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(Circulation. 2006;114:766-773.)
© 2006 American Heart Association, Inc.

Coronary Heart Disease

Skeletonized Internal Thoracic Artery Harvest Reduces Pain and Dysesthesia and Improves Sternal Perfusion After Coronary Artery Bypass Surgery

A Randomized, Double-Blind, Within-Patient Comparison

Munir Boodhwani, MD, MMSc; B. Khanh Lam, MD; Howard J. Nathan, MD; Thierry G. Mesana, MD, PhD; Marc Ruel, MD, MPH; Wanzhen Zeng, MD; Frank W. Sellke, MD; Fraser D. Rubens, MD, MSc

From the Divisions of Cardiac Surgery (M.B., B.K.L., T.G.M., M.R., F.D.R.) and Cardiac Anesthesia (H.J.N.), University of Ottawa Heart Institute, and the Department of Nuclear Medicine, The Ottawa Hospital (W.Z.), Ottawa, Ontario, Canada, and Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass (F.W.S.).

Correspondence to Dr Fraser D. Rubens, Professor, Division of Cardiac Surgery H3401, 40 Ruskin St, Ottawa, Ontario K1Y 4W7 Canada. E-mail frubens{at}ottawaheart.ca

Received January 19, 2006; revision received May 24, 2006; accepted June 12, 2006.

Background— Observational studies suggest that skeletonization of the internal thoracic artery (ITA) can improve conduit flow and length and reduce deep sternal infections and postoperative pain. We performed a randomized, double-blind, within-patient comparison of skeletonized and nonskeletonized ITAs in patients undergoing coronary surgery.

Methods and Results— Patients (n=48) undergoing bilateral ITA harvest were randomized to receive 1 skeletonized and 1 nonskeletonized ITA. Intraoperatively, ITA flow was assessed directly and with a Doppler flow probe before and after topical application of papaverine. ITA harvest time and conduit length were recorded. A blinded assessment of pain (visual analog scale) and dysesthesia (physical examination) was performed at discharge, at 2 weeks, and at a 3-month follow-up. Sternal perfusion was assessed with nuclear imaging (n=7). Skeletonization required longer ITA harvest times (27±1 versus 24±1 minutes; P=0.04). There was a trend toward increased ITA length in the skeletonized group (18.2±0.3 versus 17.7±0.3 cm; P=0.09). In situ ITA flow was lower in skeletonized arteries (7.4±0.9 versus 10.1±1.0 mL/min; P=0.01) and increased significantly after ITA division and papaverine application. Postanastomotic flows were similar between groups. Skeletonization was associated with decreased pain at the 3-month follow-up and a reduction in major sensory deficits at the 4-week and 3-month (17% versus 50%; P=0.002) follow-ups. Baseline adjusted sternal perfusion was significantly greater by 17±6% (P=0.03) on the skeletonized side.

Conclusions— Skeletonization results in reduced postoperative pain and dysesthesia and increased sternal perfusion at follow-up but does not produce increased conduit flow. ITA skeletonization may be a strategy for reducing morbidity after CABG.

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