B. Bder O. et al.99mTc-MDP bone SPECT for the evaluation of sternal ischemia following internal mammary artery dissection.Nucl Med Commun. 2002; 23: 47-52Crossref PubMed Scopus (39) Google Scholar, 15Cohen A.J. Lockman J. Lorberboym M. et al.Assessment of sternal vascularity with single photon emission computed tomography after harvesting of the internal thoracic artery.J Thorac Cardiovasc Surg. 1999; 118: 496-502Abstract Full Text Full Text PDF PubMed Scopus (112) Google Scholar, 16Kim K.B. Cho K.R. Chang W.I. Lim C. Ham B.M. Kim Y.L. Bilateral skeletonized internal thoracic artery graftings in off-pump coronary artery bypass early result of Y versus in situ grafts.Ann Thorac Surg. 2002; 74: S1371-S1376Abstract Full Text Full Text PDF PubMed Google Scholar]. Skeletonization involves meticulous dissection of the ITA conduit away from the chest wall with preservation of the collateral sternal blood supply and the internal thoracic veins. On the other hand, when skeletonized, the vessel loses its “milieu,” which theoretically may adversely affect its long-term resistance to arteriosclerosis. This coupled with the lack of long-term patency studies of the skeletonized ITA and meticulous follow-up and confirmation by angiography raises concerns about whether this technique sacrifices the superior longevity of the conduit. In this review we evaluate the available evidence on the advantages and disadvantages of skeletonization of internal thoracic artery.Search MethodologyThe scientific literature of the English language was reviewed primarily by searching MEDLINE from 1966 through March 2004 using the OVID interface [17Ovid Technologies Inc. Ovid. http://www.ovid.com; accessed March 12, 2004.Google Scholar]. Key words used in the search included skeletonized, pedicled, internal thoracic artery, internal mammary artery, conduits, grafts, and harvesting techniques. The reference lists of articles found through these searches were also reviewed for relevant articles. In addition, links on web sites containing published articles were searched for relevant information. The authors for this article chose studies relevant to the discussion. The search was done in stages to achieve high-sensitivity search strategy (ie, it has the highest likelihood of retrieving all relevant articles). Similar search terms were combined using the Boolean operator term “or” to find all abstracts that contained information about a particular search term. These individual terms were then combined using the Boolean operator term “and” to find articles that contained information of all the search terms. This is a well-recognized method for performing sensitive searches and has been described in detail in the British Medical Journal [18Greenhaligh T. How to read a paper the MEDLINE database.Br Med J. 1997; 315: 180-183Crossref PubMed Google Scholar].The articles found by the search strategy were then appraised. The appraisal of each article was performed in a structured format using critical appraisal checklists. These are widely available in several formats and aid in assessing the article for methodological and analytical soundness and to help uncover any significant methodological flaws [19Mackway-Jones K, Carley CD, Morton RJ. Best BETs critical appraisal worksheets. http://www.bestbets.org/cgi-bin/public_pdf.pl; accessed March 12, 2004.Google Scholar]. In addition, after appraisal, the article was categorized in terms of study type and level of evidence presented [20CEBM. Oxford centre for evidence based medicine. http://www.cebm.net; accessed March 12, 2004.Google Scholar]. The levels of evidence are presented in Table 1 and enable readers of the article to come to a conclusion about the certainty to which evidence exists to answer the question.Table 1Levels of EvidenceLevel I—Strong evidence from at least one published systematic review of multiple well-designed randomized controlled trials.Level II—Strong evidence from at least one published properly designed randomized controlled trial of appropriate size and in an appropriate clinical setting.Level III—Evidence from published well-designed trials without randomization, single group pre-post, cohort, time series, or matched case-control studies.Level IV—Evidence from well-designed non-experimental studies from more than one center or research