Xiang Hu1, Qiang Zhao. 1. Department of Cardiac Surgery, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China.
Abstract
BACKGROUND: Skeletonization of the internal thoracic artery is supposed to achieve extra length with added advantages of decreased sternal complications. There is no agreement whether skeletonization affects grafts, main adverse cardiac events, mortality, or pulmonary function when compared with the conventional pedicled method. The aim of our study was to determine the effectiveness and safety of different harvesting techniques. METHODS: A systematic search of the literature was undertaken of all control trials comparing the skeletonized and pedicled internal thoracic artery in MEDLINE, EMBASE, and the Cochrane Library. RESULTS: Twenty-three trials between 1966 and 2010 were identified as eligible. Combined weighted mean difference demonstrated a significant increase in the length (1.99 cm, 95% confidence interval [CI] 0.87-3.11.), caliber (0.13 mm, 95% CI 0.07-0.20) and flow capacity (23.24 ml/min, 95% CI 7.52-38.96) for skeletonization, with comparable angiographic results at midterm follow-up as the pedicled harvesting. Perhaps resulting from better preservation of sternal perfusion, patients with skeletonized internal thoracic artery experienced fewer relative risks in sternal wound infection (p=0.017) and less scores in chest wall pain (p=0.033). Moreover, the meticulous skeletonized dissection can minimize the trauma to reduce blood loss and intubation time, in spite of time consuming. Above all, in the high-risk population, skeletonization was associated with improved prognosis, with fewer mainly adverse cardiac events (relative risk 0.38; 95% CI 0.14 to 0.99) and mortality (relative risk 0.70; 95% CI 0.50 to 0.98). CONCLUSIONS: Skeletonized harvesting for the internal thoracic artery provides superiority to the quality of grafts with additional advantages of lesser trauma, producing fewer postoperative complications. Above all, skeletonized grafting in the high-risk population has a potential benefit in mortality and mainly adverse cardiac events.
BACKGROUND: Skeletonization of the internal thoracic artery is supposed to achieve extra length with added advantages of decreased sternal complications. There is no agreement whether skeletonization affects grafts, main adverse cardiac events, mortality, or pulmonary function when compared with the conventional pedicled method. The aim of our study was to determine the effectiveness and safety of different harvesting techniques. METHODS: A systematic search of the literature was undertaken of all control trials comparing the skeletonized and pedicled internal thoracic artery in MEDLINE, EMBASE, and the Cochrane Library. RESULTS: Twenty-three trials between 1966 and 2010 were identified as eligible. Combined weighted mean difference demonstrated a significant increase in the length (1.99 cm, 95% confidence interval [CI] 0.87-3.11.), caliber (0.13 mm, 95% CI 0.07-0.20) and flow capacity (23.24 ml/min, 95% CI 7.52-38.96) for skeletonization, with comparable angiographic results at midterm follow-up as the pedicled harvesting. Perhaps resulting from better preservation of sternal perfusion, patients with skeletonized internal thoracic artery experienced fewer relative risks in sternal wound infection (p=0.017) and less scores in chest wall pain (p=0.033). Moreover, the meticulous skeletonized dissection can minimize the trauma to reduce blood loss and intubation time, in spite of time consuming. Above all, in the high-risk population, skeletonization was associated with improved prognosis, with fewer mainly adverse cardiac events (relative risk 0.38; 95% CI 0.14 to 0.99) and mortality (relative risk 0.70; 95% CI 0.50 to 0.98). CONCLUSIONS: Skeletonized harvesting for the internal thoracic artery provides superiority to the quality of grafts with additional advantages of lesser trauma, producing fewer postoperative complications. Above all, skeletonized grafting in the high-risk population has a potential benefit in mortality and mainly adverse cardiac events.