Endothelial integrity of ultrasonically skeletonized internal thoracic artery: morphological analysis with scanning electron microscopy.

OBJECTIVE: The skeletonized internal thoracic artery (ITA) has several advantages over a pedicled one in coronary artery bypass grafting (CABG). An ultrasonic scalpel makes ITA skeletonization easy and speedy, however, the ultrasonic energy that is transmitted to the artery itself can occasionally injure the endothelium. Therefore, the endothelial integrity of the ultrasonically skeletonized ITA is a major concern related to this technique. The purpose of this study is to assess the endothelial integrity of the ultrasonically skeletonized ITA. METHODS: We skeletonized the left ITA with an ultrasonic scalpel in nine patients who underwent CABG, and thereafter the terminal portion of this artery was subjected to a morphological study. The endothelial integrity of this artery was morphologically assessed using scanning electron microscopy, and the results were compared to that of the left ITA skeletonized with fine scissors. RESULTS: All ITA specimens showed a completely confluent endothelium, and no endothelial injury was observed by the scanning electron microscopic study. CONCLUSIONS: The skeletonization of the ITA with an ultrasonic scalpel had no deleterious effect on the endothelium. This morphological study confirmed the safety and the reliability of this technique, and we therefore recommend its clinical use in the skeletonization of the ITA for CABG.     

Changing pattern in beating heart operations: use of skeletonized internal thoracic artery

BACKGROUND: The use of skeletonized internal thoracic artery (ITA) was reported to be technically and hemodynamically beneficial in conventional coronary artery bypass grafting with cardiopulmonary bypass assistance. The purpose of this study is to evaluate the impact of changing from conventional to skeletonized ITA harvesting on early off-pump coronary artery bypass grafting outcome. METHODS: Between 1996 and 2001, 640 patients underwent systematic off-pump coronary artery bypass grafting (single surgeon experience). The ITA was pedicled (P) in the first consecutive 440 patients and skeletonized (S) in the subsequent 200 consecutive patients. Mean age, preoperative risk factors, sex, number of involved territories, and incidence of reoperations were similar in both groups. RESULTS: In group S, number of ITAs per patient (1.7 +/- 0.08 versus 1.2 +/- 0.05; p < 0.001), bilateral ITA (46% versus 27%; p < 0.001), ITA sequential grafts (27% versus 1%; p < 0.001), and T grafts (16% versus 3%; p < 0.001) were higher. Deep sternal infections were comparable in both groups (group S: 1%, group P: 1.2%; p = 0.38). Perioperative myocardial infarction, maximal creatinine kinase-MB level, and requirement for more than 24 hours of inotropic support were comparable in both groups. Thirty-day mortality was also similar (S: 1.7%, P: 1.6%). CONCLUSIONS: Changing to routine use of skeletonized ITA in off-pump coronary artery bypass grafting is a safe alternative to routine pedicled ITA. In our experience, this procedure has facilitated the use of ITA anastomosis without increasing sternal wound complications.     

Does skeletonization compromise the integrity of internal thoracic artery grafts?

BACKGROUND: There are few reports that demonstrate the chronologic changes in the functional integrity of the internal thoracic artery (ITA) wall after skeletonization. We investigated the impact of skeletonization on ITA wall integrity by immunohistochemical analyses in acute and chronic phases. METHODS: Nine mongrel dogs underwent bilateral ITA dissection with one skeletonized vessel and the other pedicled. The following studies were performed 1 week (acute phase, n = 3) and 12 weeks (chronic phase, n = 6) after ITA harvesting. All specimens of the ITAs were stained by antibodies against von Willebrand Factor (VWF), endothelial nitric oxide synthase (eNOS), inducible nitric oxide synthase (iNOS), and proliferating cell nuclear antigen (PCNA). After observation with confocal laser scanning microscopy, quantitative analyses of the staining signal for VWF and eNOS expressed on endothelial cells were performed. RESULTS: There were significantly more microvessels positive for VWF in the adventitia of skeletonized ITAs than in the adventitia of pedicled ITAs but the expression of PCNA in both groups was minimal, as in normal vessels. iNOS was not detected in any specimen. The intensity of VWF and eNOS expressed by endothelial cells had no significant differences between groups at either phase. CONCLUSIONS: The functional integrity of skeletonized ITA was similar to that of pedicled ITA in both acute and chronic phases. Although skeletonization induced neovascularization in the adventitia it did not induce proliferation of smooth muscle cells in the media, which is supposed to be a feature of vascular remodeling.     