group.Level V—Opinion of respected authorities, based on clinical evidence, descriptive studies or reports of expert consensus committees. Open table in a new tab Skeletonization and Incidence of Sternal Wound InfectionThree major studies [21Hazelrigg S.R. Wellons H.A. Schneider J.A. Kolm P. Wound complications after median sternotomy.J Thorac Cardiovasc Surg. 1989; 98: 1096-1099PubMed Google Scholar, 22Cosgrove D.M. Lytle B.W. Loop F.D. et al.Does bilateral internal mammary artery grafting increase surgical risk?.J Thorac Cardiovasc Surg. 1988; 95: 850-856PubMed Google Scholar, 23Kouchoukos N.T. Wareing T.H. Murphy S.F. Pelate C. Marshall Jr, W.G. Risks of bilateral internal mammary artery bypass grafting.Ann Thorac Surg. 1990; 49: 210-219Abstract Full Text PDF PubMed Scopus (287) Google Scholar] have identified the use of bilateral ITAs as a significant risk factor for sternal dehiscence and mediastinal wound infection. Because each hemi-sternum loses >90% of its blood supply upon mobilization of the corresponding ITA [12Arnold M. The surgical anatomy of sternal blood supply.J Thorac Cardiovasc Surg. 1972; 64: 596-610PubMed Google Scholar, 24Seyfer A.E. Shriver C.D. Miller G.M. Graeber G.M. Sternal blood flow after median sternotomy and mobilization of the internal mammary arteries.Surgery. 1988; 104: 899-904PubMed Google Scholar], it is not surprising that wound healing can be compromised in patients after concomitant mobilization of both the left and right ITAs [25Graeber G.M. Harvesting of the internal mammary artery and the healing median sternotomy.Ann Thorac Surg. 1992; 53 ([editorial]): 7-8Abstract Full Text PDF PubMed Scopus (16) Google Scholar].Sternal ischemia after mobilization of one or two ITAs was well documented in a study by Carrier and associates [26Carrier M. Gregoire J. Tronc F. Cartier R. Leclerc Y. Pelletier L.C. Effect of internal mammary artery dissection on sternal vascularization.Ann Thorac Surg. 1992; 53: 115-119Abstract Full Text PDF PubMed Scopus (107) Google Scholar] who performed sternal bone tomography at 1 week and 4 weeks after median sternotomy in 67 patients. At 1 week, ITA dissection caused significant sternal ischemia that was more marked in patients who had bilateral ITA harvesting. These changes were less pronounced 1 month after operation, probably because of the development of vascular collateral vessels. Deep sternal wound infection is a dreaded complication that portends an increased risk of morbidity and death [27Loop F.D. Lytle B.W. Cosgrove D.M. et al.J Maxwell Chamberlain memorial paper. Sternal wound complications after isolated coronary artery bypass grafting early and late mortality, morbidity, and cost of care.Ann Thorac Surg. 1990; 49: 179-186Abstract Full Text PDF PubMed Scopus (609) Google Scholar]. Patients who have deep sternal infection have a threefold increase in intensive care unit and hospital length of stay, as well as a threefold increase in mortality [11Borger M.A. Rao V. Weisel R.D. et al.Deep sternal wound infection risk factors and outcomes.Ann Thorac Surg. 1998; 65: 1050-1056Abstract Full Text Full Text PDF PubMed Scopus (279) Google Scholar].However, skeletonization of ITA conduits results in less reduction of sternal blood flow [13Lorberboym M. Medalion B. Bder O. et al.99mTc-MDP bone SPECT for the evaluation of sternal ischemia following internal mammary artery dissection.Nucl Med Commun. 2002; 23: 47-52Crossref PubMed Scopus (39) Google Scholar, 15Cohen A.J. Lockman J. Lorberboym M. et al.Assessment of sternal vascularity with single photon emission computed tomography after harvesting of the internal thoracic artery.J Thorac Cardiovasc Surg. 1999; 118: 496-502Abstract Full Text Full Text PDF PubMed Scopus (112) Google Scholar]. Anatomic studies reveal that the sternal and anterior intercostal branches of the ITA originate either directly or as a common trunk from the ITA [28Henriquez-Pino J.A. Gomes W.J. Prates J.C. Buffolo E. Surgical anatomy of the internal thoracic artery.Ann Thorac Surg. 1997; 64: 1041-1045Abstract Full Text Full Text PDF PubMed Scopus (89) Google Scholar]. Substantial collateral blood flow to the sternum can be maintained in the absence of the ITA, provided the sternal-anterior intercostal trunk is left intact. Skeletonization of the ITA often results in preservation