American Journal of Clinical and Experimental Medicine

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Bilateral Semi-Skeletonized IMA; Less Thermal Injury, Easier to Harvest, Early Post Operative Comparison with Single IMA Patients After CABG

Received: Sep. 20, 2018    Accepted: Oct. 06, 2018    Published: Oct. 27, 2018
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Abstract

The use of BITA is prominent in coronary bypass surgery due to its positive effects on long-term mortality and morbidity. However, its use is not widespread enough among heart surgeons due to its technical difficulty and the longer period of time it requires. There are still many articles being published on the subject. In patients who receive BITA, harvesting is usually performed in a skeletonized fashion. This protects the patient from sternal complications because it disturbs the vascularity of the chest wall less compared to the pedicled technique. However, the risk for injury on IMA is high. This is where harvesting in semi-skeletonized fashion distinguishes itself. Not only does it disturb the vascularity of the chest wall less but it also has a lower risk for thermal injury. Furthermore, it provides some advantages in terms of time over skeletonized fashion. The study enrolled 24 patients who underwent an isolated CABG operation using cardiopulmonary bypass (CPB) by a single surgeon between March 2017 - December 2017. 12 patients (10 males, 2 females; mean age: 55.083) underwent CABG operation using semi-skeletonized BITA (Table 1). Another 12 patients (8 males, 4 females; mean age: 56.25) underwent CABG using LIMA and venous graft. Post-operative sternal wound complications and post-operative pain of patients were compared. In the patients of the BITA group, cross clamp time, operation time and mammary harvesting time caused a slight prolongation. None of patients had deep sternal infection or mediastinitis or mechanical sternal dehiscence. BITA harvesting patients had more postoperative pain. As a result using semi-skeletonized ITA is more beneficial for sternal wound recovery compared to IMA harvested with the pedicled technique because the former causes less trauma in the thorax and disturbs the bleeding of the chest wall less. Furthermore, we think that it has advantages in terms of time and less traumatic effects on ITA compared to ITA harvested in a skeletonized fashion.

DOI 10.11648/j.ajcem.20180605.11
Published in American Journal of Clinical and Experimental Medicine ( Volume 6, Issue 5, September 2018 )
Page(s) 107-112
Creative Commons

This is an Open Access article, distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution and reproduction in any medium or format, provided the original work is properly cited.

Copyright

Copyright © The Author(s), 2024. Published by Science Publishing Group

Keywords

Semi-Sklerotonized IMA, Bilateral Mammaria, VAS Score, Sternal Wound Infection, IMA Harvesitng