Early results of coronary grafting using ultrasonically skeletonized internal thoracic arteries

BACKGROUND: We have developed an ultrasonic complete skeletonization technique for obtaining internal thoracic artery (ITA) grafts and have used this method clinically since January 1998. In this report, we discuss the early results of bilateral ITA grafts obtained with our method. METHODS: We studied 200 consecutive patients who underwent coronary artery bypass grafting using ITAs obtained by this technique. Angiography of the grafts was performed in 188 patients (94%) within 1 month after coronary artery bypass grafting. RESULTS: The ITA grafts were about 4 cm longer than pedicled ITA grafts. The free flow through the grafts was at least 30% higher than through pedicled ITAs. The early patency rate determined by postoperative angiography of the grafts was 99.7% for left ITAs and 100% for right ITAs. No patient required postoperative intervention or repeated surgery. CONCLUSIONS: Ultrasonic complete skeletonization increases the effective length of ITA bypasses, improves free flow through the bypasses, and it is less invasive than conventional pedicled harvesting. These excellent early results indicate that this technique is a straightforward, safe, less invasive, and optimal method for obtaining ITA bypass grafts.     

Effect of skeletonization of the internal thoracic artery on vessel wall integrity

BACKGROUND: This study was conceived to evaluate the effect of internal thoracic artery (ITA) skeletonization on vessel wall integrity. METHODS: Forty consecutive patients undergoing coronary artery bypass were randomized to receive a skeletonized (n = 22) or a pedicled (n = 18) ITA graft. ITA harvesting was performed by 2 experienced surgeons using the same instrumentation and technique. Specimens were examined by light and electron microscope in order to assess vascular wall integrity. A specific immunohistochemical staining and a computerized method were used to quantify the degree of endothelial integrity after surgical preparation. RESULTS: Morphologic analysis revealed 2 cases of limited subadventitial hemorrhage (one for each group) and no case of major arterial damage. Immunohistochemical staining demonstrated an extremely high degree of maintenance of the endothelial integrity in both groups (97.2% +/- 1.9% in the skeletonized and 96.8% +/- 2.1% in the pedicled one; p = 0.53). CONCLUSIONS: Skeletonization does not affect ITA wall integrity in humans submitted to coronary artery bypass procedures.     

Effects of skeletonization on intraoperative flow and anastomosis diameter of internal thoracic arteries in coronary artery bypass grafting

BACKGROUND: We examined the hypothesis that complete skeletonization of an internal thoracic artery (ITA) results in increased diameter of the graft for anastomosis and therefore improves graft flow in coronary artery bypass grafting. METHODS: We studied 65 consecutive patients who underwent coronary artery bypass grafting, in which the left ITA was anastomosed to the left anterior descending artery. The first 20 consecutive ITA were harvested as a pedicle (group P) and later 45 consecutive ITAs were harvested as an ultrasonically skeletonized graft (group S). Intraoperative ITA graft mean flows were obtained with a transit-time flowmeter. Three diameters of the ITA graft were measured quantitatively in postoperative angiograms performed 14 +/- 5 days after the coronary artery bypass grafting; D1, at the origin from the subclavian artery; D2, at the level of the second intercostal space; and D3, just proximal to the anastomosis. RESULTS: Intraoperative mean flow was significantly greater in group S than in group P (S: 42.6 +/- 29.1 mL/min versus P: 26.4 +/- 16.1 mL/min, p = 0.03). Although the diameters D1 and D2 were not significantly different between groups, D3 was significantly larger in group S than in group p (S: 1.77 +/- 0.28 mm versus P: 1.57 +/- 0.17 mm, p = 0.02). CONCLUSIONS: Compared with pedicle harvesting, complete skeletonization of ITA may make it possible to anastomose an ITA with a larger diameter in coronary artery bypass grafting, which leads to increased graft flow by decreasing vascular resistance.     

