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Ann Thorac Surg 1999;67:1637-1642
© 1999 The Society of Thoracic Surgeons

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Original Articles

Bilateral internal mammary artery grafting: midterm results of pedicled versus skeletonized conduits

^a Department of Cardiac Surgery, "G. D’Annunzio" University, Chieti, Italy

Accepted for publication December 11, 1998.

Address reprint requests to Dr Calafiore, Department of Cardiac Surgery, "G. D’Annunzio" University, S. Camillo de’ Lellis Hospital, Via C. Forlanini, 50, 66100 Chieti, Italy
e-mail: calafiore{at}unich.it

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. To increase the number of anastomoses per patient, bilateral internal mammary arteries (BIMAs) were harvested with a skeletonized approach instead of a pedicled one.

Methods. One thousand one hundred forty-six patients underwent isolated myocardial revascularization using BIMAs, 304 receiving pedicled grafts (group A, October 1991 through May 1994) and 842 receiving skeletonized conduits (group B, June 1994 through June 1998). Group B had a higher incidence of patients with diabetes (223 versus 40, p < 0.001).

Results. The number of BIMA anastomoses per patient was significantly higher in group B (2.4 ± 0.3 versus 2.1 ± 0.4, p < 0.001), as well as the number of sequential grafts (288 versus 42, p < 0.001). Twenty-three patients (2.0%) died in the first 30 days after surgery, 5 in group A (1.6%) and 18 in group B (2.1%) (not significant). Postoperative complications were similar in both groups; the incidence of sternal wound healing problems was higher as a whole and with regard to diabetic patients (4 of 40 [10%] versus 5 of 223 [2.2%], p < 0.05) in group A. Seventy-one patients in group A and 133 (15.8%) in group B underwent a postoperative angiography. Patency rate was similar, both early (100% in group A versus 98.6% in group B, not significant) and late (98.6% in group A versus 98.4% in group B, not significant).

Conclusions. The use of skeletonized BIMA conduits allowed us to increase the number of BIMA anastomoses per patient with a lower rate of sternal wound complications and angiographic results similar to those obtained with pedicled BIMA conduits.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
Left internal mammary artery (LIMA) grafting to the left anterior descending (LAD) artery was demonstrated to be the most important determinant of survival and of minimizing late cardiac events in any patient undergoing coronary artery bypass grafting [1]. It is not clear whether the use of bilateral internal mammary artery (BIMA) conduits can enhance the quality of the results of myocardial revascularization. Some reports emphasize the better long-term outcome in patients in whom BIMA conduits were used on the left coronary artery system in comparison with patients in whom only the LIMA was used to anastomose to the LAD [2, 3]. However, other clinical experience was not able to demonstrate any advantage [4]. If survival is the end point of any research, it is very likely that we need to wait more than 15 years at least to demonstrate any advantage of one strategy over the other. On the other hand, recently, Lytle and associates [5] were able to demonstrate the superiority of BIMA grafting in comparison with single LIMA and saphenous vein grafts in the long term. In terms of event-free survival, however, the benefit of BIMA grafts, if any, could appear also in the first decade.

Lacking a definitive solution to the problem of extensive arterial grafting, we evaluated some technical aspects of BIMA grafting. The possibility of increasing the number of BIMA anastomoses per patient by harvesting the conduits in a skeletonized fashion rather than pedicled was considered, as well as the hypothesis that skeletonization of internal mammary artery (IMA) conduits could reduce sternal devascularization and the related wound healing problems. Clinical and angiographic results were analyzed to evaluate whether the difference in harvesting technique could influence the midterm outcome.

We divided our experience into two periods, the first one in which all the BIMA conduits were harvested pedicled, and the second one in which the BIMA conduits were harvested skeletonized.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
From October 1991 to May 1994, 304 patients underwent isolated myocardial revascularization using pedicled BIMA conduits (group A); from June 1994 to June 1998, 842 patients underwent the same operation using skeletonized BIMA conduits (group B). Table 1 shows the preoperative data.

The technique we used to perform the end-to-side and the end-to-end anastomosis has already been reported [8]. To avoid any distortion of the graft it is necessary only to put the mammary over the heart. The inside blood pressure will force the graft to have always the right orientation.

After heparinization, the IMA conduits, independent of which harvesting technique was used, were clipped distally, injected with 10 mL of a papaverine solution (1 mg/mL), and allowed to pharmacologically dilate.

