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Ann Thorac Surg 2007;84:1796-1797. doi:10.1016/j.athoracsur.2007.06.093
© 2007 The Society of Thoracic Surgeons
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Correspondence

Preserved Sternal Perfusion Following ITA Skeletonization: Implications for Bilateral ITA Grafting

Munir Boodhwani, MD, MMSc, Fraser D. Rubens, MD, MS

Division of Cardiac Surgery, University of Ottawa Heart Institute, H3401, 40 Ruskin St, Ottawa, Ontario K1Y 4W7, Canada

(Email: mboodhwani{at}ottawaheart.ca).

To the Editor:

We read with great interest the article by Savage and colleagues [1] who reported the increased risk of deep sternal wound infections (DSWI) in patients undergoing bilateral internal thoracic artery grafting (BITA). The authors found that the use of BITA grafting in The Society of Thoracic Surgeons’ database is disappointingly low (1.4%), and even in this carefully selected cohort the incidence of DSWI is approximately two-fold higher in BITA patients.

Skeletonization is the only proposed surgical intervention that can potentially reduce the incidence of DSWI in patients undergoing coronary artery bypass surgery. By harvesting only the internal thoracic artery (ITA), without the accompanying vein, nerves, and endothoracic fascia, and by ligating the branches close to their origin, the blood supply to the sternum can be substantially preserved [2]. We would like to point out, contrary to what is stated in the discussion, that there is now evidence from two randomized studies demonstrating that internal thoracic artery skeletonization preserves sternal perfusion to a greater degree than nonskeletonized harvest. The study by Cohen and colleagues [3] randomized patients to skeletonized versus nonskeletonized left internal thoracic artery harvest, and the study performed by our group [4] used an intra-patient comparison of sternal perfusion in patients undergoing bilateral ITA harvest using one skeletonized and one nonskeletonized ITA. These studies have demonstrated a 17% to 28% increase in sternal perfusion with the skeletonized versus the nonskeletonized technique, which may be the reason for reduced sternal wound infection rates observed with ITA skeletonization in nonrandomized studies. Ultimately, adequately powered, randomized controlled trials should be conducted to definitively determine the benefits of skeletonization on clinically relevant outcomes.


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 References
 

  1. Savage EB, Grab JD, O’Brien SM, et al. Use of both internal thoracic arteries in diabetic patients increases deep sternal wound infection Ann Thorac Surg 2007;83:1002-1006.[Abstract/Free Full Text]
  2. de Jesus RA, Acland RD. Anatomic study of the collateral blood supply of the sternum Ann Thorac Surg 1995;59:163-168.[Abstract/Free Full Text]
  3. Cohen AJ, Lockman J, Lorberboym M, et al. Assessment of sternal vascularity with single photon emission computed tomography after harvesting of the internal thoracic artery J Thorac Cardiovasc Surg 1999;118:496-502.[Abstract/Free Full Text]
  4. Boodhwani M, Lam BK, Nathan HJ, et al. Skeletonized 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;114:766-773.[Abstract/Free Full Text]

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Edward B. Savage
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Ann. Thorac. Surg., November 1, 2007; 84(5): 1797 - 1797.
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