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Ann Thorac Surg 2007;84:36-37
© 2007 The Society of Thoracic Surgeons
Department of Surgery, Montreal Heart Institute, 5000 Belanger St, Montreal, Quebec, H1T 1C8 Canada
(Email: louis.perrault{at}icm-mhi.org).
After almost 30 years of routine use, the left internal thoracic artery still remains the gold standard for coronary artery bypass grafting onto the left anterior descending coronary artery. Recently, grafting of bilateral internal thoracic arteries demonstrated long-term superiority in terms of survival and major adverse cardiac events. This benefit has also been confirmed in diabetic patients, but is counterbalanced by a significantly higher risk of deep sternal wound infection as compared with single left internal thoracic artery grafting. Skeletonization of the internal thoracic artery during harvesting has been advocated to reduce this risk.
Partisans of this technique argue that skeletonization allows harvesting a longer ITA graft, improves early postoperative blood flow, and preserves the sternal blood supply and reduces the sternal infection rate. On the other hand, opponents suggest that skeletonization may alter long-term graft patency by potentially damaging endothelial function and ITA vasoreactivity by loss of the vasa vasorum. Despite several publications, the debate about the safety and efficacy of skeletonization in diabetic patients remains open. This article by Kai and colleagues [1] tries to answer this question. The question is clinically relevant in diabetics as each surgeon should be aware of the suggested short-term benefit of skeletonization on wound infection and the possible reduced patency rate. Unfortunately, Kai and colleagues [1] do not adequately answer this concern because mean follow up is only 3.4 ± 2.1 years. Nevertheless, the authors confirm an early, significant reduction in deep sternal wound infections with the use of skeletonized BITA (0.6 vs 13%). Moreover and interestingly, the short-term clinical outcome is not different between skeletonized and pedicled groups. But the reader should pay attention to the short-term survival as both curves tend to separate to the detriment of the skeletonized group. Although the difference does not reach statistical significance, this downward trend should certainly be ruled out by future long-term studies. Yet, according to these results, short-term freedom from cardiac-related mortality and cardiac-related adverse events are similar in both groups and suggest that skeletonization does not alter graft wall integrity and function, at least initially.
Another limitation of this article is the methodology. Indeed, comparison between both groups is greatly impaired by the disparity in the number of patients, age, era, and global coronary artery bypass grafting technique used. In particular, the pedicled group was operated on under classical cardiopulmonary bypass, whereas the skeletonized group was performed in off-pump settings. However, in spite of moot results, this article is interesting because it opens the way for further clinical studies that must compare two homogeneous groups of diabetic patients and determine whether the reduction of sternal infection provided by skeletonized internal thoracic artery harvesting in this high-risk subgroup is offset by impaired long-term survival or adverse cardiac events.
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