Bilateral Internal Mammary Artery Harvesting Research Articles

177 Pedicled Or Skeletonized Bilateral Internal Mammary Artery Harvesting - A Meta- Analysis and Trial Sequential Analysis

Abstract Objective There is varying evidence on the role of skeletonization of internal mammary artery in reducing the risk of sternal wound infections and ischemia following bilateral internal mammary artery grafting. We opt to compare post-operative clinical outcomes of skeletonized bilateral internal mammary artery versus pedicled bilateral internal mammary artery harvesting in patients undergoing coronary artery bypass surgery. Method A comprehensive electronic search was conducted using PubMed/MEDLINE, Scopus, EMBASE, Cochrane database and Google Scholar from inception until 15th June 2020. All studies directly comparing skeletonized and pedicled bilateral internal mammary artery harvesting were included. Meta-analysis and trial sequential analysis was conducted. Results Ten studies consisting of 3728 patients (2098 patients with skeletonized bilateral internal mammary artery grafting and 1630 patients with pedicled bilateral internal mammary artery grafting) were included. Pooled effects analysis and trial sequential analysis reported significantly lower risk of sternal wound infection with skeletonized bilateral internal mammary artery harvesting (OR 0.32, 95% CI 0.20 – 0.51, p < 0.00001). S-BIMA may be associated with lower late mortality, but more information is required to confirm this. Conclusions Skeletonization reduces the risk of sternal wound infections by preserving vasculature as much as possible. This makes it an important technique for use in bilateral internal mammary artery grafting for high-risk patients.

Conventional coronary artery bypass grafting

: It was in 1969 that Dr. René Favaloro first used a saphenous vein graft the way we use it today to perform an aorto-coronary bypass. Since then, there have been plenty of trials in the literature trying to prove the inferiority or not of conventional coronary artery bypass grafting. Left internal mammary artery to left anterior descending coronary artery anastomosis and saphenous vein grafts to other coronary artery targets performed through full median sternotomy in a safe, motionless and bloodless environment provided by cardiopulmonary bypass and cardioplegic arrest is typical of conventional coronary artery bypass grafting. Non-conventional approaches include bilateral internal mammary artery harvesting or total arterial revascularization instead of saphenous vein grafts, off-pump coronary artery bypass grafting avoiding the use of cardiopulmonary bypass machine and minimally invasive direct coronary artery bypass or hybrid coronary revascularization instead of full median sternotomy. However, conventional coronary artery bypass grafting appears non-inferior to any of the aforementioned approaches in terms of mortality and major morbidity. On the other hand, only highly selected patients can benefit from non-conventional approaches. Furthermore, experience is critical for achieving optimal outcomes with any of these approaches. High-volume centres with expert surgeons can offer the best results. Conventional coronary artery bypass grafting continuously competes with modern alternative approaches. However, which of these is the best remains a contentious affair.

Sternal healing after bilateral internal mammary arteries use for Coronary artery bypass grafting in diabetic Patients; short-term results

Background: Bilateral internal mammary artery (BIMA) use may improve long-term outcomes after coronary artery bypass grafting (CABG); however, the risk of infection is high. Skeletonization of the internal mammary may decrease the risk of infection, especially in patients with diabetes. Our study aimed at evaluation of sternal healing in diabetic patients with different techniques of bilateral internal mammary artery harvesting.
 Methods: This prospective randomized study included 200 diabetic patients who underwent CABG using BIMA between 2017 and 2019. We divided patients into two groups; Group A had skeletonization of both internal mammary arteries, and Group B had pedicled left mammary and skeletonized right mammary. Patients were observed for three months, post-operatively for any sternal wound problems.
 Results: There was no significant difference regarding the baseline variables. Type I diabetes mellitus was present in 25% in group A (n= 24) and 13.64% in group B (n= 12) (p= 0.324). There was no difference in harvest time between groups (83 ±4 vs. 81 ±3 minutes in group A vs. B, respectively. P= 0.1). The mean number of grafts was 3± 0.5 in Group A and 3± 0.6 in Group B (p= 0.8). Postoperative drainage was 402.9 ± 174.1 ml in Group A vs. 387.2 ± 153.6 ml in Group B (p= 0.474). The duration of ICU stay did not differ significantly between groups (2± 0.7 in Group A vs. 2± 0.5 in Group B; p= 0.8). Deep sternal wound infection occurred in 4.17% in group A (n= 4) and 4.55% in group B (n= 4) (p= 0.705). Superficial wound infection occurred in eight patients in group A (8.33%) and eight patients in group B (9.1%) (p= 0.59). No patient had sternal dehiscence in group A vs. four patients in group B (4.55%) (p= 0.39).
 Conclusion: We did not find differences between bilateral mammary artery harvest with skeletonization of both arteries versus skeletonization of the right mammary only on sternal healing nor wound infection in diabetic patients undergoing CABG. A larger study is recommended.

