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J Thorac Cardiovasc Surg 2004;127:1534-1535
© 2004 The American Association for Thoracic Surgery

Letter to the editor

Safe bilateral use of skeletonized internal thoracic artery in patients with diabetes

^a Department of Cardiovascular Surgery, Juntendo University Hospital, Tokyo, Japan
^b Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, OH 44106, USA

To the Editor:

We read with great interest the article by Peterson and coworkers¹ on skeletonization of bilateral internal thoracic artery (ITA) grafts and lowered risk of sternal infection in patients with diabetes. Peterson and coworkers¹ reviewed 115 patients with diabetes undergoing bilateral ITA grafting and compared the incidence of postoperative sternal infection between the skeletonized ITA group and the pedicled ITA group. The study concluded that the skeletonization of the ITA would reduce the incidences of both superficial and deep sternal infections.

The most important point of the skeletonization of the ITA is preservation of sternal blood flow, which may have favorable effect on sternal infection relative to pedicled ITA harvesting.² Other benefits of skeletonization include longer graft length, larger graft caliber, and greater graft flow. The long-term benefit of bilateral ITA grafting has been reported.³ However, sternal infection has been a great concern in determining which patients should undergo bilateral ITA grafting.

Previously, we reported a study similar to that by Peterson and coworkers, and we concluded that skeletonized ITA harvesting reduces the risk of the sternal infection without increasing the risk of graft injury or early graft occlusion.⁴ The studies were similar in design, focusing on sternal infection in high-risk patients with diabetes who were undergoing bilateral ITA grafting. The only difference between the two studies was in the technique used for skeletonization (scissors and clip versus ultrasonic scalpel).

Skeletonization of the artery is immobilization of the arterial trunk from the satellite veins and surrounding tissue. The greatest concerns during skeletonization are graft injury and vasospasm, both often related to inadequate handling of the graft or incomplete hemostasis. Skeletonization can be done with clips and scissors, as described by Peterson and coworkers.¹ In our experience, however, skeletonization of the ITA can be performed much more easily and quickly with an ultrasonic scalpel, because transection of the vessel and coagulation occur at the same time. Unlike with electrocautery, heart injury to the ITA does not occur as long as the ultrasonic scalpel is applied at least 1 mm from the main trunk.² Furthermore, dissection of the ITA from the surrounding tissue can easily be performed with an ultrasonic scalpel without injuring the main trunk. In our use of the ultrasonic scalpel, we have not encountered any graft injuries or harvesting-related complications.⁴ Spasm of the graft may occur during skeletonization; in the skeletonized graft, however, spasm can be easily reversed with intraluminal injection of vasodilators.

Although neither our study nor that of Peterson and coworkers was randomized, both results support the hypothesis that skeletonized bilateral ITA grafting reduces the risk of sternal infection in diabetic patients. We strongly agree with the proposal that diabetes is no longer a contraindication for bilateral ITA grafting provided adequate skeletonization is performed.

	References

Top References

 

1. Peterson MD, Borger MA, Rao V, Peniston CM, Feindel CM. Skeletonization of bilateral internal thoracic artery grafts lowers the risk of sternal infection in patients with diabetes. J Thorac Cardiovasc Surg. 2003;126:1314–1319[Abstract/Free Full Text]
   
2. Higami T, Kozawa S, Asada T, Shida T, Ogawa K. Skeletonization and harvest of the internal thoracic artery with an ultrasonic scalpel. Ann Thorac Surg. 2000;70:307–308[Abstract/Free Full Text]
   
3. Lytle BW, Blackstone EH, Loop FD, Houghtaling PL, Arnold JH, Akhrass R, et al. Two internal thoracic artery grafts are better than one. J Thorac Cardiovasc Surg. 1999;117:855–872[Abstract/Free Full Text]
   
4. Hirose H, Amano A, Takanashi S, Takahashi A. Skeletonized bilateral internal mammary artery grafting for patients with diabetes. Interactive Cardiovasc Thorac Surg. 2003;2:287–292[Abstract/Free Full Text]
   

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Hitoshi Hirose Atsushi Amano Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Hirose, H. Articles by Amano, A. Search for Related Content PubMed PubMed Citation Articles by Hirose, H. Articles by Amano, A. Related Collections Coronary disease Related Article