Ann Thorac Surg 2006;81:144
© 2006 The Society of Thoracic Surgeons
Original article: Cardiovascular
Invited commentary
Michel Carrier, MD, FRCSC
Department of Surgery, Montreal Heart Institute, 5000 Belanger St E, Montreal, PQ, Canada H1T 1C8
(Email: michel.carrier{at}icm-mhi.org).
Bilateral internal thoracic artery (BITA) grafting has been shown to prolong life and decrease the risk of myocardial infarction and coronary reoperation. Despite the enthusiasm of authors who have reviewed their experience with BITA grafts, the number of patients who receive BITA grafts remains low and averages only 42% in my own group practice [1]. Why are surgeons so reluctant to proceed with BITA grafting? The most real, persistent, and serious objection to BITA grafting has been an increased risk of sternal wound complications, especially in diabetic and obese patients.
The present study of Zeitani and colleagues [2] represents the most comprehensive published report that addresses this problem. The authors describe a partial right skeletonized BITA grafting technique that is intended to preserve the vascular supply to the right lower sternum in 78 patients. Using transthoracic Doppler, direct distal RITA injections and computed tomographic scanning, the blood supply to the right middle and distal hemisternum was found to be preserved. In a previous study we showed serious, but transient, hypoperfusion of the distal third of the sternum using scintitomogram after pedicled BITA grafting [3]. Zeitani and colleagues [2] are correct in attempting to preserve vascular perfusion of the distal sternum.
Now that partial-right and skeletonized BITA grafting is shown to preserve lower sternal perfusion, can this information translate into clinical benefits for patients? The present study reported a 2.6% rate of sternal wound complications with the partial-right BITA as compared with 9.8% in patients who had full length skeletonized BITA grafting; this is a significant difference. In studying our experience, we reported a 1.4% rate of sternal wound complications in 214 BITA grafted diabetic patients [4]. On the other hand, Lytle [5] wrote that the skeletonized ITA technique is not a panacea for avoiding wound problems; nevertheless, the bulk of evidence indicates that it decreases these complications.
Sternal wound complications, infection, and dehiscence remain related to a variety of factors that are difficult to fully understand. Tight perioperative glucose control, tight sternal closure with meticulous wound closing technique, and avoidance not only of bone wax but also of electrocautery in the sternal wound may also help to decrease wound complication rates.
Several years ago, during my own residency, Grondin [6] wrote that the use and indications for ITA grafts must be widened to retain the enormous benefits of CABG throughout the years. We can restate his editorial in suggesting that sternal wound infection remains one of "the last flags on the field" of coronary revascularization in restraining surgeons from using the best technical approach to CABG (ie, BITA grafting). Although of great interest and spurred by unlimited enthusiasm, the results presented in the Zeitani and colleagues [2] study should be confirmed in a well-designed, randomized, clinical trial.
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References
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- Stevens LM, Carrier M, Perrault LP, et al. Single versus bilateral internal thoracic artery grafts with concomitant saphenous vein grafts for multivessel coronary artery bypass graftingeffects on mortality and event-free survival. J Thorac Cardiovasc Surg 2004;127:1408-1415.[Abstract/Free Full Text]
- Zeitani J, Penta de Peppo A, De Paulis R, et al. Benefit of partial right-bilateral internal thoracic artery harvesting in patients at risk of sternal wound complications Ann Thorac Surg 2006;81:139-144.[Abstract/Free Full Text]
- Carrier M, Grégoire J, Tronc F, Cartier R, Leclerc Y, Pelletier LC. Effect of internal mammary artery dissection on sternal vascularization Ann Thorac Surg 1992;53:115-119.[Abstract]
- Stevens LM, Carrier M, Perrault LP, et al. Influence of diabetes and bilateral thoracic artery grafts on long-term outcome for multivessel coronary artery bypass grafting Eur J Cardiothorac Surg 2005;27:281-288.[Abstract/Free Full Text]
- Lytle BW. Skeletonized internal thoracic artery grafts and wound complications J Thorac Cardiovasc Surg 2001;121:625-627.[Free Full Text]
- Grondin CM. Late results of coronary artery graftingis there a flag on the field?. J Thorac Cardiovasc Surg 1984;87:161-166.[Medline]
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