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

This single-center study aimed to evaluate the incidence of deep sternal wound infection (DSWI) following skeletonized bilateral internal mammary artery (BIMA) harvest in a Chinese cohort. Using propensity score matching, this study also provided a present-day assessment of the impacts of skeletonized BIMA grafting versus skeletonized single internal mammary artery (SIMA) grafting on early outcomes.From January 2014 to December 2017, 2403 eligible patients were entered into either a BIMA group (n = 368) or a SIMA group (n = 2035). The incidence of DSWI was recorded. Analysis of early outcomes was further performed for propensity score-matched (1:1) cohorts.The BIMA group received a similar incidence of DSWI as did the SIMA group (1.6% versus 0.9%, P = 0.247). No significant differences between subgroup diabetic-BIMA, subgroup nondiabetic-BIMA, subgroup diabetic-SIMA, and subgroup nondiabetic-SIMA were found regarding the incidence of DSWI (2.0%, 1.4%, 1.0%, and 0.7%, respectively; P > 0.05 between groups). After matching, treatment type (skeletonized BIMA grafting versus skeletonized SIMA grafting) was not an independent risk factor for postoperative DSWI (OR = 1.309, 95% CI 0.897-2.714, P = 0.704) or predictors of other early outcomes. Additionally, the two matched groups shared similar early outcomes (including postoperative DSWI), regardless of whether or not the merger with diabetes (all P > 0.05).Skeletonized BIMA harvest as compared with skeletonized SIMA harvest was not associated with an increased risk of DSWI, regardless of whether or not the merger with diabetes. Patients with skeletonized BIMA grafting received similar surgical mortality and major postoperative morbidity as did matched patients with skeletonized SIMA grafting.

Sternal wound closure in the current era: the need of a tailored approach.

Median sternotomy remains the most common access to perform cardiac surgery procedures. However, the experience of the operating surgeon remains a crucial factor during sternal closure to avoid potential complications related to poor sternal healing, such as mediastinitis. Considering the lack of major randomized controlled trials and the heterogeneity of the current literature, this narrative review aims to summarize the different techniques and approaches to sternal closure with the aim to investigate their reflections into clinical outcomes and to inform the choice on the most effective closure method after median sternotomy. A literature search through PubMed, Embase, EBSCO, Cochrane database of systematic reviews, and Web of Science from its inception up to April 2019 using the following search keywords in various combinations: sternal, sternotomy, mediastinitis, deep sternal wound infection, cardiac surgery, closure. Single wire fixation methods, at present, seems the most useful method to perform sternal closure in routine patients, although patients with a fragile sternum might benefit more from a figure-of-eight technique. In high-risk patients (e.g. chronic pulmonary disease, obesity, bilateral internal mammary artery harvesting, diabetes, off-midline sternotomy), rigid plate fixation is currently the most effective method, if available; alternatively, weave techniques could be used. The choice among the sternal closure techniques should be mainly inspired and tailored on the patient's characteristics, and correct judgement and experience play a pivotal role. A decisional algorithm has been proposed as an attempt to overcome the absence of specific guidelines and to guide the operative approach. This operative approach might be used also in non-cardiac procedure in which median sternotomy is required, such as in case of thoracic surgery.

