Skeletonization of the internal thoracic artery for coronary artery bypass grafting

Multiple cohort studies have shown that long-term outcomes after coronary surgery can be markedly improved when bilateral internal thoracic arteries (BITA) are used for revascularization. Applying this strategy is challenging, however, as a large proportion of patients suffer from comorbidities such as diabetes, and sternal devascularization with BITA may increase the risk of complications. Skeletonization is a technique of internal thoracic artery (ITA) harvest that has been proposed to reduce chest wall ischemia and thus minimize these problems.

Evidence is presented from animal and human studies which confirm that skeletonization preserves sternal blood flow. When meticulously completed, skeletonization is not associated with vessel wall damage. Intrapatient comparisons have conclusively demonstrated that skeletonization minimizes chest wall pain and discomfort. Many studies have confirmed that, when this strategy is used for BITA, the incidence of sternal wound infection approximates that seen with single ITA use, even in diabetic patients on insulin. Finally, there is no evidence in the current literature to suggest that skeletonization jeopardizes ITA patency.

The strategy of skeletonization is an advance that will facilitate complete arterial revascularization in high-risk patients whose surgery has previously been limited to saphenous vein conduits. Theoretical concerns challenging this approach should be tested long-term in a randomized clinical trial in patients undergoing BITA revascularization.