Does a skeletonized or pedicled left internal thoracic artery give the best graft patency?
Erden Ali 1,
Srdjan Saso 1,
Hutan Ashrafian 1,
Thanos Athanasiou 1*
1 Imperial College London, UK
* To whom correspondence should be addressed. E-mail: tathan5253{at}aol.com.
 |
Abstract |
|---|
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether skeletonization of the internal thoracic artery (ITA) improves graft patency in coronary artery bypass grafting (CABG). Altogether more than 60 papers were found using the reported search, of which 17 papers represented the best evidence to answer the clinical question. Grafts used were either as single ITAs (left or right, LITA or RITA) or bilateral ITAs (BITAs). The author, journal, date and country of publication, patient group studied, study type, relevant outcomes and results are tabulated. We acknowledge that evidence is limited in this area of cardiac surgery. The skeletonized ITA has not been used long enough to establish whether a decline in patency will occur after several years. The follow-up data was not long-term with only 2 studies providing patency rates beyond 5 years. Also, only 4 out of 17 papers were comparative studies (skeletonized conduits versus pedicled conduits). However the available evidence demonstrates that short- and medium-term patency rates of both skeletonized and pedicled conduits are excellent. In the 4 comparative studies, skeletonization patency was at least comparable to pedicled conduits and in 2 studies even higher. Patency was assessed with the use of angiography, performed on average within 4 years of CABG surgery. Patency rates exceeded 95% in the 10 non-comparative studies where angiographic follow-up was within 3 years of surgery. This is an important finding because it justifies further use of skeletonized technique for CABG surgery. It adds also to a growing field of evidence that skeletonized ITA grafts are preferable to pedicled grafts because they may cause less degree of devascularization of the sternum and consequently reduction of sternal wound infection. The evidence presented here demonstrates that in terms of patency, skeletonized and pedicled left internal thoracic arteries provide excellent patency rates. Keywords: Arterial conduits; CABG; Internal thoracic artery; Patency; Skeletonized; Pedicled