Off-pump coronary artery bypass grafting using in situ bilateral skeletonized internal thoracic arteries

Objective All arterial off-pump coronary artery bypass grafting (OPCAB) with in situ bilateral skeletonized internal thoracic arteries (ITAs) may become a standard procedure that would provide better long-term results without affecting early results. Methods Our study included 404 consecutive patients who underwent OPCAB with one or two ITAs. We compared the clinical results of 135 patients who underwent OPCAB using unilateral ITA (UITA group) to those of 269 patients using bilateral ITAs (BITA group). Results The average number of distal anastomoses was 3.07 in the UITA group and 3.47 in the BITA group (P < 0.01). Four operative mortalities occurred in the UITA group and two in the BITA group. There were no significant differences in morbidity between the two groups. Conclusion OPCAB using bilateral skeletonized ITAs is technically feasible, with good early results. Arterial OPCAB using in situ bilateral skeletonized ITAs may become a standard procedure in the future.     

In situ bilateral skeletonized internal thoracic arterial grafting for left-side myocardial revascularization using an off-pump technique

The aim of this study was to review the clinical and angiographic outcomes of in situ skeletonized bilateral internal thoracic artery (ITA) grafting for left coronary arterial revascularization using an off-pump technique in 144 consecutive patients. We also assessed the difference between left and right ITA grafting to the left anterior descending coronary artery (LAD). Arrangement of the bilateral ITAs (grafting of the left/right ITA to the LAD) was decided according to the coronary anatomy and quality of the grafts. Early postoperative angiograms were evaluated in 110 patients. The average numbers of anastomoses and bilateral ITA anastomoses per patient were 3.4 and 2.3, respectively. There were no surgical deaths or sternal infection. The left and right ITA were anastomosed to the LAD in 106 (73.6%) and 38 (26.4%) patients, respectively. There were no differences in preoperative conditions and postoperative complications between the left ITA and right ITA to LAD groups. The patencies of the left and right ITAs were 99.1 and 100%, respectively. In situ skeletonized bilateral ITA grafting for left-side revascularization using an off-pump technique was shown to be feasible, producing excellent early clinical and angiographic outcomes. Furthermore, arrangement of bilateral ITAs did not affect outcomes.     

Free flow capacity of skeletonized versus pedicled internal thoracic artery grafts in coronary artery bypass grafts.

OBJECTIVE: The internal thoracic artery (ITA) is the ideal conduit for coronary artery bypass grafting (CABG). The skeletonization technique of this arterial conduit has been proposed to reduce chest wall trauma, increase graft length and facilitate construction of sequential anastomoses. Nevertheless, some surgeons decline this technique because of potentially increased trauma to the ITA with impairment of flow. In this investigation we compared the free flow of skeletonized with that of pedicled ITA grafts. METHODS: Two surgeons operated on 80 consecutive patients with coronary artery disease for elective CABG. In group I (n = 40), the left ITA was dissected using the skeletonization technique. In group II (n = 40), it was harvested as a pedicled graft. In 23 patients of group I both ITA's were dissected in skeletonized fashion for complete arterial revascularization. Diluted papaverine was instilled into the lumen of the ITA after distal transection of the vessel in both groups. Free flow of the ITA was registered before and 15 min after intraluminal application of diluted papaverine. Mean arterial pressure was maintained at 70 mmHg. RESULTS: Before the application of papaverine, free flow of skeletonized and pedicled ITA grafts was identical between the two groups. After treatment with papaverine maximum free flow was significantly higher in the skeletonized ITA's (group I 197.2 (+/-66.6) ml/min; group II 147.1 (+/-70.5) ml/min; P < 0.05). There was no significant difference between free flow after dilatation of the left and right ITA in group I (left 197.2 (+/-66.6) ml/min; right 198.9 (+/-61.8) ml/min). CONCLUSIONS: Preparation of the ITA with the skeletonization technique results in significantly, higher free flow capacity than in pedicled grafts. This may increase the safety of arterial revascularization by reducing the risk of ITA hypoperfusion syndrome.     

