Bilateral internal thoracic artery harvesting carries a higher risk of sternal infection than harvesting a single internal thoracic artery. Skeletonization of both internal thoracic arteries significantly decreases this risk. A strategy of bilateral thoracic artery grafting can also be offered to patients at high risk for wound infection.

Inadvertent paramedian sternomoty strongly affects postoperative chest wound stability independently from sternal size, requiring prompt reinforcement of chest closure.

In our study, muscle flap reconstruction guaranteed better early and late-term results as shown by lower rates of mortality, procedure failure and hemisternum stability. Moreover, Group 1 patients had greater postoperative VC, lower NYHA class and better quality of life. These results suggest that, in patients with multiple bone fracture, the rewiring approach does not promote physiological bone consolidation, whereas the muscle flap reconstruction can assure more physiological ventilatory dynamics.

T he surgical mortality rate for type A acute aortic dissection (AAD) still remains high (8%-34%), despite improvements in perioperative and postoperative management during the last decade.1-3 Complete resection of the intimal tear and prosthetic replacement of the ascending aorta are still considered the standard of care for type A dissection surgery. Because the residual dissection flap in the aortic arch and descending aorta carries risks of progressive aortic dilation and rupture and the need for secondary intervention, several groups have suggested immediate extensive surgery that involves the aortic arch, although concomitant distal aortic manipulation has been associated with an increased risk of morbidity and death. [4][5][6][7][8][9][10][11][12][13] In this situation, 2 different surgical strategies have been proposed: total arch replacement or hemiarch replacement (a more conservative repair limited to the ascending aorta and proximal arch). 4,[9][10][11][12] We evaluated the early and intermediate outcomes of aortic arch surgery in patients with type A AAD, investigating the effect, upon postoperative results, of aortic arch extension. Patients and MethodsWe undertook a retrospective, observational study of prospectively collected data on consecutive patients who had presented with type A AAD at our institution. This cohort study was approved by our local ethics committee, and individual consent was obtained by each patient's physician. From January 2006 through July 2013, 201 patients with type A AAD underwent urgent surgery at our institution. For the purposes of this study, we did not consider 109 AAD patients who underwent isolated replacement of the ascending aorta. We included only the 92 patients who underwent

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