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Coronary: Erden Ali, Srdjan Saso, Hutan Ashrafian, and Thanos Athanasiou Does a skeletonized or pedicled left internal thoracic artery give the best graft patency? Interactive CardioVascular and Thoracic Surgery published on Oct 23, 2009 as doi:10.1510/icvts.2009.221242 [Abstract] [Journal Format PDF]

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eComment. Sternal microcirculation following pedicled or skeletonized internal thoracic artery harvesting

Karsten Knobloch, Peter M. Vogt, Artur Lichtenberg   (29 October 2009)

eComment. Sternal microcirculation following pedicled or skeletonized internal thoracic artery harvesting 29 October 2009
Karsten Knobloch Hannover Medical School, Plastic, Hand and Reconstructive Surgery, Hannover, Germany, Peter M. Vogt, Artur Lichtenberg Send ecomment to journal: Re: eComment. Sternal microcirculation following pedicled or skeletonized internal thoracic artery harvesting kknobi{at}yahoo.com Karsten Knobloch, et al.	Interactive CardioVascular and Thoracic Surgery 2009, doi:10.1510/icvts.2009.221242 © 2009 European Association of Cardio-Thoracic Surgery We read with great interest the recent review from Dr. Ali and coworkers [1]. Besides graft patency, sternal microcirculatory issues seem to favour skeletonized rather than pedicled internal thoracic artery (ITA) harvesting. Following pedicled conventional ITA harvesting, retrosternal capillary blood flow as well as retrosternal tissue oxygen saturation decrease significantly up to 50%, respectively [2]. In addition, pedicled ITA harvesting leads to retrosternal venous congestion. In case of experimental sternal infection in a porcine model, changes of microvascular sternal blood flow are evident depending on the applied pressure using vacuum-assisted closure (VAC) [3]. VAC has been suggested to stimulate blood flow in the peristernal region after ITA harvesting [4]. A clinical randomized trial compared pedicled vs. skeletonized harvesting techniques of the ITA with 24 consecutive patients enrolled [5]. Skeletonized ITA harvesting demonstrated significantly less deterioration of sternal microcirculation with improved tissue oxygen saturation. Thus, from a microcirculatory point of view, preserved internal thoracic veins faciliate venous outflow and diminish venous congestion, which otherwise might facilitate retrosternal infection in a clinical setting. References [1] Ali E, Saso S, Ashrafian H, Athanasiou T. Does a skeletonized or pedicled left internal thoracic artery give the best graft patency? Interact Cardiovasc Thorac Surg doi:10.1510/ictvs.2009.221242. [2] Knobloch K, Lichtenberg A, Pichlmaier M, Mertsching H, Krug A, Klima U, Haverich A. Microcirculation of the sternum following harvesting of the left internal mammary artery. Thorac Cardiovasc Surg 2003;51:255-259. [3] Wackenfors A, Gustafsson R, Sjörgren J, Algotsson L, Ingemannsson R, Malmsjö M. Blood flow responses in the peristernal thoracic wall during vacuum-assisted closure therapy. Ann Thorac Surg 2005;79:1724-1730. [4] Petzina R, Gustafsson L, Mokhtari A, Ingemansson R, Malmsjö M. Effect of vacuum-assisted closure on blood flow in the peristernal thoracic wall after internal mammary artery harvesting. Eur J Cardiothorac Surg 2006;30:85-89. [5] Kamiya H, Akhyari P, Martens A, Karck M, Haverich A, Lichtenberg A. Sternal microcirculation after skeletonized versus pedicled harvesting of the internal thoracic artery: a randomized study. J Thorac Cardiovasc Surg 2008;135:32-37.