Left-Sided Myocardial Revascularization with Bilateral Skeletonized Internal Thoracic Artery

Abstract

The current conventional and most commonly used operative procedure for myocardial revascularization includes one internal thoracic artery (ITA) together with one or more saphenous vein grafts (SVG) [1, 2]. Themajor surgical objective is to supply the left anterior descending coronary artery with an ITA in order to improve patient survival [3, 4]. ITA patency rate exceeds that of SVG and long-term patency remains high, in contrast to vein grafts which are subject to late closure as a result of progressive atherosclerosis [3]. Besides better survival, the superior patency rate is associated with better angina-free survival and decreased rates of reoperations and reinterventions [5]. Since SVG failure is a major drawback of coronary artery bypass grafting (CABG), surgical techniques of arterial myocardial revascularization withminimal use of SVG were attempted. Two popular techniques for achieving this goal are bilateral and sequential ITA grafting [6–8]. Inmost centers, the ITA is isolated from the chest wall as a pedicle, together with the vein, muscle, fat and accompanying endothoracic fascia [3, 4, 9]. Harvesting is relatively quick due to the fact that cautery is used to separate the pedicle from the chest wall. However, cauterization damages the blood supply to the sternum, which in turn impedes sternal healing and exposes the sternum to the risks of early dehiscence and infection, particularly in operations in which both ITAs are used [10–13]. A surgical technique was recently developed wherein the ITA is dissected as a skeletonized vessel [14, 15]. The skeletonized artery is isolated gently with scissors and silver clips, without the use of cauterization. Skeletonized ITA dissection leaves the vein, muscle and accompanying tissue in place (Fig. 14.1). The advantage is that the dissected artery is longer [16] and its spontaneous blood flow is greater than that of the pedicled ITA [17], allowing the use of both ITAs as grafts to all necessary coronary vessels [9]. In many cases, no additional vein grafts are required [9]. Another advantage of using ITA as a skeletonized artery is the preservation of colFig. 14.1. Pedicled internal thoracic artery (left), the “Jacuzzi”: skeletonized ITA inside a syringe filled with papaverine solution (middle) and skeletonized ITA (right)