of this common trunk, particularly if meticulous dissection is performed [29Peterson M.D. Borger M.A. Rao V. Peniston C.M. Feindel C.M. Skeletonization of bilateral internal thoracic artery grafts lowers the risk of sternal infection in patients with diabetes.J Thorac Cardiovasc Surg. 2003; 126: 1314-1319Abstract Full Text Full Text PDF PubMed Scopus (153) Google Scholar].In a recently published study, Peterson and colleagues [29Peterson M.D. Borger M.A. Rao V. Peniston C.M. Feindel C.M. Skeletonization of bilateral internal thoracic artery grafts lowers the risk of sternal infection in patients with diabetes.J Thorac Cardiovasc Surg. 2003; 126: 1314-1319Abstract Full Text Full Text PDF PubMed Scopus (153) Google Scholar] confirmed an unacceptably high prevalence of deep sternal wound infection in patients with diabetes (11.1%) receiving pedicled bilateral ITA grafts. Skeletonization of both conduits resulted in a significantly lower prevalence of deep sternal infection (1.2%) that was comparable with rates in patients without diabetes (1.6%). The prevalence of any sternal infection (superficial or deep) was also significantly lower in patients in the skeletonized group. They concluded that skeletonization allows safe application of bilateral ITA grafting in patients with diabetes, a finding that has been demonstrated by others [30Pevni D. Mohr R. Lev-Run O. et al.Influence of bilateral skeletonized harvesting on occurrence of deep sternal wound infection in 1,000 consecutive patients undergoing bilateral internal thoracic artery grafting.Ann Surg. 2003; 237: 277-280PubMed Google Scholar, 31Matsa M. Paz Y. Gurevitch J. et al.Bilateral skeletonized internal thoracic artery grafts in patients with diabetes mellitus.J Thorac Cardiovasc Surg. 2001; 121: 668-674Abstract Full Text Full Text PDF PubMed Scopus (122) Google Scholar, 32Kramer A. Mastsa M. Paz Y. et al.Bilateral skeletonized internal thoracic artery grafting in 303 patients seventy years and older.J Thorac Cardiovasc Surg. 2000; 120: 290-297Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar, 33Sofer D. Gurevitch J. Shapira I. et al.Sternal wound infections in patients after coronary artery bypass grafting using bilateral skeletonized internal mammary arteries.Ann Surg. 1999; 229: 585-590Crossref PubMed Scopus (66) Google Scholar, 34Bical O. Braunberger E. Fischer M. et al.Bilateral skeletonized mammary artery grafting experience with 560 consecutive patients.Eur J Cardiothorac Surg. 1996; 10: 971-975Crossref PubMed Scopus (53) Google Scholar]. Table 2 summarizes the impact of skeletonization of internal thoracic arteries on the incidence of sternal wound infection.Table 2Impact of Skeletonization of Incidence of Sternal Wound InfectionAuthorPatient GroupStudy Type (Level of Evidence)Outcome(s)Key ResultPeterson and colleagues [29Peterson M.D. Borger M.A. Rao V. Peniston C.M. Feindel C.M. Skeletonization of bilateral internal thoracic artery grafts lowers the risk of sternal infection in patients with diabetes.J Thorac Cardiovasc Surg. 2003; 126: 1314-1319Abstract Full Text Full Text PDF PubMed Scopus (153) Google Scholar]; 200379 diabetics who received skeletonized and 36 diabetics who received pedicled ITARetrospective level 3Prevalence of sternal wound infectionSignificantly lower incidence of deep sternal wound infection (1.3% vs 11.3%; p = 0.03) as well as overall sternal infection (5.1% vs 22.2%; p = 0.03) in patients with skeletonized ITAPevni and colleagues [30Pevni D. Mohr R. Lev-Run O. et al.Influence of bilateral skeletonized harvesting on occurrence of deep sternal wound infection in 1,000 consecutive patients undergoing bilateral internal thoracic artery grafting.Ann Surg. 2003; 237: 277-280PubMed Google Scholar]; 2003aMetachronous studies from the same center.1,000 consecutive patients who received skeletonized BITARetrospective level 3Risk of deep sternal wound infectionDeep sternal wound infection rate was 2.2% with no difference in the rate of deep sternal wound infection among the specific high-risk groups (ie, diabetic, obesity, female, and elderly) compared with patients without these risk factorsMatsa and colleagues [31Matsa M. Paz Y. Gurevitch J. et al.Bilateral skeletonized internal thoracic artery grafts in patients with diabetes mellitus.J Thorac Cardiovasc Surg. 2001; 121: 