Original Articles
Technical aspects of double-skeletonized internal mammary artery grafting

https://doi.org/10.1016/S0003-4975(99)01407-1Get rights and content

Abstract

Background. Bilateral internal mammary artery (IMA) grafting is performed to provide complete arterial myocardial revascularization with the intention of decreasing postoperative return of angina and the need for reoperation. We present here technical views of double-skeletonized IMA grafting, and evaluate its clinical outcome.

Methods. Skeletonized IMA is harvested gently with scissors and silver clips, without use of cauterization, and embedded in a small syringe filled with papaverine. Three strategies for arterial revascularization were employed in 762 consecutive patients: (1) the cross arrangement (242 patients, 32%), where the in situ right internal mammary artery (RIMA) is used for the left anterior descending artery (LAD), in situ left internal mammary artery (LIMA) to circumflex marginal branches and the gastroepiploic artery for the right coronary artery (RCA); (2) the composite arrangement (476 patients, 62%), where free IMA is attached end-to-side to the other in situ IMA; and (3) the natural arrangement (44 patients, 6%), where the in situ RIMA is connected to the RCA and in situ LIMA to LAD. Mean age was 66 years (range 30 to 92). Two hundred ninety-two patients (38%) were older than 70, and 229 (30%) were diabetic.

Results. Operative mortality was 2.5% (n = 19). The mortality of urgent and elective cases was 1.2% (8 of 663), and that of emergency operation was 11% (11 of 99). There were 9 (1.2%) perioperative myocardial infarctions, and 10 patients (1.3%) sustained strokes. Sternal wound infection occurred in 14 (1.8%).

Conclusions. The three strategies described here provide the surgeon with the versatility required for arterial revascularization with bilateral IMAs in most patients referred for coronary artery bypass grafting.

Section snippets

Harvesting and preparing the skeletonized IMA

In our harvesting technique, we basically follow instructions and recommendations given before by Cunningham and associates [5], and add our experience. A standard median sternotomy incision is used with only rare application of bone wax. Later dissection of the IMA is easier if meticulous hemostasis is obtained on the sternal edges to avoid accumulation of blood in the field. The IMAs are dissected as skeletonized arteries [3], before heparin administration, to decrease the risk of damage and

Results

We prospectively evaluated the use of double-skeletonized IMA in 762 patients between April 1996 and April 1998. Mean age was 66 years, range 30 to 92 years, 595 (78%) were men, and 167 (22%) women. Two hundred ninety-two (38%) were older than 70, 229 (30%) were diabetic, and 141 (18%) had left ventricular dysfunction. Myocardial preservation technique was intermittent anterograde warm blood cardioplegia. Mean bypass time was 102 minutes, and cross-clamp time was 85 minutes. Average number of

Comment

This report focuses on technical aspects of bilateral skeletonized IMA grafting. The technical experience we gathered with the first 762 patients operated upon is detailed above. The patients here are typical for an urban population (relatively old), and this technique was used in 71% of the patients who underwent CABG in our institution, including those older than 70 years of age and diabetic patients, over a relatively short period of time (3 years). The only important contraindication for

Cited by (0)

View full text