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J Thorac Cardiovasc Surg 2003;125:S71-S73
© 2003 The American Association for Thoracic Surgery

Editorials

Skeletonized internal thoracic artery grafts and wound complications

From the Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio.

Received for publication Aug 9, 2000. Accepted for publication Sept 8, 2000. Address for reprints: Bruce W. Lytle, MD, Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, 9500 Euclid Ave, F-25, Cleveland, OH 44195 (E-mail: lytleb@ccf.org).

The first 20% of the full text of this article appears below.

There is increasing evidence that patients who receive bilateral internal thoracic artery (BITA) grafts have better long-term outcomes than those receiving single ITA grafts. ^1,2 However, surgeons have resisted the idea of routine BITA grafting for multiple reasons. BITA grafting increases the difficulty and usually the duration of the operation. These objections are not fundamental and have become less important with effective myocardial protection and increased experience with microsurgical and arterial grafting techniques. The most real, persistent, and serious objection to BITA grafting has been an increased risk of sternal wound complications. ^3,4

Multiple retrospective clinical studies of patients undergoing bypass surgery have documented an increased risk of sternal wound complications associated with BITA grafting, and some series have specifically identified diabetes as a factor associated with a greatly increased risk, ^3,4 an observation that has often led surgeons to avoid BITA grafting in diabetic patients. The disadvantage of this policy is that it withholds from diabetic patients a strategy that may be of particular benefit to patients with severe and diffuse coronary artery disease. The increased risk of wound complications appears to be caused by sternal ischemia. Anatomic studies predict a decrease in sternal blood flow resulting from BITA dissection and, in fact, perioperative flow studies have confirmed that sternal blood flow is decreased perioperatively by ITA dissection, more after BITA grafting than after single ITA grafting. ^5-9 Traditionally, at most . . . [Full Text of this Article]