Arterial myocardial revascularization with in situ crossover right internal thoracic artery to left anterior descending artery

BACKGROUND: The extra length obtained by skeletonizing the internal thoracic arteries (ITAs) enables versatile use of in situ bilateral ITAs for coronary artery bypass grafting, as the longer skeletonized right ITA more easily reaches the anastomotic site on the left anterior descending coronary artery. METHODS: Between April 1996 and November 1999, 365 consecutive patients underwent revascularization with bilateral in situ ITAs (29% of 1,250 grafting procedures performed with both ITAs in our department during this period). The right ITA was routed anterior to the aorta to graft the left anterior descending coronary artery, and the in situ left ITA was used to graft circumflex branches. Right coronary artery branches were grafted with right gastroepiploic artery or saphenous vein graft. The right ITA crossed the midline above the aorta at the most cranial point to avoid damage in case of a repeat sternotomy in the future. RESULTS: The operative mortality rate was 2.2% (8 patients). Postoperative morbidity included seven strokes (1.9%), eight sternal wound infections (2.2%), and four perioperative myocardial infarctions (1.1%). Follow-up (6 to 49 months) of 97% of hospital survivors showed a return of angina in 3%. Postoperative coronary angiography (22 patients) revealed a 95% patency rate of both ITAs. One-year and 4-year survival rates (Kaplan-Meier) were 95% and 92.4%, respectively. Important predictors of an early unfavorable event were chronic obstructive pulmonary disease, old age (> or = 70 years), emergency operation, and diabetes. Chronic obstructive pulmonary disease was the only independent predictor of sternal wound infection (odds ratio, 15; 95% confidence interval, 2.8 to 80). It also predicted decreased late survival (hazard ratio, 8.3; 95% confidence interval, 3 to 21.5). CONCLUSIONS: With skeletonized dissection of ITAs, the right ITA easily reaches the left anterior descending coronary artery for left-sided arterial revascularization with in situ bilateral ITAs. This procedure is safe, but we recommend avoiding its use in patients with chronic obstructive pulmonary disease.     

Coronary-coronary bypass using the internal thoracic artery: a sparing procedure of the arterial conduit

BACKGROUND: The internal thoracic artery (ITA) is well known to be the best conduit for coronary artery bypass grafting. However, the bilateral use of ITAs remains limited because in situ right ITAs (RITAs) do not possess an adequate length to be directed to the posterolateral myocardium. We thus considered using free ITAs for conduits between the two segments of the same coronary artery. METHODS: From March 1997 to May 1999, 17 patients underwent coronary-coronary bypass grafting (C-CBG) using free ITAs. Early operative results were analyzed. C-CBG was indicated when the right ITA had an inadequate length or when a distal part of the ITA was left unused. RESULTS: No patient died after C-CBG and none have experienced angina since C-CBG (mean follow-up period 27.3 +/- 19.8 months). Postoperative angiography was performed in all subjects at discharge. Only one coronary-coronary bypass graft was occluded, the other grafts were patent, and there were no stenotic changes. Bilateral ITAs were used in 75% of the patients undergoing CABG during the period of this study. CONCLUSIONS: C-CBG can expand the use of bilateral ITAs and can provide an alternative method for revascularization of the posterolateral myocardium.     

Free right internal thoracic artery composite graft: an option in left anterior descending artery grafting?

Myocardial revascularization using bilateral internal thoracic arteries (ITA) decreases the risk of reinterventions and provides potential survival benefit. From May 1996 to April 2000, 1,057 patients underwent myocardial revascularization using skeletonized bilateral ITAs. A free right ITA as a composite graft was used for the left anterior descending artery grafting in 38 (3.6%) cases when the left ITA was not long enough to reach the left anterior descending artery. Operative mortality was 2.6% (1 patient). There was no observable reversible myocardial ischemia on the postoperative thallium single-photon emission computed tomography study. Myocardial revascularization with the use of a skeletonized free right ITA as a composite graft to the left anterior descending artery is an alternative option in cases when an in situ ITA cannot be used.     