In 28 patients the LIMA length was measured when the dissection was finished and 10 minutes after papaverine injection; the conduit being harvested was pedicled in 14 and skeletonized in the remaining 14. The same was done with 14 skeletonized right internal mammary arteries (RIMAs); however, these were not compared with the pedicled RIMA conduits, as there was no comparison group. The sternal length was measured (with the exclusion of the xyphoid appendix, which is an anatomic variable), and the ratio of LIMA to sternum length was obtained.

When used, the radial artery was harvested while the LIMA was dissected, whereas the inferior epigastric artery and the right gastroepiploic artery were harvested when both IMAs were already dissected.

When a composite graft was constructed, the proximal anastomosis of the free arterial graft to the IMA was performed before starting cardiopulmonary bypass (CPB) [6]. As soon as the aorta was unclamped (or when the last anastomosis was accomplished if CPB was not used), a continuous infusion of diltiazem (5 mg/h) was begun and continued up to the first postoperative day, when oral diltiazem was started (60 mg three times a day for 4 weeks).

From the operating theater the patients were transferred to the intensive care unit, where they remained generally up to the first postoperative day, and then to the ward.

Some patients accepted an early angiographic control (in the first 30 days), and others accepted a postoperative angiography in the first year or later. The quality of the anastomosis and conduit was graded according to Fitzgibbon and colleagues [9].

Follow-up
All patients were followed up in our outpatient clinic 3, 6, and 12 months after surgery and then every year. We were able to follow up all our patients, directly or by telephone, except for 22 that we were not able to reach by telephone. However, we had information about them during 1997.

Statistical analysis
Results are expressed as the mean ± standard deviation unless otherwise indicated. Statistical analysis comparing two groups was performed with unpaired two-tailed Student’s t test for the means or ² test for categorical variables. Survival and event-free survival curves were obtained with the Kaplan-Meier method (BMDP 1L software). The statistical significance was calculated with the Mantel-Cox test and z test. A p value less than 0.05 was considered significant.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
Preoperative data in both groups were not similar, because the population was older, with lower ejection fraction and with more redo patients in group B (Table 1), owing to the modification with time of the coronary population.

The CPB time was longer in group A (69.0 ± 19.9 versus 59.8 ± 19.2 minutes, p < 0.001), but the cross-clamping time was similar (50.5 ± 14.2 versus 51.5 ± 16.8 minutes, not significant, in groups A and B, respectively). However, in 157 patients in group B, CPB was not used. Technical details are shown in Table 2.

Sequential grafts were significantly more frequent in group B (288 versus 42, p < 0.001). Specifically, the diamond-shaped anastomoses become very common as well as the sequential grafting in the lateral wall (Table 2).

The distribution of distal anastomoses, shown in Table 3, was different in the two groups. The LAD was grafted in group A indifferently with either IMA (LIMA, 50.9% versus RIMA, 46.9%, not significant), whereas in group B the RIMA was used more often than the LIMA (51.8% versus 35.3%, p < 0.05). The circumflex system was grafted in both groups more often with the LIMA in higher proportion in group B (50.2% versus 39.9%, not significant), but the RIMA was used more in group B than in group A, although not significantly (29.3% versus 20.5%). In the right coronary artery system, the RIMA was used infrequently in group B in comparison with group A (12.9% versus 26.4%, p < 0.05).

Sternal wound healing problems were present in 28 patients (2.5%), the incidence being higher in group A (14 cases, 4.5%, versus 14 cases, 1.7%, p < 0.005). In patients with diabetes the different incidence was also evident (4 of 40, 10.0%, in group A versus 5 of 223, 2.2%, in group B, p < 0.05).

Follow-up
Cumulatively, after a mean global follow-up of 28.2 ± 20.5 months, 1,109 patients (96.7%) were alive and 1,098 (95.8%) were alive without myocardial infarction, surgical reoperation, or stent or percutaneous transluminal angioplasty. Six-year actuarial survival was 95.5% ± 1.1% and event-free survival was 93.1% ± 0.7% (Fig 1).

View larger version (9K): [in this window] [in a new window]   Fig 1. Six-year survival () and event-free survival () of the global population.

View larger version (20K): [in this window] [in a new window]   Fig 2. Forty-six–month survival (A) and event-free survival (B) in group A () and group B ().

Four patients in group B needed further revascularization after 15.3 ± 2.7 months; among them 3 underwent a surgical redo and 1 a stenting of left main stem. The outcome was uneventful.