References
[1] Kolh P, Windecker S, Alfonso F, Collet JP, Cremer J, Falk V et al. 2014 ESC/EACTS guidelines on myocardial revascularization: the task force on myocardial revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur J Cardiothorac Surg 2014;46:517–92.
[2] Loop FD, Lytle BW, Cosgrove DM, Stewart RW, Goormastic M, Williams GW et al. Influence of the internal-mammary-artery graft on 10-year survival and other cardiac events. N Engl J Med 1986; 314:1–6.
[3] Ruttmann E, Fischler N, Sakic A, Chevtchik O, Alber H, Schistek R et al. Second internal thoracic artery versus radial artery in coronary artery bypass grafting: a long-term, propensity score-matched follow-up study. Circulation 2011; 124: 1321–9.
[4] Buttar SN, Yan TD, Taggart DP, Tian DH. Long-term and short-term outcomes of using bilateral internal mammary artery grafting versus left internal mammary artery grafting: a meta-analysis. Heart 2017;103: 1419–26.
[5] Lytle BW, Blackstone EH, Sabik JF, Houghtaling P, Loop FD, Cosgrove DM. The effect of bilateral internal thoracic artery grafting on survival during 20 postoperative years. Ann Thorac Surg 2004;78:2005–12; discussion 12–14.
[6] Tabata M, Grab JD, Khalpey Z, Edwards FH, O’Brien SM, Cohn LH et al. Prevalence and variability of internal mammary artery graft use in contemporary multivessel coronary artery bypass graft surgery: analysis of the Society of Thoracic Surgeons National Cardiac Database. Circulation 2009;120:935–40.
[7] Lytle BW, Blackstone EH, Loop FD, Houghtaling PL, Arnold JH, Akhrass R, et al. Two internal thoracic artery grafts are better than one. J Thorac Cardiovasc Surg 1999;117:855–72.
[8] Buxton BF, Komeda M, Fuller JA, Gordon I. Bilateral internal thoracic artery grafting may improve outcome of coronary artery surgery. Risk-adjusted survival. Circulation 1998;98(Suppl 2):1–6.
[9] Kouchoukos NT, Wareing TH, Murphy SF, Pelate C, Marshall WG Jr. Risks of bilateral internal mammary artery bypass grafting. Ann Thorac Surg 1990;49:210–7.
[10] Loop FD, Lytle BW, Cosgrove DM, Mahfood S, McHenry MC, Goormastic M, et al. J. Maxwell Chamberlain memorial paper. Sternal wound complications after isolated coronary artery bypass grafting: early and late mortality, morbidity, and cost of care. Ann Thorac Surg 1990;49:179–86.
[11] Grossi EA, Esposito R, Harris LJ, Crooke GA, Galloway AC, Colvin SB, et al. Sternal wound infections and use of internal mammary artery grafts. J Thorac Cardiovasc Surg 1991;102:342–6.
[12] Calafi ore AM, Vitolla G, Iaco AL, Fino C, Di Giammarco G, Marchesani F, et al. Bilateral internal mammary artery grafting: midterm results of pedicled versus skeletonized conduits. Ann Thorac Surg 1999;67:1637–42.
[13] Galbut DL, Traad EA, Dorman MJ, DeWitt PL, Larsen PB, Kurlansky PA, et al. Seventeen-year experience with bilateral internal mammary artery grafts. Ann Thorac Surg 1990;49:195–201.
[14] Sofer D, Gurevitch J, Shapira I, Paz Y, Matsa M, Kramer A, et al. Sternal wound infections in patients after coronary artery bypass grafting using bilateral skeletonized internal mammary arteries. Ann Surg 1999;229:585–90.
[15] Matsa M, Paz Y, Gurevitch J, Shapira I, Kramer A, Pevny D, et al. Bilateral skeletonized internal thoracic artery grafts in patients with diabetes mellitus. J Thorac Cardiovasc Surg 2001;121:668–74.
[16] Horii T, Suma H. Semiskeletonization of internal thoracic artery: alternative harvest technique. Ann Thorac Surg 1997;63:867–8.
[17] Kenan A K, Zafer E, Aytuğ K, Şenol G, Hüseyin O. The Comparison between Two Sternum Closure Techniques after Coronary Bypass Surgery; Sterna-Band® (Peninsula) and Sternum Band (Ethicon®). Adv Card Res 1(2)- 2018. ACR.MS.ID.000106