Composite arterial grafting with double skeletonized internal thoracic arteries.

OBJECTIVES: Composite arterial grafting is a surgical technique for arterial myocardial revascularization, in which free arterial conduits are proximally anastomosed end-to-side to an intact internal thoracic artery (ITA). This report describes technical aspects and results of composite grafting using bilateral skeletonized ITAs. METHODS: From April 1996 to February 1999, 1057 patients underwent coronary artery bypass grafting (CABG) using bilateral skeletonized internal thoracic arteries. In 600 of them (57%), composite arterial grafting was performed. There were 452 men and 148 women. The mean age was 69 +/- 7 years. Two-hundred and six patients (34%) were diabetics, 84 (14%) had severe left ventricular dysfunction (ejection fraction of < 35%), and 26 (4.3%) underwent emergency operations. In 574 patients, the right ITA was used as a free graft connected to the in-situ left ITA. In 26, the free left ITA was attached to the in-situ right ITA, and in 38, mini-composite grafts (free distal left ITA on the left ITA, or free distal right ITA on the right ITA) were constructed. The average number of grafts was 3.0/patient (range, 2--6). RESULTS: The operative mortality was 2.8% (n = 17), and there were ten (1.7%), deep sternal wound infections. The mean follow-up was 25 months (range, 14--36 months). The 3-year survival was 92.5%. Ninety-seven percent of the surviving patients were angina-free. CONCLUSIONS: We currently perform this surgery routinely in most patients referred for CABG, and regard bilateral skeletonized internal thoracic arteries as the most appropriate arterial conduits for the composite technique.     

Effects of ultrasonic skeletonization on internal thoracic and gastroepiploic arteries for coronary artery bypass grafting.

OBJECTIVE: There are few data available on the effect of ultrasonic skeletonization with the harmonic scalpel on internal thoracic artery (ITA) and gastroepiploic artery (GEA) vessel function. METHODS: Rings of segments of the skeletonized ITA, pedicled ITA, skeletonized GEA, and pedicled GEA were studied. Arterial segments were treated with high KCl and norepinephrine (NE) to obtain smooth muscle contractions. Endothelium-dependent and independent vasorelaxant potencies in 10(-6)mol/l NE-pre-constricted arteries were assessed by acetylcholine (ACh), and isosorbide dinitrate (ISDN) and diltiazem, respectively. RESULTS: There were no differences in contractile potencies induced by high KCl and NE between the rings cut from skeletonized and pedicled grafts. The rings from skeletonized and pedicled vessels also showed equal sensitivity to ISDN and diltiazem. However, the rings from pedicled grafts showed greater relaxation responses to ACh than rings from skeletonized grafts. CONCLUSION: Ultrasonic complete skeletonization with the harmonic scalpel may retain smooth muscle function of skeletonized grafts, whereas endothelial function of ultrasonic skeletonized grafts may be significantly compromised.     

Skeletonization of the internal thoracic artery: a randomized comparison of harvesting methods

We performed a randomized study to compare internal thoracic artery (ITA) flow response to two harvesting methods used in the skeletonization procedure: ultrasonic scalpel and bipolar electrocautery. Sixty patients scheduled for CABG were randomized to receive either ultrasonically (n=30 patients) or electrocautery (n=30 patients) skeletonized ITAs. Intraoperative ITA graft mean flows were obtained with a transit-time flowmeter. ITA flows were evaluated at the beginning (Time 1) and at the end (Time 2) of the harvesting procedure. Post-cardiopulmonary bypass (CPB) flow measurement (Time 3) was obtained in the ITA grafts anastomosed to the left anterior descending artery. Intraoperative mean flow decreased significantly within ultrasonic group (Group U) and electrocautery group (Group E) at the end of the harvesting procedure (P<0.0001 in both cases). Within both groups the final mean flow measured on anastomosed ITAs (Time 3) was significantly higher than the beginning ITA flow value (Time 1). No statistical difference was noted comparing ITA flows between the two groups at any time of evaluation. Skeletonization harvesting of the ITA produces a modification of the mean flow. The quantity and the reversibility of this phenomenon, probably related to vasospasm, are independent from the energy source used in the skeletonization procedure.     