Is bilateral internal thoracic artery grafting in poorly controlled diabetic obese patients a contraindication? A single center pilot study

BackgroundIn spite of substantial evidence supporting a long-term survival benefit with bilateral internal mammary artery (BIMA) grafts in CABG, this technique remains grossly underutilized worldwide. The incidence of deep sternal wound infection (DSWI) following BIMA harvest ranges from 0.6% to 4.2%. The high incidence of obesity and diabetes among Kuwait population encouraged us to study the incidence of DSWI among our patients with BIMA. Methods101 patients who underwent CABG procedure with BIMA use in Al-Dabbous Cardiac center, Al-Adan Hospital, Kuwait. Between June 2014 and December 2016, were included and analyzed retrospectively. Results92 patients included in our study were males (91.1%) and were 9 females (8.9%). 86 patients had HbA1c > 7% (85.2%). 20 patients (19.8%) had Body Mass Index (BMI) > 30. Of all studied patients, 12 patients (11.9%) had both BMI > 30 and HbA1c > 7. DSWI occurred in 3 patients (3%) out of the studied 101 patients, 2 of them had BMI > 30 and HbA1c > 7. The multi-variable analysis showed a significant correlation between the occurrence of DSWI and female gender (p value = 0.001) as well as a combination of BMI > 30 and level of HbA1c > 7 (p value = 0.037). Age, HbA1c > 7 with BMI <30 and BMI >30 with HbA1c < 7, failed to show any statistically significant increase in the incidence of DSWI in our study group. ConclusionsBased on our results, BIMA grafting in poorly controlled diabetic obese patients especially of female gender shouldn't be used to avoid the higher incidence of DSWI among them.

A Novel Robotic Bilateral Internal Mammary Artery Harvest Using Double Docking Technique for Coronary Artery Bypass Grafting.

da Vinci Surgical System (da Vinci) enabled port access for internal mammary arteries (IMA) harvesting. However, bilateral IMA (BIMA) harvesting is difficult when performed on single side. We developed a novel technique of double docking the da Vinci by transpositioning from the left side to the right and examined the feasibility. Twelve patients underwent BIMA harvesting using the double-docking technique. First, the da Vinci was set on the patient's left side for the right IMA harvesting. Afterward, the da Vinci was undocked and transpositioned from the patient's left side to the right side. The time elapsed during rotation was measured. Subsequently, the left IMA was harvested from patient's right side. Distal anastomoses were performed by a small anterolateral thoracotomy. All of the IMAs were harvested and then bypassed without damage. The mean ± SD time that elapsed during rotation was 6.5 ± 0.6 minutes. There was no conversion to sternotomy. Bilateral IMA harvesting by the bilateral docking technique was performed successfully with acceptable feasibility.

A Novel Robotic Bilateral Internal Mammary Artery Harvest Using Double Docking Technique for Coronary Artery Bypass Grafting

A Novel Robotic Bilateral Internal Mammary Artery Harvest Using Double Docking Technique for Coronary Artery Bypass Grafting

Continuous Intraoperative Cefazolin Infusion May Reduce Surgical Site Infections During Cardiac Surgical Procedures: A Propensity-Matched Analysis.

The authors sought to determine whether an institutional transition from intermittent to continuous dosing of intraoperative antibiotics in cardiac surgery affected surgical site infection (SSI) outcomes. A retrospective chart review utilizing propensity matching. A single academic, tertiary care hospital. One thousand one hundred seventy-nine patients undergoing coronary artery bypass grafting (CABG) and/or cardiac valvular surgery between April 2013 and November 2014 who received perioperative cefazolin. By method of cefazolin administration, patients were divided into an "intermittent-dosing" (ID) group and a "continuous-infusion" (CI) group. Of the 1,179 patients who underwent cardiac surgery during the study period, 1:1 propensity score matching yielded 399 patients in each group. Rates of diabetes (33.6% ID v 33.8% CI, p = 0.94), coronary artery bypass (62.3% v 61.4%, p = 0.66), and bilateral internal mammary artery harvesting (6.0% v 8.3%, p = 0.22) were similar between groups. SSIs occurred in more ID patients than CI patients (2.3% v 0.5%, p = 0.03). This difference was driven by decreases in extremity and conduit harvest site SSIs (1.8% v 0.3%, p = 0.03), as there were no episodes of mediastinitis, and superficial sternal SSI rates did not differ (0.5% v 0.3%, p = 0.56). There also were significantly fewer episodes of pneumonia in the CI group (6.0% v 2.3%, p = 0.008). Intensive care unit and total lengths of stay did not differ. Thirty-day mortality was 2.8% in both groups (p = 1.00). As compared to ID regimens, CI cefazolin infusion may reduce post-cardiac surgery infectious complications. Further study in larger patient populations is needed.

