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Ann Thorac Surg 2000;70:1005
© 2000 The Society of Thoracic Surgeons
a Department of Thoracic and Cardiac Surgery—414, University Hospital Nijmegen, PO Box 9101, 6500 HB Nijmegen, The Netherlands
e-mail: l.noyez{at}thchir.azn.nl
To the Editor
In their article, Gaudino and colleagues showed that skeletonization does not affect the internal thoracic artery (ITA) wall integrity [1]. The clinical question now is should all ITAs be harvested skeletonized? In their discussion Gaudino and colleagues suggest several advantages of skeletonization: the additional length, probable reduction in sternal wound and pulmonary complications, and superior free flow. However, all of these arguments are open for discussion [2].
On the other hand, even patients with ITA grafts come back for reoperation because of progression of atherosclerosis in the native coronary system, eventually combined with atherosclerosis in vein grafts. In most of these patients the ITA grafts are patent and essential for myocardial vascularization. Preservation of these patent ITA grafts is a challenge during the reoperation. First, the ITA graft may not be damaged during resternotomy. Second, the ITA graft must be dissected free for manipulation of the heart, eventually for clamping the ITA if cardioplegia is administered, or in some selected cases for recycling this ITA graft. The routing of the internal mammary artery (IMA) away from the mediastinum during the primary operation is important to avoid damage during resternotomy. The pedicle can be helpful for identification of the ITA but is certainly a "protecting cloak" during the dissection of the ITA itself. Adherences are formed around the pedicle and, in fact, only one-fourth of the artery (the upper side) is directly exposed in the operative field. The pedicle makes dissection of a patent ITA graft during reoperation much easier and safer [3].
Gaudino and colleagues clearly demonstrate excellent preservation of the structural and ultrastructural integrity of human skeletonized ITAs, which we can consider as a basic science endpoint [1, 4]. To prove that this technique results in an amelioration of the results of (total) arterial revascularization—survival—an event-free period will be difficult because of the low sensitivity of these clinical endpoints and the good results that we have with the use of normal harvested "pedicled" ITAs [5].
In conclusion, the article of Gaudino and colleagues is interesting because it demonstrated that skeletonization does not affect ITA wall integrity in human patients undergoing coronary artery bypass procedures [1]. Skeletonization of ITA grafts can certainly be useful in some selected patients; however, in routine myocardial revascularization, I advocate the use of pedicled ITAs because several of these patients will be reoperated on for progression of atherosclerosis in the native coronary arteries. At that time, the pedicle can function as a protecting cloak of the (it is to be hoped) patent ITA graft during the reoperation.
References
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  A. Kalangos Stentless bioprostheses should be properly adjusted according to the disposition of patient coronary ostia at both the inflow and outflow insertion levels J. Thorac. Cardiovasc. Surg., April 1, 2001; 121(4): 818 - 819. [Full Text] [PDF]
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A. Kalangos Reply J. Thorac. Cardiovasc. Surg., March 1, 2001; 121(3): 600 - 601. [Full Text] [PDF]
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