668-674Abstract Full Text Full Text PDF PubMed Scopus (122) Google Scholar]; 2001aMetachronous studies from the same center.231 diabetic and 534 nondiabetic patients with skeletonized BITARetrospective level 3Early and midterm outcomesComparable incidence of deep sternal wound infection in diabetics and nondiabetics (2.6% vs 1.7%; p = 0.40)Kramer and colleagues [32Kramer A. Mastsa M. Paz Y. et al.Bilateral skeletonized internal thoracic artery grafting in 303 patients seventy years and older.J Thorac Cardiovasc Surg. 2000; 120: 290-297Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar]; 2000aMetachronous studies from the same center.303 consecutive patients ≥ 70 years with skeletonized BITARetrospective level 3Early and midterm outcomesOnly 6 patients (2%) had deep sternal wound infectionSofer and colleagues [33Sofer D. Gurevitch J. Shapira I. et al.Sternal wound infections in patients after coronary artery bypass grafting using bilateral skeletonized internal mammary arteries.Ann Surg. 1999; 229: 585-590Crossref PubMed Scopus (66) Google Scholar]; 1999aMetachronous studies from the same center.545 consecutive patients with skeletonized BITARetrospective level 330-day and 1-year outcomes9 patients (1.7%) had deep infections and 15 (2.8%) had superficial infectionsBical and colleagues [34Bical O. Braunberger E. Fischer M. et al.Bilateral skeletonized mammary artery grafting experience with 560 consecutive patients.Eur J Cardiothorac Surg. 1996; 10: 971-975Crossref PubMed Scopus (53) Google Scholar]; 1996560 consecutive patients with skeletonized BITA, including 63 diabeticsRetrospective level 3Early and 7-year follow-up outcomes (mean, 29 ± 20 months)6 patients (1.1%) had sternal complications. No wound complications were observed in diabetic patientsITA = internal thoracic artery; BITA = bilateral internal thoracic arteries.a Metachronous studies from the same center. Open table in a new tab Skeletonization and Length of Internal Thoracic ArteryThe use of skeletonized ITAs allows the use of both ITAs as grafts to practically all coronary vessels requiring surgical revascularization, thus obtaining complete arterial revascularization [35Pevni D. Mohr R. Lev-Ran O. et al.Technical aspects of composite arterial grafting with double skeletonized internal thoracic arteries.Chest. 2003; 123: 1348-1354Crossref PubMed Scopus (35) Google Scholar]. The pedicled right internal thoracic artery (RITA) is less useful than the left internal thoracic artery (LITA), as it will not always reach the right coronary artery branches without tension, leading to its use predominantly as a free graft with a lower patency rate when attached to the ascending aorta [36Tatoulis J. Buxton B. Fuller J. Results of 1,454 free right internal thoracic artery-to-coronary artery grafts.Ann Thorac Surg. 1997; 64: 1263-1268Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar]. Skeletonization bestows the advantage of extra length [37Tector A.J. Kress D.C. Downey F.X. Schmahl T.M. Complete revascularization with internal thoracic artery grafts.Semin Thorac Cardiovasc Surg. 1996; 8: 29-46PubMed Google Scholar], which permits composite arterial grafting. Connecting the skeletonized free RITA end-to-side to the skeletonized LITA as a T graft or end-to-end as a tandem–sequential graft locates the RITA 10 or more cm closer to the coronary arteries on the inferior and posterior surface of the heart [38Purely internal thoracic artery grafts outcomes.Ann Thorac Surg. 2001; 72: 450-455Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar]. Combining the T graft or tandem–sequential graft with sequential grafting makes it possible for most patients to undergo bypass with purely ITA grafts [38Purely internal thoracic artery grafts outcomes.Ann Thorac Surg. 2001; 72: 450-455Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar]. The coronary arteries on the anterior surface of the heart are mostly bypassed with the LITA, and the arteries on the posterior and inferior areas are grafted with the RITA. The most important coronary artery in nearly all patients, the left anterior descending artery, is always bypassed with the graft having the greatest proved patency (ie, the attached LITA). A separate harvesting incision and an aortic anastomosis are not needed. In addition, the bypass conduits are placed out of the