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Interact CardioVasc Thorac Surg 2008;7:1160-1161. doi:10.1510/icvts.2008.189100 © 2008 European Association of Cardio-Thoracic Surgery
Left internal thoracic artery harvesting: measurement of the length required for coronary bypass surgeryDepartment of Cardiac Surgery, University Hospital, I. P. Pavlova 6, 775 15 Olomouc, Czech Republic Received 23 July 2008; received in revised form 26 August 2008; accepted 27 August 2008
Corresponding author. Tel.: +420 724253745; fax: +420 585852377.
The left internal thoracic artery (LITA) is used routinely for coronary bypass surgery. A simple technique for assessing, prior to harvesting, the length of LITA required for an individual bypass of the left anterior descending artery (LAD) is described.
Key Words: Coronary artery disease; CABG; Arterial revascularization
The left internal thoracic artery (LITA) is used routinely for coronary bypass surgery [1]. It is usually harvested either with a pedicle or in a skeletonized fashion [2]. The debate over which harvesting technique is better for the patient has yet to be resolved. However, it is important to realize that taking down the LITA always leads to impairment of the sternal vasculature, which may have a negative effect on sternotomy healing. Most surgeons, including those who try to minimize surgical trauma by harvesting the LITA in a skeletonized fashion, do not measure the length of the LITA that is needed for the bypass and may therefore unnecessarily harvest the whole length of the vessel down to its bifurcation or even beyond. It is usual to resect and discard the distal portion (1–5 cm) of the LITA before the coronary anastomosis is performed. Described herein is a simple technique for assessing, prior to harvesting, the length of LITA required for an individual bypass of the left anterior descending artery (LAD). After performing a sternotomy, the pericardial sack is opened and the coronary arteries are inspected to define the shape of coronary reconstruction. A swab is placed beneath the heart and the point of planned anastomosis with the LAD is transferred vertically to the sternal edge (Fig. 1, point A). The LITA is dissected in a skeletonized fashion from the subclavian vein to 2 cm beyond this point (Fig. 1, point B), preserving the remaining part of the vessel and its branches in situ.
After completion of the coronary anastomosis, the left pleural space and a portion of the adjacent pericardium are opened vertically, and the LITA graft is placed underneath the left lung.
The LITA is a cornerstone of coronary revascularizations. However, while creating a new blood supply for the ischemic myocardium by harvesting the LITA, it should be remembered that this procedure damages the vasculature of the sternum, sometimes leading to complications in wound healing. The distal part of the sternum, which has been shown to have poor blood vessel collateralization, is particularly susceptible to ischemia [3]. This is the reason why regardless of the LITA-harvesting technique used (i.e. with a pedicle or skeletonized), at least the distal LITA bifurcation should always be preserved. Using the technique described above in 20 consecutive patients in whom the LITA was used as an individual bypass for LAD, it was always possible to preserve not only the LITA bifurcation, but also a substantial portion (2–9 cm; mean 5.3 cm) of its distal segment, thus minimizing the surgical trauma to the sternal vasculature. No LITA was damaged during its preparation. All bypasses were free of tension. In most cases stenotic lesions occur only proximally in the LAD and the course of the vessel is superficial, allowing the bypass to be positioned on its proximal half. Use of a shorter segment of the LITA for coronary bypass with the LAD not only preserves the distal part of sternal blood supply, but also avoids use of the distal, muscular part of the LITA, which is prone to spasm, and provides the surgeon with a greater vessel diameter for the anastomosis. Adjustment of the length of LITA harvested is also important while using the skeletonization technique, since excessive lengths of LITA may lead to graft kinking. While using the schema of LITA measurement described herein, it is mandatory to dissect the vessel up to the subclavian vein and position the sutured graft beneath the left lung. Routine opening of the left pleural cavity may lead to increased number of pleural effusions. There is no surgery without trauma, but it should be minimized whenever possible. I believe that by preserving as much of the distal segment of the LITA as possible, especially during bilateral internal thoracic artery harvesting, some patients could be spared from the associated wound-healing complications.
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Abstract
1. Introduction
