Invited Commentary

Abstract

The authors of this study [1Rubens F.D. Chen L. Bourke M. Assessment of the association of bilateral internal thoracic artery skeletonization and sternal wound infection after coronary artery bypass grafting.Ann Thorac Surg. 2016; 101: 1677-1683Abstract Full Text Full Text PDF Scopus (25) Google Scholar] have again verified the safety of bilateral internal thoracic arterial (BITA) grafting in patients requiring coronary revascularization. Their sizeable experience involving a large cohort of patients comparing skeletonized pedicle harvesting with traditional pedicle harvesting techniques demonstrated equivalent rates of sternal infections and other related complications. Over time, arterial conduit use has become the standard of care, relegated to hallowed evidence-based acceptance in appropriately selected patients. However, despite the universal acceptance of single arterial grafting, ElBardissi and colleagues [2ElBardissi A.W. Aranki S.F. Sheng S. O’Brien S.M. Greenberg C.C. Gammie J.S. Trends in isolated coronary artery bypass grafting: an analysis of the Society of Thoracic Surgeons adult cardiac surgery database.J Thorac Cardiovasc Surg. 2012; 143: 273-281Abstract Full Text Full Text PDF PubMed Scopus (345) Google Scholar] revealed that only 4% to 12% of surgical revascularization procedures use BITA; clearly, evidence-based practice is rarely translated into routine clinical practice outside of reporting centers. Previous guidelines supporting arterial grafting with BITA conduits were often dependent on the severity of the native vessel disease; these studies often discouraged the use of BITA when the stenosis was not critical (<90%) [3Hillis L.D. Smith P.K. Anderson J.L. et al.American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines2011 ACCF/AHA guideline for coronary artery bypass graft surgery: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.J Thorac Cardiovasc Surg. 2012; 143: 4-34Abstract Full Text Full Text PDF PubMed Scopus (186) Google Scholar]. In regards to sternal complications, Dorman and coworkers [4Dorman M.J. Kurlansky P.A. Traad E.A. Galbut D.L. Zucker M. Ebra G. Bilateral internal mammary artery grafting enhances survival in diabetic patients a 30-year follow-up of propensity score–matched cohorts.Circulation. 2012; 126: 2935-2942Crossref PubMed Scopus (123) Google Scholar] addressed the effects of diabetes in a high-volume center with extensive BITA use. An even earlier large-scale, multicenter randomized arterial revascularization trial (ART) compared revascularization using BITA for the two most important left-sided target arteries with single internal thoracic artery (ITA) coupled with a combination of radial arteries or venous conduits for the remaining graft sites. This study demonstrated equivalent low 30-day (1%) and 1-year (2.5%) mortality rates, as well as similar rates of stroke and myocardial infarction, and the need for repeat revascularization for BITA grafting compared with the more traditional single ITA grafting strategy. Of note in this study was the increased incidence of sternal wound healing complications requiring reconstruction (1.9% versus 0.6%) in BITA patients compared with single ITA use, especially in diabetic patients. Although this randomized trial used a variety of ITA harvesting techniques, the results suggested that skeletonization of the ITA during harvesting may yield fewer sternal complications [5Taggart D.P. Altman D.G. Gray A.M. et al.ART InvestigatorsRandomized trial to compare bilateral vs. single internal mammary coronary artery bypass grafting: 1-year results of the Arterial Revascularisation Trial (ART).Eur Heart J. 2010; 31: 2470-2481Crossref PubMed Scopus (303) Google Scholar]. It is clear that skeletonization affords the surgeon increased arterial conduit length, creating the potential for multiple grafts of the left coronary circulation with a longer left ITA, as well as improving the distal reach of the right coronary arterial target sites with a skeletonized right ITA. Importantly, the known risk factors for suspected increased sternal complications from BITA use (increased body mass index, diabetes, peripheral vascular disease, female sex, and preoperative anemia) are more related to full sternotomy itself, instead of ITA harvesting, and were not significantly different in this report. Bilateral ITA utilization strategies for complex coronary revascularization has clearly demonstrated safety, diminished future interventions, improved graft longevity, and increased patient survival rates. The current report provides further evidence that harvesting techniques matter; hopefully studies like these will prevail over the continued reluctance to commit to more arterial grafting among the cardiac surgery community. The authors are to be congratulated for their excellent results, as well as advancing our understanding of this important topic. Assessment of the Association of Bilateral Internal Thoracic Artery Skeletonization and Sternal Wound Infection After Coronary Artery Bypass GraftingThe Annals of Thoracic SurgeryVol. 101Issue 5PreviewSkeletonization is a technique of bilateral internal thoracic artery (BITA) harvest that preserves sternal blood flow. We sought to identify the relationship of skeletonization and sternal wound infection in a population undergoing BITA harvest. Full-Text PDF