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Skeletonized versus pedicled internal mammary artery: impact of surgical technique on post CABG surgery pain
Yaron Bar-El1, Boaz Gilboa, Nina Unger
1The B. Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel. y_bar_el@rambam.health.gov.il
Insights
Post CABG pain syndrome (PCP) is common after heart surgery. Skeletonization of the internal mammary artery (IMA) does not reduce PCP incidence, suggesting nerve ischemia, not direct injury, causes this pain.
Area of Science:
- Cardiothoracic Surgery
- Pain Management
- Neurology
Background:
- Coronary artery bypass graft (CABG) surgery can lead to chronic chest wall pain, known as post CABG pain syndrome (PCP).
- Intercostal nerve injury during surgery was the presumed cause of PCP.
- Two internal mammary artery (IMA) harvesting techniques, skeletonization (S-LIMA) and pedicle (P-LIMA), are compared for their impact on PCP.
Purpose of the Study:
- To investigate the effect of S-LIMA and P-LIMA harvesting techniques on the occurrence and incidence of PCP.
- To compare the prevalence of PCP between different IMA harvesting methods and vein grafting.
- To assess pain characteristics, sensory changes, and disability in patients experiencing PCP after IMA harvesting.
Main Methods:
- A mailed questionnaire was sent to 482 CABG patients (1999-2000) to identify PCP.
- A subgroup of IMA patients with PCP underwent detailed clinical evaluations.
- Standardized tests and indices were used to assess pain localization, intensity, thermal/tactile sensitivity, and disability.
Main Results:
- Of 380 responders, 169 (44%) reported PCP.
- PCP prevalence was similar between S-LIMA (45%) and P-LIMA (50%) groups, but significantly lower in vein graft (V) patients (18%).
- Clinical assessments confirmed similar neuropathic pain occurrence and intensity, sensory changes, and disability between S-LIMA and P-LIMA groups.
Conclusions:
- PCP is a frequent complication following CABG surgery.
- The skeletonization technique for IMA harvesting does not reduce PCP occurrence despite less direct trauma.
- Ischemic injury to intercostal nerves, rather than direct mechanical injury, is the likely cause of PCP.
Objective:
Recent evidence suggests that coronary artery bypass graft (CABG) surgery often results in chronic chest wall pain, termed: 'post CABG pain syndrome' (PCP). Direct injury to intercostal nerves during the surgical procedure was presumed to underlie this syndrome. The aim of this study was to investigate the effect of two harvesting techniques of the internal mammary artery (IMA)-skeletonization (S-LIMA) and pedicle (P-LIMA) on the occurrence and incidence of PCP.
Methods:
A mailed questionnaire enquiring about the presence and characteristics of PCP was sent to all 482 patients who had undergone CABG in our institution in the years 1999-2000. A randomly chosen subgroup of IMA patients reporting PCP were summoned for evaluations of pain localization and intensity, thermal and tactile sensitivity, and disability assessment using recognized tests and indices.
Results:
Of the 380 responders (S-LIMA: 221, P-LIMA: 125, veins only V-34) 169 (44%) reported having PCP. Its prevalence was similar between the two IMA groups (S-LIMA: 45%, P-LIMA: 50%) but significantly lower in the V group (18%, P=0.003). Physical assessment in the subgroup of 43 IMA patients (S-LIMA: 22, P-LIMA: 21) performed 40.2+/-8.7 months after surgery confirmed equal occurrence of mostly left and midline chest wall neuropathic pain in both IMA groups. No significant differences were found between the two groups in respect to indices of pain intensity, thermal and tactile sensitivity and disability.
Conclusions:
PCP is a prevalent finding in post CABG patients. The skeletonization technique of IMA harvesting although causing significantly less inner chest wall trauma does not appear to reduce the occurrence of PCP. This finding may imply that ischemic injury rather than direct mechanical injury to the intercostal nerves is the putative mechanism underlying PCP.
