Is skeletonised internal mammary harvest better than pedicled internal mammary harvest for patients undergoing coronary artery bypass grafting?

Abstract

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether skeletonised internal mammary artery (IMA) is better than pedicle IMA in coronary artery bypass grafting? Altogether 106 papers were found using the reported search, of which 12 presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that skeletonisation increases the length of conduit by around 3 cm and may also increase flow and conduit diameter. Skeletonisation should be the technique of choice for diabetics in whom BIMA harvest is desired, but at the expense of an extra 15-20 min per operation, no convincing outcome benefits have been shown for single IMA harvest.

Impacts of Skeletonized Bilateral Internal Mammary Artery Bypass Grafting on the Risk of Deep Sternal Wound Infection

“…1) Also, several observational studies have reported that skeletonized BIMA harvest reduced the incidence of DSWI to as low as 1%-2% from 10%-11% observed with the pedicled technique in diabetic patients. [6][7][8] Despite the reported advantages, skeletonized technique of IMA harvest has so far been used by a minority of surgical groups, 2,5,6,[8][9][10][11] especially in China. Data about the incidence of DSWI following skeletonized BIMA harvest and the impacts of skeletonized BIMA grafting on clinical outcomes came almost entirely from American, European, and Japanese published studies; nevertheless, data from Chinese patients were lacking.…”

A rare cadaveric case of a duplicated internal thoracic artery

“…Then dissection of the artery continues down toward the bifurcation of the vessel, avoiding the phrenic nerve and finally removing the artery from parasternal tissues and fascia down toward the 6th intercostal space. The resulting graft is about 3 cm longer than a pedicle graft and can have a larger conduit diameter and flow [10].…”

Conduits for Coronary Bypass: Internal Thoracic Artery

“…The internal thoracic vein joins the subclavian vein and is usually not divided although it may be. Additional ITA length can be gained by dividing the vein and dissecting the ITA from the subclavian vein when more ITA length is required as this maneuver can add up to 3 cm of length [16]. This length is gained by greater posterior positioning of the proximal ITA which normally is an anterior structure while its destination, usually the LAD, lies posterior to the in situ ITA, even though the LAD is an anterior structure on the heart.…”

“…It was also found to increase conduit length and in some reports free flow was greater [16]. With increasing experience and facility some surgeons expanded this technique to single ITA harvest.…”

“…The ultimate application being skeletinized dissection of the artery incorporating ultrasonic dissection, control of branches using clips or ultrasound and minimal or absent use of electrocautery to preserve collateral blood flow to the chest wall [27]. These modifications were shown to not harm the conduit and extend its length by 1 to 3 cm as attachment to the pedicle restricted its length [16,28]. The latter is particularly important for the right because its usual targets (right coronary/posterior descending or left sided targets) lie further from the thoracic inlet, and the aorta as well, than do usual targets of the left ITA.…”