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Ann Thorac Surg 1997;63:653-655
© 1997 The Society of Thoracic Surgeons

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Original Article: Cardiovascular

Effect of Different Methods of Internal Thoracic Artery Harvest on Pulmonary Function

Department of Cardiovascular Surgery, Wakayama Red Cross Hospital, Wakayama, Japan

Accepted for publication September 25, 1996.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. In several clinical studies, internal thoracic artery (ITA) grafting for myocardial revascularization has been identified as increasing the risk of postoperative pulmonary complications. This study was designed to determine whether the technique used to harvest the ITA has an effect on postoperative pulmonary function.

Methods. Seventy-nine consecutive patients undergoing coronary artery bypass grafting using the left ITA were compared with patients undergoing coronary artery bypass grafting using saphenous vein grafts only. Two methods of ITA harvesting were used: (1) incision of the endothoracic fascia dissected off the ITA as a skeletonized vessel (group 1, n = 33) and (2) mobilization of the ITA as a wide musculofascial pedicle (group 2, n = 46). Thirty-two patients underwent coronary artery bypass grafting using saphenous vein grafts only (group 3). Pulmonary function tests were performed between postoperative days 20 and 30.

Results. The postoperative values of forced vital capacity were reduced in patients in all groups (p < 0.0001). The ratios of postoperative to preoperative forced vital capacity were 84% in group 1, 77% in group 2, and 84% in group 3. The reduction in group 2 was significant compared with group 1 (p < 0.05) and group 3 (p < 0.05).

Conclusions. Postoperative pulmonary dysfunction was significantly greater in patients who underwent wide musculofascial pedicle dissection of the ITA compared with skeletonization of the artery. Thus, of the two techniques, the latter may be the method of choice with regard to lowering the incidence of postoperative pulmonary dysfunction.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
See also page 655a.

The internal thoracic artery (ITA) is now used as the conduit of choice for myocardial revascularization because of its superior late patency compared with saphenous veins. In several clinical studies, ITA grafting has been identified as increasing the risk of postoperative pulmonary complications [1–6]. This study was designed to determine whether the method of ITA harvesting has an effect on postoperative pulmonary function compared with patients who received only saphenous vein grafts.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Seventy-nine consecutive patients undergoing elective coronary artery bypass grafting (CABG) using the left ITA, either alone or in combination with saphenous vein grafts, were compared with 32 consecutive patients who were undergoing CABG using saphenous vein grafts only. Inclusion criteria required preoperative pulmonary function testing and repeat pulmonary function testing between postoperative days 20 and 30. Patients with other valvular procedures, with operations using the right ITA, requiring intraaortic balloon support, or with postoperative phrenic nerve paralysis were excluded from the analysis.

The patients with ITA grafting were divided into two groups for analysis depending on the method of harvesting the ITA: (1) incision of the endothoracic fascia dissected off the left ITA and mobilization of the left ITA as a skeletonized vessel [7, 8] (group 1, n = 33) and (2) mobilization of the left ITA as a wide pedicle including a 1- to 2-cm width of the endothoracic fascia (group 2, n = 46). Group 3 (n = 32) did not undergo ITA harvesting; these patients had CABG with saphenous vein grafts only (Table 1).

All patients were operated on by the same surgeon (M.M.). A standard retractor for median sternotomy was used to harvest the ITA. Operative technique consisted of standard cardiopulmonary bypass with moderate systemic hypothermia. Antegrade infusion of cold crystalloid cardioplegia and topical cooling were used for myocardial protection. The mean interval between operation and repeat study for postoperative pulmonary function was 23 days in group 1, 24 days in group 2, and 24 days in group 3 (range, 20 to 30 days in each group).

