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To skeletonize or not to skeletonize the internal thoracic artery: a randomized trial
Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.ORCID iD: 0000-0001-5585-1783
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Background The left internal thoracic artery (LITA) is the gold standard conduit for grafting of the left anterior descending (LAD) coronary artery in coronary artery bypass grafting (CABG) surgery due to superior long-term patency rates and evidence of improved long-term outcomes. The LITA grafts are traditionally harvested with a pedicle of surrounding tissue (PLITA). Alternatively the LITA can be harvested in a skeletonized fashion (S-LITA) where the graft is being dissected from all surrounding tissues. Advocates of skeletonization postulate that this technique reduces sternal devascularisation, the incidence of chest wall pain and dysesthesia, wound healing problems, and increase the number of arterial anastomoses per patient by increasing the length of the LITA. To our knowledge this is the first randomised trial comparing angiographic mid-term patency rates between skeletonized andpedicled ITAs.

Methods This randomized trial included 109 patients undergoing coronary artery bypass grafting surgery and compared the patency for P-LITA and S-LITA. The patients were assigned to receive either one P-LITA or one S-LITA to the LAD. Complementary grafting was performed using both No-touch saphenous vein and radial artery grafts.

Results Graft patency was evaluated with angiography in 100 patients (92 %) at mean 36 months postoperatively. The patency rate for P-LITA (46/48, 96 %) did not differ (p=0.44) compared to S-LITA (47/52, 90 %). All failed grafts, except one with a localised stenosis, (S-LITA) were connected to LAD coronary arteries with a stenosis less than 70%.

Conclusions The evidence presented here demonstrates that in terms of patency, both P-LITA and S-LITA provide excellent results. It seemed that the most important factor for ITA occlusion was the degree of stenosis of the LAD and not the technique used for their preparation.

Clinical Trial registration 

NCT01310725 ClinicalTrials.gov [http://clinicaltrials.gov/ct2/show/NCT01310725]

National Category
Medical and Health Sciences
Research subject
Medicine
Identifiers
URN: urn:nbn:se:oru:diva-33420OAI: oai:DiVA.org:oru-33420DiVA, id: diva2:691853
Available from: 2014-01-29 Created: 2014-01-29 Last updated: 2017-10-17Bibliographically approved
In thesis
1. Conduits in coronary artery bypass grafting surgery: Saphenous vein, radial and internal thoracic arteries
Open this publication in new window or tab >>Conduits in coronary artery bypass grafting surgery: Saphenous vein, radial and internal thoracic arteries
2013 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

A novel technique for saphenous vein (SV) graft harvesting, the No-touch technique (NT), has been developed at the Dept. of Cardiovascular surgery, Örebro University hospital. With NT the SV is harvested with a pedicle of surrounding tissue. This avoids graft spasm and eliminates the need for distension. The surrounding tissue acts as a structural support and is a rich source of vaso-dilating agents. A randomized controlled trial (RCT) has shown a significantly higher patency rate for NT SV grafts compared to SV grafts harvested with conventional technique (CT). This thesis evaluates some of the properties of the surrounding tissue and compares patency rates between NT SV and radial artery (RA) grafts and patency rates for internal thoracic artery (ITA) grafts harvested with and without surrounding tissue. Paper I investigated vasa vasorum (VV) in SV grafts and showed that the NT preserves an intact VV whereas CT does not. This could be one of the mechanisms underlying the improved patency for NT SV grafts. Paper II evaluated VV and associated nitric oxide (NO) in SV and arterial grafts. SV grafts showed a higher number and larger VV, which correlated with NO production, compared to arterial grafts. NT SV grafts showed higher activity for e-NOS compared to CT SV grafts. Paper III is a RCT comparing patency rates between NT SV and RA grafts, three years after surgery, showing a significantly higher patency rate for NT SV grafts. Paper IV is a RCT comparing patency rates for ITA graft harvested with and without surrounding tissue and did not show any difference between graft preparations. In conclusion, the NT for SV graft harvesting preserves an intact vasa vasorum and associated NO production. NT SV grafts show a higher patency rate than RA grafts. Harvesting of ITA with or without surrounding tissue does not affect patency rate. 

Place, publisher, year, edition, pages
Örebro: Örebro universitet, 2013. p. 65
Series
Örebro Studies in Medicine, ISSN 1652-4063 ; 93
Keywords
Cardiac surgery, Coronary artery bypass, Saphenous vein, Radial artery, Internal thoracic artery, Vasa vasorum, Nitric oxide, Graft patency
National Category
Medical and Health Sciences
Research subject
Medicine
Identifiers
urn:nbn:se:oru:diva-33265 (URN)978-91-7668-960-8 (ISBN)
Public defence
2013-10-11, Wilandersalen, Universitetssjukhuset, Örebro, Södra Grev Rosengatan, 703 62 Örebro, 13:15 (Swedish)
Opponent
Supervisors
Available from: 2014-01-23 Created: 2014-01-23 Last updated: 2017-10-17Bibliographically approved

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Dreifaldt, Mats

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