After a mean of 9.2 ± 12.1 months, 14 patients died, 7 of cardiac (4 acute myocardial infarction, 3 sudden death) and 7 of noncardiac causes (2 malignancy, 1 pneumonia, 1 hepatic failure, 2 stroke, 1 intestinal infarction). Among them, 5 died in group A and 9 in group B.

Angiographic controls
Seventy-one patients (23.0%) in group A and 133 (15.8%) in group B accepted an early (during the first 30 days) or a late postoperative angiography (Fig 3). Globally, 432 distal and 23 intermediate (Y grafts) anastomoses were controlled. Results are shown in Table 6.

View larger version (90K): [in this window] [in a new window]   Fig 3. Angiographic control after 36 months. (A) Left internal mammary artery is grafted to the first diagonal, the second diagonal, and the left anterior descending artery. (B) Right internal mammary artery is grafted to the first and second obtuse marginal branches.

	Comment

Top Abstract Introduction Material and methods Results Comment References

One of the major concerns is the increase of postoperative mortality and morbidity. Some reports showed that morbidity and mortality is essentially similar using either a single LIMA or both IMAs [10]. Moreover Accola and colleagues [11] demonstrated that increasing use of BIMA conduits reduces postoperative complications. In a recent report from Sergeant and coworkers [12], the in-hospital mortality in patients who had BIMA grafting was lower than in patients who had a single LIMA graft.

The incidence of sternal wound complications was found to be higher in patients with BIMA grafts in comparison with patients who had only saphenous vein grafts or a single IMA graft [13]. However, other reports did not confirm these findings; Galbut and associates [2], harvesting both IMAs in a skeletonized fashion, reported in more than 1,000 patients an incidence of sternal wound infections of only 1.5%, with the incidence in diabetic patients being 20.4%.

Recent studies demonstrate that the collateral circulation to the sternum can be partially preserved if the conduit is harvested as a skeletonized conduit [7]. Dividing the collateral branches with hemoclips and scissors, the possibility of collateral perfusion from the intercostal or the muscular branches is maintained. The use of the cautery and the dissection of the conduit as a pedicle will destroy all possibility of maintaining a collateral sternal circulation. This aspect was demonstrated also by Parish and colleagues [14] in the dog using radioactive microspheres. The lack of complete sternal devascularization in the first days after the operation can be the basis of improved sternal wound healing in diabetic patients. Our experience supports this hypothesis, as our incidence of sternal wound problems was significantly reduced in group B.

The harvesting of the IMA as a skeletonized conduit is not recent. Vineberg [15] used the skeletonized IMA in 1964, followed by other authors [2, 16–20] who routinely used this technique. The IMA is nourished by the lumen, and, as in the media, vasa vasorum is not present. The devascularization of the conduit does not have any adverse effect [21].

In this study, although in a limited number of patients, we were able to demonstrate that skeletonized LIMA is longer than pedicled LIMA at the end of harvesting. Moreover, the increase in length after papaverine injection is significantly more important in skeletonized conduits (+13.9% versus +1.7%). This aspect, together with the bigger diameter, gave us two conduits that can be harvested in about 1 hour and can be used for up to six distal anastomoses.

In-hospital mortality and postoperative morbidity was similar in the two groups; however, postoperative bleeding was lower, as was the number of patients in group B receiving transfusion. The incidence of hypoperfusion syndrome that was related to BIMA grafts was significantly lower in group B. We think that, although the harvesting technique brings the instruments close to the IMA, any injury during the dissection will be immediately detected before the use of the conduit, which is not evident with pedicled BIMA.

Midterm results of skeletonized and pedicled BIMA grafts are similar, at least for the period when a comparison could be made. Because postoperative angiographies, when performed, showed similar conduit quality in both groups, we can expect that the same quality will be maintained in the future. The midterm patency rate did not change with the harvesting technique, and this aspect seems to us to justify our technical choice. Bical and associates [20] also reported satisfying midterm patency rate, although no control group was considered.

In conclusion, in our experience the use of skeletonized BIMA conduits was a useful tool to expand the use of IMAs, in terms of the number of anastomoses per patient and of reducing the incidence of sternal complications. Early and midterm clinical and angiographic results are similar to those obtained with the use of pedicled BIMA conduits. Thus, we think that this technique can be safely used if the use of BIMA grafting is considered.

	References

Top Abstract Introduction Material and methods Results Comment References

 

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