Skeletonized Internal Thoracic Artery Harvest Reduces Pain and Dysesthesia and Improves Sternal Perfusion After Coronary Artery Bypass Surgery

Abstract

Background-Observational studies suggest that skeletonization of the internal thoracic artery (ITA) can improve conduit flow and length and reduce deep sternal infections and postoperative pain. We performed a randomized, double-blind, within-patient comparison of skeletonized and nonskeletonized ITAs in patients undergoing coronary surgery. Methods and Results-Patients (nϭ48) undergoing bilateral ITA harvest were randomized to receive 1 skeletonized and 1 nonskeletonized ITA. Intraoperatively, ITA flow was assessed directly and with a Doppler flow probe before and after topical application of papaverine. ITA harvest time and conduit length were recorded. A blinded assessment of pain (visual analog scale) and dysesthesia (physical examination) was performed at discharge, at 2 weeks, and at a 3-month follow-up. Sternal perfusion was assessed with nuclear imaging (nϭ7). Skeletonization required longer ITA harvest times (27Ϯ1 versus 24Ϯ1 minutes; Pϭ0.04). There was a trend toward increased ITA length in the skeletonized group (18.2Ϯ0.3 versus 17.7Ϯ0.3 cm; Pϭ0.09). In situ ITA flow was lower in skeletonized arteries (7.4Ϯ0.9 versus 10.1Ϯ1.0 mL/min; P‫)10.0؍‬ and increased significantly after ITA division and papaverine application. Postanastomotic flows were similar between groups. Skeletonization was associated with decreased pain at the 3-month follow-up and a reduction in major sensory deficits at the 4-week and 3-month (17% versus 50%; Pϭ0.002) follow-ups. Baseline adjusted sternal perfusion was significantly greater by 17Ϯ6% (Pϭ0.03) on the skeletonized side. Conclusions-Skeletonization

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“…These results were found, probably as a result of better sternal perfusion after ITA skeletonization compared to the pedicled ITA [22][23][24][25][26][27][28]. Boodhwani et al [26] conducted a study with 48 patients, in which each individual was submitted to CABG using bilateral ITA, and all ITAs were dissected skeletonized in the left side and pedicled in the right side.…”

“…Boodhwani et al [26] conducted a study with 48 patients, in which each individual was submitted to CABG using bilateral ITA, and all ITAs were dissected skeletonized in the left side and pedicled in the right side. Afterwards, patients were evaluated for sternal perfusion through scintigraphy (radio nuclear image).…”

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“…More recently, Boodhwani et al [24] used a bone scintigraphy to assess the sternal perfusion in a group of seven patients in whom were used ITAs dissected on one side through skeletonization techinque and on the other, through pedicle preparation. It was noted better sternal perfusion in the side on which the ITA was dissected through skeletonization technique.…”

“…Korbmacher et al [22] used the cervical spine, but we supposed that the presence of other structures that are in front of the spine may lead to increased uptake, Rivas et al [23] used the humerus, Cohen et al [21], the contralateral half of the sternum in which the ITA has not been dissected and Boodhwani et al [24] used the two halves of the sternum that had the ITAs dissected by different techniques. Except for one study [20] in which the uptake analysis was totally visual, all others have been based on quantitative analysis of uptake by the mean count per "pixel" by automated program.…”

“…After, it was established a quantitative analysis, by comparing the uptake of radioactive tracer by the sternum with another bone structure chosen as reference [23]. Other studies used the same principle for the evaluation of sternal perfusion, but using different methods [21,22,24].…”