Long-term follow-up of coronary artery bypass grafting in three-vessel disease using exclusively pedicled bilateral internal thoracic and right gastroepiploic arteries

BACKGROUND: Considerable data now exist that show that coronary artery bypass grafting with bilateral internal thoracic artery (ITA) grafts produce better outcomes than the use of a single ITA graft. The benefit of a third arterial graft has been less well established. Therefore this article describes the survival and cardiac-related event-free survival in patients having bilateral ITA and gastroepiploic artery (GEA) grafting for 3-vessel disease. METHODS: From November 1992 to May 2002, 201 patients (mean age 53 +/- 7 years) presented with 3-vessel disease and received exclusively bilateral internal thoracic (ITAs) and right gastroepiploic (GEA) arteries as pedicled grafts for coronary artery bypass procedure. Twenty-seven (13%) patients were not elective, 10 (5%) were reoperations, 115 (57%) had one or more myocardial infarction, 21 (10%) had diabetes. In total 733 anastomoses were constructed (3.7/patient), with sequential grafting in 124 (62%) patients. The clinical follow-up was complete. The patients were followed for up to 10 years (mean 6.4 +/- 2.7 years). RESULTS: Ten-year actuarial survival (including in-hospital death) was 87%. The actuarial freedom from angina pectoris, after hospital discharge, was 97% and 86% at 5 and 10 years respectively. None of the patients needed a repeat surgical revascularization after leaving the hospital, whereas 9 (5%) patients underwent a percutaneous transluminal coronary angioplasty. At 5 years 86% and at 10 years 69% of the patients remained free of any cardiac-related event. CONCLUSIONS: The results of this study clearly indicate that the exclusive and extensive use of pedicled bilateral ITA and GEA in coronary bypass grafting provides excellent 10-year patient survival and functional improvement in terms of freedom from return of angina pectoris and, more impressive, freedom from any cardiac-related event. Our findings clearly corroborate the concomitant use of bilateral ITA and GEA grafts in selected patients with 3-vessel disease.     

Off-pump coronary artery bypass using bilateral in situ internal thoracic artery grafts for left coronary artery system: a case report

A 63-year-old man with triple vessel disease in the coronary artery and multiple arterial stenoses in intra-cranial vessels underwent off-pump coronary artery bypass (OPCAB). We were able to perform three coronary artery bypass grafting (in situ left internal thoracic artery (left ITA)--left anterior descending artery, in situ right ITA--circumflex artery through the transverse sinus, and saphenous vein graft--right coronary artery) using octopus 2 and "Lima" suture technique without cardio-pulmonary bypass. Operation time was 355 minutes and established blood loss was 440 ml. Postoperative course was uneventful. Postoperative angiogram revealed well patent three grafts. Using bilateral in situ ITAs OPCAB could achieve high quality.     

Bilateral Thoracoscopic Minimally Invasive Direct Coronary Artery Bypass Grafting Using Internal Thoracic Arteries

Background. Single-vessel coronary artery bypass grafting of the left internal mammary artery (ITA) to the left anterior descending coronary artery using a minithoracotomy has been shown to produce excellent results with a very low mortality. However, this procedure cannot be used in patients with double- or triple-vessel disease. Our goal was to develop a minimally invasive direct coronary artery bypass grafting procedure without cardiopulmonary bypass for patients with multivessel disease.

Methods. Both ITAs were thoracoscopically harvested using video imaging. Limited bilateral anterior thoracotomies were performed in the fourth intercostal spaces, thus exposing the right coronary artery and the left anterior descending coronary artery. The right ITA–right coronary artery and ITA–left anterior descending coronary artery anastomoses were performed without cardiopulmonary bypass using 8-0 polypropylene sutures.

