Pedicled versus skeletonized internal thoracic artery grafts: a randomized trial.

Mats Dreifaldt,Håkan Geijer,Ninos Samano,Mats Lidén,Lennart Bodin,Domingos Souza

doi:10.1177/0218492320983491

Mats Dreifaldt, Håkan Geijer + Show 4 more

Open Access

https://doi.org/10.1177/0218492320983491

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Abstract

ObjectiveConcerns have been raised regarding whether skeletonization of the internal thoracic artery could damage the graft and thereby reduces its patency. The objective of this study was to compare patency rates at mid- and long-term follow-up between pedicled and skeletonized left internal thoracic artery grafts.MethodsThis randomized controlled trial included 109 patients undergoing coronary artery bypass surgery. The patients were assigned to receive either one pedicled or one skeletonized left internal thoracic artery graft to the left anterior descending artery. Follow-up was performed at 3 years with conventional angiography, and at 8 years with computed tomography angiography. Differences between patency rates were analyzed with Fisher’s exact test and a generalized linear model.ResultsThe patency rates for pedicled and skeletonized left internal thoracic artery grafts were 46/48 (95.8%) versus 47/52 (90.4%), p = 0.44 at 3 years, and 40/43 (93.0%) versus 37/41 (90.2%), p = 0.71 at 8 years, respectively. The difference in patency rates for pedicled and skeletonized grafts was 5.4% (95% confidence interval: −4.2–14.5) at 3 years and 2.8% (95% confidence interval: −9.9–14.1) at 8 years. All failed grafts, except for one with a localized stenosis, were anastomosed to native coronary arteries with a stenosis less than 70%. Three patients suffered sternal wound infections (two in the pedicled group, one in the skeletonized group).ConclusionsThe skeletonization technique can be used without jeopardizing the patency of the left internal thoracic artery. The most important factor in graft failure was target artery stenosis below 70%.

Highlights

The left internal thoracic artery (LITA) is the graft of choice in coronary artery bypass grafting (CABG)
To obtain a reliable confidence interval (CI) for the central effect parameter, that is, the difference in patency rates, to supplement the calculation of p values, a generalized linear model was used. The outcome in this model was the difference in patency rates (p1 – p2) and the analysis provided an estimate of this difference and its 95%CI
One patient who did not participate in the first follow-up showed a patent pedicled LITA (P-LITA) at 8 years. This is the first randomized longitudinal study comparing mid- and long-term patency rates between P-LITA and skeletonized LITA (S-LITA)

Summary

Introduction

The left internal thoracic artery (LITA) is the graft of choice in coronary artery bypass grafting (CABG). This is based on convincing evidence of improved survival in patients with critical left anterior descending artery (LAD) disease in whom an LITA graft has been placed.[1] The long-term patency of the LITA is approximately 90% 10 years after CABG.[2] Bilateral internal thoracic arteries (BITA) are used in a low percentage of CABG operations despite excellent results.[3] Patients who received BITA grafts for left coronary system revascularization have improved early and late outcomes and decreased risk of death, reoperation, and additional reinterventions.[4] Most commonly, the LITA is harvested as a pedicled graft and used to bypass the LAD. The LITA can be harvested in a skeletonized fashion, especially when using the BITA approach, reducing trauma and postoperative sternal complications.[5] Advocates of skeletonization emphasize that it increases the number of arterial anastomoses per patient by increasing the

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