way of re-entry and are well protected from injury in case the patient needs a repeat sternal incision. Thus, skeletonization allows the use of only two arterial grafts and avoidance of the harvesting of multiple conduits, thereby reducing the morbidity of the operation [38Purely internal thoracic artery grafts outcomes.Ann Thorac Surg. 2001; 72: 450-455Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar].Skeletonization and Internal Thoracic Artery FlowTakami and Ima [39Takami Y. Ina H. Effects of skeletonization on intraoperative flow and anastomosis diameter of internal thoracic arteries in coronary artery bypass grafting.Ann Thorac Surg. 2002; 73: 1441-1445Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar] used quantitative coronary angiography with an edge detection algorithm and transit-time graft flow measurement to show that complete ITA skeletonization results in increased graft diameter for the anastomosis, thereby improving graft flow in CABG. Similar findings were reported by Choi and Lee [40Choi J.B. Lee S.Y. Skeletonized and pedicled internal thoracic artery grafts effects on free flow during bypass.Ann Thorac Surg. 1996; 61: 909-913Abstract Full Text PDF PubMed Scopus (67) Google Scholar] and Wendler and colleagues [41Wendler O. Tscholl D. Huang Q. Schäfers H.J. Free flow capacity of skeletonized versus pedicled internal thoracic artery grafts in coronary artery bypass grafts.Eur J Cardiothorac Surg. 1999; 15: 247-250Crossref PubMed Scopus (87) Google Scholar]. An anastomosis with a larger diameter and decrease in graft vascular resistance secondary to skeletonization are factors that may prevent the hypoperfusion syndrome in CABG using ITA. This syndrome is a rare but life-threatening perioperative clinical syndrome manifested by low cardiac output, left ventricular failure, and cardiac arrest [42Jones E.L. Lattouf O.M. Weintraub W.S. Catastrophic consequences of internal mammary artery hypoperfusion.J Thorac Cardiovasc Surg. 1989; 98: 902-907PubMed Google Scholar, 43Loop F. Thomas J. Hypoperfusion after arterial bypass grafting.Ann Thorac Surg. 1993; 56: 812-813Abstract Full Text PDF PubMed Scopus (46) Google Scholar]. The major contributory factor to ITA hypoperfusion is a disproportion between ITA flow and myocardial demand because of the small ITA size, overzealous use of sequential grafting, and severe left ventricular hypertrophy. Considering the current wide use of ITAs, including sequential and bilateral, ITA skeletonization may be an efficient strategy to prevent perioperative hypoperfusion syndrome, especially in off-pump CABG without assisted circulation [44Cartier R. Leacche M. Couture P. Changing pattern in beating heart operations use of skeletonized internal thoracic artery.Ann Thorac Surg. 2002; 74: 1548-1552Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar].Additional Benefits of SkeletonizationSkeletonization also allows visual inspection of the vessel to identify any injury, which if unnoticed may jeopardize the long-term outcome [45Raja S.G. Skeletonized bilateral internal thoracic arteries additional advantages and concerns.J Thorac Cardiovasc Surg. 2004; 127: 1870Abstract Full Text Full Text PDF Scopus (4) Google Scholar]. Another potential benefit of skeletonization is decreased postoperative chest wall pain. Intercostal nerve damage occurs frequently after pedicled ITA harvesting [46Mailis A. Chan J. Basinski A. et al.Chest wall pain after aortocoronary bypass surgery using internal mammary artery graft a new pain syndrome?.Heart Lung. 1989; 18: 553-558PubMed Google Scholar]. In one study, three quarters of patients who underwent coronary bypass showed evidence of intercostal nerve damage after pedicled harvesting, and 15% of these patients experienced persistent postoperative pain [47Mailis A. Umana M. Feindel C.M. Anterior intercostal nerve damage after coronary artery bypass graft surgery with use of internal thoracic artery graft.Ann Thorac Surg. 2000; 69: 1455-1458Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar]. The anterior branch of the intercostal nerve is avoided during skeletonized" @default.
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• W2000349594 title "Internal Thoracic Artery: To Skeletonize or Not to Skeletonize?" @default.
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