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Ann Thorac Surg 1996;61:913
© 1996 The Society of Thoracic Surgeons

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Invited Commentary

Invited Commentary

Columbus Cardiothoracic and Vascular Surgical Associates 2522 Warm Springs Rd Columbus, GA 31904

See also page 909.

Currently, one or more arterial conduits are used routinely in primary or secondary myocardial revascularization procedures. If the internal thoracic artery (ITA) is available, most cardiac surgeons dissect the vessel as a variable-width pedicle containing an assortment of venae comitantes, lymphatics, adipose tissue, muscle, and fascia. Topical or intraluminal papaverine solution is frequently used to minimize spasm and enhance ITA diameter and flow. Some surgeons, however, prefer ITA skeletonization as an alternate harvesting technique. Each method has its own inherent advantages and disadvantages, but both techniques provide excellent long-term results.

In this report, Choi and Lee used both ITA procurement techniques and then compared free flow rates after initiating cardiopulmonary bypass. Skeletonized ITAs had higher initial flow rates than the pedicled ITAs and essentially the same preanastomosis flow rates as ITAs subjected to intraluminal papaverine. Choi and Lee concluded that ``skeletonization of the ITA is as efficient a strategy to increase ITA flow as intraluminal papaverine injection for the pedicled graft.''

In the final analysis, both harvesting techniques produce satisfactory conduits with equivalent flow rates. Therefore, is there any reason to spend the extra prebypass time and effort required to skeletonize the ITA? Perhaps. If the ITA is going to be used for sequential grafting, side-to-side anastomoses are technically easier to construct if the ITA is skeletonized. Also, anastomoses can be done expeditiously because no further dissection of tissue surrounding the ITA is required. Additionally, a skeletonized ITA may provide more distal anastomotic options because it usually is longer and has a larger diameter than a pedicled ITA. Finally, if both ITAs are used in diabetic, obese, or pulmonary compromised patients, there is a definite increase in postoperative sternal wound infection. Previous reports suggest that the incidence of sternal wound infection may be decreased in these patients if the ITAs are skeletonized rather than dissected as pedicles.

Footnotes

Address reprint requests to Dr Choi, Department of Thoracic and Cardiovascular Surgery, Wonkwang University School of Medicine, 344-2 Sinyong-dong, Iksan, Jeonbuk, 570-180, South Korea.

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): James M. Cunningham Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Cunningham, J. M. Search for Related Content PubMed Articles by Cunningham, J. M.