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Interact CardioVasc Thorac Surg 2007;6:787-791. doi:10.1510/icvts.2007.164343
© 2007 European Association of Cardio-Thoracic Surgery
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Best evidence topic - Cardiopulmonary bypass

Does bilateral internal thoracic artery harvest increase the risk of mediastinitis?

Ioannis K. Toumpoulisa,*, Nikolaos Theakosb and Joel Dunningc

a Department of Cardiothoracic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 77 Avenue Louis Paster, Room 144, Boston, MA 02115, USA
b Department of Cardiac Surgery, Evangelismos General Hospital, Athens, Greece
c Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, UK

Received 31 July 2007; accepted 2 August 2007

*Corresponding author. Tel.: +1-978-846-4609.

E-mail address: itoumpou{at}bidmc.harvard.edu (I.K. Toumpoulis).


   Abstract
Top
 Abstract
1. Introduction
 2. Clinical scenario
 3. Three-part question
 4. Search strategy
 5. Search outcome
 6. Comments
 7. Clinical bottom line
 References
 
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether bilateral internal thoracic artery (BITA) coronary bypass increases the risk for mediastinitis. Using the reported search 140 papers were identified. Twenty-four papers represented the best evidence on the subject and the author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study comments and weaknesses were tabulated. In general, BITA grafting carries a 2.5- to 5-fold higher risk for mediastinitis after CABG. This risk is about 1.3–4.7% in non-diabetic patients compared to 0.2–1.2% for single internal thoracic artery (SITA) grafting. For diabetic patients with BITA grafting the risk of mediastinitis is significantly increased and can be as high as >10% in some series. However, for patients who undergo BITA harvest using skeletonization the risk is significantly lower and may be similar to patients receiving SITA graft only at around 0.4–2.6%. BITA grafting can be performed with acceptable risk in all patients including higher risk patients such as diabetics, in whom skeletonization of the internal thoracic arteries should be strongly considered rather than pedicled harvest.

Key Words: Coronary artery bypass grafting; Bilateral internal thoracic arteries; Mediastinitis


   1. Introduction
Top
 Abstract
 1. Introduction
2. Clinical scenario
 3. Three-part question
 4. Search strategy
 5. Search outcome
 6. Comments
 7. Clinical bottom line
 References
 
A best evidence topic was constructed according to a structured protocol. This protocol is fully described in the ICTVS [1].


   2. Clinical scenario
Top
 Abstract
 1. Introduction
 2. Clinical scenario
3. Three-part question
 4. Search strategy
 5. Search outcome
 6. Comments
 7. Clinical bottom line
 References
 
You are seeing a 60-year-old man who has been referred for multivessel coronary artery bypass grafting (CABG). He is an insulin-treated diabetic with a body mass index of 27 and no previous myocardial infarction. His father also died of a heart attack when he was 65 years old. You tell him that the grafts with the best long-term patency are the internal thoracic arteries. You would like to perform CABG using bilateral internal thoracic arteries (BITA) and a vein graft. You inform the patient that this configuration of the procedure carries higher risk for mediastinitis, which is associated with about 20% in-hospital mortality and higher long-term mortality [2]. He is not that keen on the idea and asks if there are any other configurations that could have the same long-term results without the risks of mediastinitis. You wonder whether BITA would be performed in diabetics with low risk of mediastinitis.


   3. Three-part question
Top
 Abstract
 1. Introduction
 2. Clinical scenario
 3. Three-part question
4. Search strategy
 5. Search outcome
 6. Comments
 7. Clinical bottom line
 References
 
In [patients who undergo coronary artery bypass grafting] does [bilateral internal thoracic artery grafting] increase the risk of [mediastinitis]?


   4. Search strategy
Top
 Abstract
 1. Introduction
 2. Clinical scenario
 3. Three-part question
 4. Search strategy
5. Search outcome
 6. Comments
 7. Clinical bottom line
 References
 
Medline 1995 – July 2007 using the OVID interface.

[Coronary artery bypass OR CABG OR aortocoronary bypass OR off-pump bypass OR on-pump bypass.mp] AND [Internal thoracic OR internal mammary.mp] AND [double OR bilateral] AND [Mediastinitis OR deep sternal OR sternal infection OR chest infection OR surgical site infection.mp].


   5. Search outcome
Top
 Abstract
 1. Introduction
 2. Clinical scenario
 3. Three-part question
 4. Search strategy
 5. Search outcome
6. Comments
 7. Clinical bottom line
 References
 
One hundred and forty papers were found in Medline. Twenty-four were deemed to be relevant. The papers are documented in Table 1.