[18] Succi J E, Gerola L R, Succi M, Kim HC, Paredes JE, Bufollo E. Intraoperative coronary grafts flow measurement using the TTFM flowmeter: results from a domestic sample. Rev Bras Cir Cardiovasc. 2012;27:401-404.
[19] Lehnert M, Moller C, Damgard S, et al. Transit-Time flow measurement as a predictor of Coronary bypass graft failure at one year angiographic follow-up. J Card Surg. 2014;30:46–52.
[20] Walker P, Daniel W, Moss E, et al. The accuracy of transit time flow measurement in predicting graft patency after coronary artery bypass grafting. Innovations. 2013;8:416–419.
[21] Banjanović B, Bergsland J, Mujanović E, Kabil E. Importance of fulllength scan of arterial grafts in coronary artery bypass grafting. Innovations. 2015;10:352-353.
[22] Peterson MD, Borger MA, Rao V, et al. Skeletonization of bilateral internal thoracic artery grafts lowers the risk of sternal infection in patients with diabetes. J Thorac Cardiovasc Surg 2003;126:1314-9.
[23] Gaudino M, Toesca A, Nori SL, et al. Effect of skeltonization of the internal thoracic artery on vessel wall integrity. Ann Thorac Surg 1999;68:1623-7.
[24] Yoshikai M, Ito T, Kamohara K, et al. Endothelial integrity of ultrasonically skeletonized internal thoracic artery: morphological analysis with scanning electron microscopy. Eur J Cardiothorac Surg 2004;25:208-11.
[25] Boodhwani M, Lam BK, Nathan HJ, et al. Skeltonized internal thoracic artery harvest reduces pain and dysesthesia and improves sternal perfusion after coronary artery bypass surgery: a randomized, double-blind, within patient comparison. Circulation 2006;114:766-73.
[26] Higami T, Yamashita T, Nohara H, et al. Early results of coronary grafting using ultrasonically skeletonized internal thoracic arteries. Ann Thorac Surg 2001;71:1224-8.
[27] Glineur D, Boodhwani M, Poncelet A, et al. Comparison of fractional flow reserve of composite Y-grafts with saphenous vein or right internal thoracic arteries. J Thorac Cardiovasc Surg 2010;140:639-45.
[28] Maniar HS, Sundt TM, Barner HB, et al. Effect of target stenosis and location on radial artery graft patency. J Thorac Cardiovasc Surg 2002;123:45-52.
[29] Ngu JMC, Guo MH, Glineur D, Tran D, Rubens FD. The balance between short-term and long-term outcomes of bilateral internal thoracic artery skeletonization in coronary artery bypass surgery: a propensity-matched cohort study. Eur J Cardiothorac Surg 2018; doi:10.1093/ejcts/ezy025.
[30] Wang FD, Chang CH: Risk factors of deep sternal wound infections in coronary artery bypass graft surgery. J Cardiovasc Surg (Torino) 41:709-713, 2000.
[31] Abboud CS, Wey SB, Baltar VT: Risk factors for mediastinitis after cardiac surgery. Ann Thorac Surg 77:676-683, 2004
[32] Nagachinta T, Stephens M, Reitz B, et al: Risk factors for surgical-wound infection following cardiac surgery. J Infect Dis 156: 967-973, 1987.
[33] Stahle E, Tammelin A, Bergstrom R, et al: Sternal wound complications—Incidence, microbiology and risk factors. Eur J Cardiothorac Surg 11:1146-1153, 1997.
[34] Grossi EA, Culliford AT, Krieger KH, et al: A survey of 77 major infectious complications of median sternotomy: A review of 7,949 consecutive operative procedures. Ann Thorac Surg 40:214-223, 1985.
[35] Ottino G, De Paulis R, Pansini S, et al: Major sternal wound infection after open-heart surgery: A multivariate analysis of risk factors in 2,579 consecutive operative procedures. Ann Thorac Surg 44:173-179, 1987.
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  • APA Style