Does the number of wires used to close a sternotomy have an impact on deep sternal wound infection?

We studied the influence of the number of sternotomy mechanical fixation points on deep sternal wound infection (DSWI). Between September 2007 and February 2011, 2672 patients underwent a standard peri-sternal wire closure following a median sternotomy for a first-time cardiac surgery. Data were collected during the study period. The mean age of the patients was 66 ± 11 and 1978 (74.0%) were male. The mean body mass index (BMI) was 28.9 ± 9.3 and the median of the logistic EuroSCORE was 3.14, with a range of 0.88-54.1. Postoperatively, 40 (1.5%) patients developed DSWI after 14 ± 6 days, of whom 39 (92.5%) had positive deep sternal wound specimen cultures, predominantly Staphylococci (62.5%). The risk of DSWI was significantly increased in patients in whom eight or fewer paired points of sternal wire fixation were used when compared with patients in whom nine or more paired points of fixation were used (P = 0.002). Preoperative myocardial infarction (P = 0.001), elevated BMI (P = 0.046), bilateral internal mammary artery harvest (P < 0.0001), postoperative hypoxia (P < 0.0001), sepsis (P = 0.019) and postoperative inotrope use (P = 0.007) significantly increased the risk of DSWI. DSWI is associated with hypoxia, ischaemia, sepsis and mechanical sternal instability. DSWI may be prevented by using nine or more paired fixation points when closing with standard peri-sternal wires.

Robotic-enhanced arterial revascularization for multivessel coronary artery disease

Background. A tendency to reduce operative trauma is determining the evolution of cardiac surgical techniques lately. The introduction of robotic-enhanced endoscopic systems enables surgeons to perform arterial revascularization for multivessel disease without sternotomy. Methods. From May 1999, 17 (4 women, 13 men; median age 63 ± 7.4 years) patients with multivessel coronary artery disease were treated surgically using arterial revascularization by means of bilateral internal mammary arteries. Both arteries were harvested endoscopically using the da Vinci system (Intuitive Surgical, Mountain View, CA). These vessels were anastomosed using the “Dresden technique.” Results. Survival was 100%. Mean duration of the operation was 255 ± 40.4 minutes. Bilateral internal mammary artery harvesting took 88.5 ± 15.9 minutes; cross-clamp time was 36 ± 8.7 minutes. An average of 2.06 anastomoses were performed per operation. Postoperatively, patients remained in the intensive care unit for 21 ± 13 hours. One patient (5.8%) needed reexploration due to bleeding. Conclusions. The robotic surgical system introduces a new treatment of coronary artery disease to surgical practice, and enables arterial revascularization with distinctly reduced surgical trauma.

Acute Repair of a Full-Thickness Right Ventricular Defect with a Composite Myofascial Pedicle Flap

A full-thickness defect of the right ventricle presented acutely after mediastinitis and sternal dehiscence. This developed 29 days after bilateral internal mammary artery harvest for coronary artery bypass grafting. The defect was managed successfully with a pedicled left rectus abdominis muscle flap using an attached island of the anterior rectus sheath for endocardial lining. The vascular anatomic basis for viability of the rectus abdominis muscle flap after internal mammary artery harvest is derived primarily from musculophrenic, lumbar, lower sixth intercostal, and subcostal artery communications. In addition, the advantages of a myofascial pedicle flap for reconstruction of full-thickness cardiac defects are its ready availability and a strong anterior fascial sheath that can be used as a neoendocardial lining. The patient did well and remains asymptomatic after 3 years.