View this table:
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  		Table 1 Best evidence papers

 

   6. Comments
Top
 Abstract
 1. Introduction
 2. Clinical scenario
 3. Three-part question
 4. Search strategy
 5. Search outcome
 6. Comments
7. Clinical bottom line
 References
 
Mediastinitis (or deep sternal wound infection) is an infrequent, yet potentially devastating complication after CABG, which is associated with increased cost of care, prolonged hospitalization, and increased morbidity and mortality. The reported incidence of mediastinitis range from 1.3% to 4.7% in patients with BITA grafting [2–6] and indeed BITA has been shown to be an independent predictor for mediastinitis with an odds ratio ranging from 2.6 to 4.8 [7–11]. Furthermore, in diabetic patients undergoing CABG the use of BITA has been associated with higher percentages of mediastinitis which can be as high as >10% [12–14].

There is a subgroup of patients in whom skeletonized BITA was used with lower rates of mediastinitis. Skeletonized use of BITA has been associated with mediastinitis ranging from 0.4% to 2.6% in the whole context of CABG [15–17] and from 0.5% to 3.3% in diabetic patients [4, 15, 16, 18, 19]. The beneficial effect of BITA skeletonization with respect to reduced rates of mediastinitis can be attributed to the statistically significant increased sternal perfusion with skeletonized BITA compared to pedicled BITA. This was shown clearly in a randomized, double-blind within-patient comparison study, in which patients were randomized to receive one skeletonized and one pedicled internal thoracic artery graft [20].


   7. Clinical bottom line
Top
 Abstract
 1. Introduction
 2. Clinical scenario
 3. Three-part question
 4. Search strategy
 5. Search outcome
 6. Comments
 7. Clinical bottom line
References
 
In general, the use of pedicled BITA grafts carries increased risk for mediastinitis after CABG and this is even higher among diabetic patients, thus rendering many surgeons reluctant in using BITA grafting in this subgroup of patients. However, the use of skeletonized BITA grafts can reduce this risk and both non-diabetics and diabetics can be operated on without increased risk of mediastinitis. The current available evidence shows that skeletonized BITA grafting can be safely applied in almost every patient. All cardiac surgeons should be trained efficiently in using skeletonized BITA.


   References
Top
 Abstract
 1. Introduction
 2. Clinical scenario
 3. Three-part question
 4. Search strategy
 5. Search outcome
 6. Comments
 7. Clinical bottom line
 References
 

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  2. Toumpoulis IK, Anagnostopoulos CE, DeRose JJ Jr, Swistel DG. The impact of deep sternal wound infection on long-term survival after coronary artery bypass grafting. Chest 2005; 127:464–471.[CrossRef][Medline]
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  12. Kai M, Hanyu M, Soga Y, Nomoto T, Nakano J, Matsuo T, Umehara E, Kawato M, Okabayashi H. Off-pump coronary artery bypass grafting with skeletonized bilateral internal thoracic arteries in insulin-dependent diabetics. Ann Thorac Surg 2007; 84:32–36.[Abstract/Free Full Text]
  13. 126: Peterson MD, Borger MA, Rao V, Peniston CM, Feindel CM. Skeletonization of bilateral internal thoracic artery grafts lowers the risk of sternal infection in patients with diabetes. J Thorac Cardiovasc Surg 2003;1314–1319.
  14. Tavolacci MP, Merle V, Josset V, Bouchart F, Litzler PY, Tabley A, Bessou JP, Czernichow P. Mediastinitis after coronary artery bypass graft surgery: influence of the mammary grafting for diabetic patients. J Hosp Infect 2003; 55:21–25.[CrossRef][Medline]
  15. Endo M, Tomizawa Y, Nishida H. Bilateral versus unilateral internal mammary revascularization in patients with diabetes. Circulation 2003; 108:1343–1349.[Abstract/Free Full Text]
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Related Article

Bilateral internal thoracic artery harvesting: which harvesting technique is preferred?
Senol Yavuz
Interactive CardioVascular and Thoracic Surgery 2007 6: 791-792. [Full Text] [PDF]



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S. Yavuz
Bilateral internal thoracic artery harvesting: which harvesting technique is preferred?
Interactive CardioVascular and Thoracic Surgery, December 1, 2007; 6(6): 791 - 792.
[Full Text] [PDF]

This Article
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Joel Dunning
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