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

Letter to the editor

Reply to the Editor

Mark D. Peterson, MD, Michael A. Borger, MD, PhD

Division of Cardiac Surgery, Toronto General Hospital, Department of Surgery, University of Toronto, Toronto, Ontario, Canada

Reply to the Editor:

We thank Hirose and Amano for their comments, and we are encouraged that they report a similarly low risk of sternal wound infection in patients with diabetes who received bilateral skeletonized internal thoracic artery (ITA) grafts. Several additional studies have evaluated the safety of bilateral skeletonized ITA grafts in patients at high risk for sternal wound infection.1,2 All these studies have reported a low incidence of sternal wound infection in patients with diabetes. However, we do caution against generalizing these results to patients with diabetes who have multiple risk factors for sternal infection such as obesity, peripheral vascular disease, and chronic obstructive pulmonary disease.

Hirose and Amano suggest that harvesting of skeletonized ITAs with an ultrasonic scalpel reduces the risk of graft injury and lowers the time required for dissection. Higami and colleagues3 described skeletonization of ITAs with an ultrasonic scalpel; they reported harvesting times of 20 to 25 minutes, similar to pedicled harvesting. Provided the ITA side branches are sectioned at a distance of 1 mm from the main ITA trunk, the use of an ultrasonic scalpel appears safe.4 We do not currently use an ultrasonic scalpel at our institution and therefore cannot comment more specifically on this technique. However, we definitely believe that meticulous dissection of ITA grafts, regardless of the technique used, results in a low risk of graft injury.


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 References
 

  1. Pevni D, Mohr R, Lev-Run O, Locer C, Paz Y, Kramer A, et al. Influence of bilateral skeletonized harvesting on occurrence of deep sternal wound infection in 1,000 consecutive patients undergoing bilateral internal thoracic artery grafting. Ann Surg. 2003;237:277–280
  2. Matsa M, Paz Y, Gurevitch J, Shapira I, Kramer A, Pevny D, et al. Bilateral skeletonized internal thoracic artery grafts in patients with diabetes mellitus. J Thorac Cardiovasc Surg. 2001;121:668–674
  3. 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
  4. Higami T, Maruo A, Yamashita T, Shida T, Ogawa K. Histologic and physiologic evaluation of skeletonized internal thoracic artery harvesting with an ultrasonic scalpel. J Thorac Cardiovasc Surg. 2000;120:1142–1147

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Safe bilateral use of skeletonized internal thoracic artery in patients with diabetes
Hitoshi Hirose and Atsushi Amano
J. Thorac. Cardiovasc. Surg. 2004 127: 1534-1535. [Extract] [Full Text] [PDF]

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Margaret A. Olsen, Thoralf M. Sundt, Jennifer S. Lawton, Ralph J. Damiano, Jr, Diane Hopkins-Broyles, Patricia Lock-Buckley, and Victoria J. Fraser
J. Thorac. Cardiovasc. Surg. 2004 127: 1536. [Extract] [Full Text] [PDF]



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