Ann Thorac Surg 2006;81:406
© 2006 The Society of Thoracic Surgeons
Shahzad G. Raja, MRCS
Gilles D. Dreyfus, MD, PhD
a Department of Cardiac Surgery, Royal Hospital for Sick Children, Yorkhill NHS Trust, Dalnair St, Glasgow, G3 8SJ United Kingdom
b Department of Cardiac Surgery, Harefield Hospital, London, United Kingdom
To the Editor:
We greatly appreciate the remarks of Dr Cunningham , a proponent of skeletonization technique, and will take this opportunity to inform him that we also believe in the numerous benefits of skeletonization and routinely practice this technique. However, as our publication was a systematic review, we had to present an unbiased evaluation of available scientific evidence and unfortunately to date no prospective, randomized controlled trial (RCT) with long-term follow-up has been published on the subject. We are currently practicing in an era of evidence-based medicine where RCTs have been allotted the highest level of evidence [2, 3]. Despite several large retrospective studies  including that of Cunningham and colleagues  who have reported encouraging results for the skeletonization technique, one has to concede that for the skeptics to accept skeletonization as advantageous, convincing evidence from RCTs with long-term angiographic as well as clinical follow-up is essential in the present era.
With respect to Dr Cunningham's remark that we regard skeletonization "a relatively new surgical technique" we will humbly point out that we never made such a comment in our article. Instead we stated that due to the various benefits, the skeletonization technique, pioneered by Sauvage and colleagues , has been recently advocated. Furthermore, we agree with Dr Cunningham that the speculations about worse long-term patency rates have not been substantiated by retrospective comparative studies (evidence grade C). However, lack of convincing evidence from RCTs in our opinion is probably one of the major reasons that only a minority of surgeons uses the technique worldwide.
In conclusion, we hope that Dr Cunningham will agree with us that despite skeletonization being a safe and useful surgical technique for surgeons using the concept of total arterial revascularization, there is limited published literature, especially a paucity of large, multicenter RCTs on this technique.
- Cunningham JM. Skeletonization of the internal thoracic arterypros and cons. Ann Thorac Surg 2006;81:405-406.[Free Full Text]
- Raja SG. OPCAB and the incidence of atrial fibrillationignoring the current best available evidence. Eur J Cardiothorac Surg 2005;27:930.[Medline]
- Raja SG, Dreyfus GD. Off-pump coronary artery bypass surgery: to do or not to do? Current best available evidence J Cardiothorac Vasc Anesth 2004;18:486-505.[Medline]
- Raja SG, Dreyfus GD. Internal thoracic arteryTo skeletonize or not to skeletonize?. Ann Thorac Surg 2005;79:1805-1811.[Abstract/Free Full Text]
- Cunningham JM, Gharavi MA, Fardin R, Meek RA. Considerations in the skeletonization technique of internal thoracic artery dissection Ann Thorac Surg 1992;54:947-950.[Abstract/Free Full Text]
- Sauvage LR, Wu HD, Kowalsky TE, et al. Healing basis and surgical techniques for complete revascularization of the left ventricle using only the internal mammary arteries Ann Thorac Surg 1986;42:449-465.[Abstract/Free Full Text]