Results. This procedure was successfully performed in 3 patients. The patients were extubated in the operating room. Postoperative angiographic studies showed patent left ITA and right ITA grafts.

Conclusions. Bilateral thoracoscopic minimally invasive direct coronary artery bypass grafting can be used to treat patients with a proximally diseased left anterior descending coronary artery and right coronary artery. Bilateral thoracoscopic ITA harvesting is a less invasive surgical technique that may become an option for the management of multivessel coronary artery disease.     

Bilateral skeletonized internal thoracic artery graftings in off-pump coronary artery bypass: early result of Y versus in situ grafts

BACKGROUND: Use of bilateral skeletonized internal thoracic arteries (ITAs) in off-pump coronary artery bypass (OPCAB) retains several advantages that may eventually result in better patient outcomes. We compared the early results of OPCAB using bilateral ITAs as Y grafts with results of OPCAB using bilateral ITAs as in situ grafts. METHODS: A total of 223 consecutive patients who underwent OPCAB using bilateral skeletonized ITAs as Y grafts (group I, n = 113) or in situ grafts (group II, n = 110) were studied. RESULTS: Both the number of distal anastomoses per patient and the number of distal anastomoses per bilateral ITA were higher in group I (3.5 +/- 1.0 and 2.9 +/- 0.7) than in group II (3.0 +/- 0.7 and 2.4 +/- 0.5) (p < 0.01). Hospital mortality was 1.8% (2/113) in group I and 0.9% (1/110) in group II (p = ns). There were no differences in postoperative complications including atrial fibrillation (13.3% vs 10.9%), perioperative myocardial infarction (0.9% vs 2.7%), mediastinitis (0.9% vs 1.8%), and hypoperfusion syndrome (0.9% vs 0%) between groups I and II (p = ns). Postoperative coronary angiographies performed in 110 patients in group I and 108 patients in group II showed 99.0% (382/386) overall patency and 99.4% (319/321) patency for distal anastomoses using ITAs in group I, and 98.1% (312/318) overall patency and 98.1% (258/263) patency for distal anastomoses using ITA in group II. There were no significant differences in graft patency rates between the two groups (p = ns). CONCLUSIONS: Our results demonstrate that OPCAB using bilateral skeletonized ITAs is technically feasible, with excellent graft patency. Using bilateral skeletonized ITAs as Y grafts increases the number of distal anastomoses that can be performed and does not cause additional postoperative morbidity.     

Pitfalls of skeletonized internal thoracic artery: comparison of graft kinking between skeletonized and pedicled grafts based on postoperative angiography findings

BACKGROUND AND AIM OF THE STUDY: Skeletonization of the internal thoracic artery (ITA) has several advantages: sequential bypass grafting can be easily performed, and a graft of increased length can make the distal coronary artery accessible. However, kinking of the grafts has been observed on postoperative angiograms in a few cases. We investigated whether there were significant differences in the frequency of graft kinking and stenosis degree at the kink site between pedicled and skeletonized grafts. METHODS: Postoperative angiography was performed for all cases. In pedicled (n = 65) and skeletonized (n = 129) groups, the results of postoperative graft angiography were analyzed to investigate the presence of graft kinking and stenosis degree at the kink site. RESULTS: Kinking was observed in 4 (5.9%) and 9 (3.9%) arteries in the pedicled and skeletonized groups, respectively (p = 0.341). The stenosis degree at the kink site (mean +/- SD) was significantly higher in the skeletonized group (47.2 +/- 16.8%) than in the pedicled group (23.5 +/- 13.7%), (p = 0.032). In four patients in whom early postoperative angiography showed a kink with more than 50% stenosis, late-term angiography was performed. All four cases showed regression of the stenosis degree at the kink site. CONCLUSIONS: When the ITA had a kink, the stenosis degree at the kink site was significantly higher in the skeletonized group than in the pedicled group. Late angiography often reveals regression of stenosis at the kink site. Immediate intervention need not always be performed if the patient has no angina caused by a stenotic lesion at the kink site.