    Kenan Abdurrahman Kara. (2018). Bilateral Semi-Skeletonized IMA; Less Thermal Injury, Easier to Harvest, Early Post Operative Comparison with Single IMA Patients After CABG. American Journal of Clinical and Experimental Medicine, 6(5), 107-112. https://doi.org/10.11648/j.ajcem.20180605.11

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    ACS Style

    Kenan Abdurrahman Kara. Bilateral Semi-Skeletonized IMA; Less Thermal Injury, Easier to Harvest, Early Post Operative Comparison with Single IMA Patients After CABG. Am. J. Clin. Exp. Med. 2018, 6(5), 107-112. doi: 10.11648/j.ajcem.20180605.11

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    AMA Style

    Kenan Abdurrahman Kara. Bilateral Semi-Skeletonized IMA; Less Thermal Injury, Easier to Harvest, Early Post Operative Comparison with Single IMA Patients After CABG. Am J Clin Exp Med. 2018;6(5):107-112. doi: 10.11648/j.ajcem.20180605.11

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  • @article{10.11648/j.ajcem.20180605.11,
      author = {Kenan Abdurrahman Kara},
      title = {Bilateral Semi-Skeletonized IMA; Less Thermal Injury, Easier to Harvest, Early Post Operative Comparison with Single IMA Patients After CABG},
      journal = {American Journal of Clinical and Experimental Medicine},
      volume = {6},
      number = {5},
      pages = {107-112},
      doi = {10.11648/j.ajcem.20180605.11},
      url = {https://doi.org/10.11648/j.ajcem.20180605.11},
      eprint = {https://download.sciencepg.com/pdf/10.11648.j.ajcem.20180605.11},
      abstract = {The use of BITA is prominent in coronary bypass surgery due to its positive effects on long-term mortality and morbidity. However, its use is not widespread enough among heart surgeons due to its technical difficulty and the longer period of time it requires. There are still many articles being published on the subject. In patients who receive BITA, harvesting is usually performed in a skeletonized fashion. This protects the patient from sternal complications because it disturbs the vascularity of the chest wall less compared to the pedicled technique. However, the risk for injury on IMA is high. This is where harvesting in semi-skeletonized fashion distinguishes itself. Not only does it disturb the vascularity of the chest wall less but it also has a lower risk for thermal injury. Furthermore, it provides some advantages in terms of time over skeletonized fashion. The study enrolled 24 patients who underwent an isolated CABG operation using cardiopulmonary bypass (CPB) by a single surgeon between March 2017 - December 2017. 12 patients (10 males, 2 females; mean age: 55.083) underwent CABG operation using semi-skeletonized BITA (Table 1). Another 12 patients (8 males, 4 females; mean age: 56.25) underwent CABG using LIMA and venous graft. Post-operative sternal wound complications and post-operative pain of patients were compared. In the patients of the BITA group, cross clamp time, operation time and mammary harvesting time caused a slight prolongation. None of patients had deep sternal infection or mediastinitis or mechanical sternal dehiscence. BITA harvesting patients had more postoperative pain. As a result using semi-skeletonized ITA is more beneficial for sternal wound recovery compared to IMA harvested with the pedicled technique because the former causes less trauma in the thorax and disturbs the bleeding of the chest wall less. Furthermore, we think that it has advantages in terms of time and less traumatic effects on ITA compared to ITA harvested in a skeletonized fashion.},
     year = {2018}
    }
    

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    AB  - The use of BITA is prominent in coronary bypass surgery due to its positive effects on long-term mortality and morbidity. However, its use is not widespread enough among heart surgeons due to its technical difficulty and the longer period of time it requires. There are still many articles being published on the subject. In patients who receive BITA, harvesting is usually performed in a skeletonized fashion. This protects the patient from sternal complications because it disturbs the vascularity of the chest wall less compared to the pedicled technique. However, the risk for injury on IMA is high. This is where harvesting in semi-skeletonized fashion distinguishes itself. Not only does it disturb the vascularity of the chest wall less but it also has a lower risk for thermal injury. Furthermore, it provides some advantages in terms of time over skeletonized fashion. The study enrolled 24 patients who underwent an isolated CABG operation using cardiopulmonary bypass (CPB) by a single surgeon between March 2017 - December 2017. 12 patients (10 males, 2 females; mean age: 55.083) underwent CABG operation using semi-skeletonized BITA (Table 1). Another 12 patients (8 males, 4 females; mean age: 56.25) underwent CABG using LIMA and venous graft. Post-operative sternal wound complications and post-operative pain of patients were compared. In the patients of the BITA group, cross clamp time, operation time and mammary harvesting time caused a slight prolongation. None of patients had deep sternal infection or mediastinitis or mechanical sternal dehiscence. BITA harvesting patients had more postoperative pain. As a result using semi-skeletonized ITA is more beneficial for sternal wound recovery compared to IMA harvested with the pedicled technique because the former causes less trauma in the thorax and disturbs the bleeding of the chest wall less. Furthermore, we think that it has advantages in terms of time and less traumatic effects on ITA compared to ITA harvested in a skeletonized fashion.
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Author Information
  • Department of Cardiovascular Surgery, Yeditepe Univesity Hospital, Ata?ehir, Istanbul, Turkey

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