Statistical analyses were performed using analysis of variance. The three groups were compared by Scheffé's multiple comparison test. Student's t test for paired data was performed to compare the pre- and postoperative pulmonary function tests. Discrete variables were compared with a ² test using the Yates correction. A p value of less than 0.05 was considered significant.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
All patients were extubated within 48 hours. The preoperative and postoperative pulmonary function tests are compared in Table 2. The postoperative values of forced expiratory volume at 1 second were not reduced. However, the postoperative values of forced vital capacity were reduced in patients in all groups (p < 0.0001). The ratios of postoperative to preoperative forced vital capacity were 84% in group 1, 77% in group 2, and 84% in group 3. The reduction in group 2 was significant when compared with patients in group 1 (p < 0.05) and group 3 (p < 0.05). Group 2 had a significantly higher incidence of pleurotomy (p < 0.0001, group 2 versus group 1 or group 3). Table 3 indicates the effects of pleurotomy on patients in group 1 and group 2. In group 1, the ratio of postoperative to preoperative forced vital capacity was 84% regardless of whether the pleura was entered. In group 2, the ratio was 78% when the pleura was not entered and 77% when the pleura was entered. These results show that pleurotomy itself did not affect postoperative pulmonary function.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

Controversy exists regarding the postoperative pulmonary effect of pleurotomy. Burgess and associates [3] have demonstrated that pleurotomy increases postoperative pulmonary shunting. Rolla and associates [6] also reported greater pulmonary function abnormalities after ITA grafting with pleurotomy. However, it has been reported that pleurotomy does not appear to influence postoperative pulmonary morbidity [1]. The incidence of pleurotomy was significantly greater in our group 2 patients than in group 1 patients, but no significant difference was found in postoperative pulmonary function between the patients with and without pleurotomy.

Shapira and associates [5] demonstrated that ITA harvesting itself has an adverse effect on postoperative pulmonary function. In the present study, the technique of ITA harvesting with a wide musculofascial pedicle may have accounted for more severe impairment of the postoperative pulmonary function. We suspect that the low incidence of postoperative pulmonary dysfunction was due to a lesser degree of surgical trauma and injury to the chest wall in patients with ITA harvesting with a skeletonized vessel [7, 8].

In conclusion, postoperative pulmonary dysfunction was significantly greater in patients who underwent wide musculofascial pedicle dissection of the ITA compared with skeletonization of the artery. The technique of ITA harvesting with a skeletonized vessel may be the method of choice to reduce the incidence of postoperative pulmonary dysfunction.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Address reprint requests to Dr Matsumoto, Department of Cardiovascular Surgery, Wakayama Red Cross Hospital, 4-20 Komatsubara-dori, Wakayama 640, Japan.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

1. Hurlbut D, Myers ML, Lefcoe M, Goldbach M. Pleuropulmonary morbidity: internal thoracic artery versus saphenous vein graft. Ann Thorac Surg 1990;50:959–64.[Abstract]
2. Cohen AJ, Moore P, Jones C, et al. Effect of internal mammary harvest on postoperative pain and pulmonary function. Ann Thorac Surg 1993;56:1107–9.[Abstract]
3. Burgess GE, Cooper JR, Marino RJ, Peuler MJ, Mills NL, Ochsner JL. Pulmonary effect of pleurotomy during and after coronary artery bypass with internal mammary artery versus saphenous vein grafts. J Thorac Cardiovasc Surg 1978;76:230–4.[Medline]
4. Jenkins SC, Soutar SA, Forsyth A, Keates JR, Moxham J. Lung function after coronary artery surgery using the internal mammary artery and the saphenous vein. Thorax 1989;44:209–11.[Abstract/Free Full Text]
5. Shapira N, Zabatino SM, Ahmed S, Murphy DMF, Sullivan D, Lemole GM. Determinants of pulmonary function in patients undergoing coronary bypass operations. Ann Thorac Surg 1990;50:268–73.[Abstract]
6. Rolla G, Fogliati P, Bucca C, et al. Effect of pleurotomy on pulmonary function after coronary artery bypass grafting with internal mammary artery. Respir Med 1994;88:417–20.[Medline]
7. Brown AH, Dougenis D. Dissection of the two internal mammary arteries with maximal exposure and minimal adverse sequelae by means of an inexpensive, simple, atraumatic retractor. J Thorac Cardiovasc Surg 1991;102:753–6.[Abstract]
8. Noera G, Pensa PM, Guelfi P, Biagi B, Lodi R, Carbone C. Extrapleural takedown of the internal mammary artery as a pedicle. Ann Thorac Surg 1991;52:1292–4.[Abstract]

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This Article Abstract 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): Masahiko Matsumoto Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Matsumoto, M. Articles by Minakata, K. Search for Related Content PubMed PubMed Citation Articles by Matsumoto, M. Articles by Minakata, K.