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Skeletonisation contributing to a reduction of sternal wound complications: a retrospective study in OPCAB patients
Jef Van den Eynde1, Astrid Heeren1, Delphine Szecel1
1Department of Cardiovascular Diseases, Research Unit of Cardiac Surgery, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.
Insights
Skeletonised harvesting of bilateral internal mammary artery (BIMA) grafts significantly reduces sternal wound complications (SWC) in diabetic patients undergoing off-pump coronary artery bypass grafting (OPCAB). This technique offers a safer approach for this high-risk population.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Surgical Complications
Background:
- Sternal wound complications (SWC) are serious risks after coronary artery bypass grafting (CABG).
- Bilateral internal mammary artery (BIMA) grafts increase SWC risk compared to single internal mammary artery (SIMA) grafts.
- Skeletonised harvesting is a proposed method to mitigate SWC risk.
Purpose of the Study:
- To investigate the impact of skeletonised versus non-skeletonised graft harvesting on SWC.
- To assess SWC in a high-volume center for off-pump coronary artery bypass grafting (OPCAB) with frequent BIMA use.
Main Methods:
- Retrospective analysis of 1900 consecutive OPCAB patients (2010-2016).
- Comparison of SWC incidence and grade between non-skeletonised (n=1487) and skeletonised (n=413) IMA graft groups.
- Development of a new four-grade classification for SWC assessment.
Main Results:
- Diabetic patients with skeletonised grafts had significantly lower SWC incidence (8.5% vs. 19.8%) and grade.
- The benefit was most pronounced in diabetic patients receiving BIMA grafts (10.7% vs. 24.6% SWC).
- No significant impact on overall survival was observed; advantages were not significant for SIMA grafts or the overall population.
Conclusions:
- Skeletonisation technique, combined with optimized wound management, reduces SWC incidence and grade in diabetic patients undergoing OPCAB with BIMA grafts.
- This finding supports the expanded use of BIMA grafts in OPCAB for diabetic patients.
- A refined SWC classification aids in identifying the benefits of surgical techniques.
Background:
Sternal wound complications (SWC) are a rare but potentially life-threatening complication after coronary artery bypass grafting (CABG) surgery. Especially the use of bilateral IMA (BIMA) grafts as opposed to single IMA (SIMA) grafts is associated with an increased risk of SWC. Skeletonised harvesting has been proposed to reduce this risk. The purpose of this study was to retrospectively investigate the effect of skeletonisation on SWC after off-pump coronary artery bypass grafting (OPCAB) in a centre with a high volume of off-pump procedures and high frequencies of BIMA.
Methods:
From January 2010 to November 2016, 1900 consecutive patients underwent OPCAB surgery at the University Hospitals of Leuven. The first group (n = 1487) received non-skeletonised IMA grafts, whereas the second group (n = 413) received skeletonised grafts. Optimal wound management was pursued in all patients. A new four-grade classification for SWC was developed. Incidence and grade of SWC as well as overall survival were assessed.
Results:
Analysis of diabetic patients showed a lower incidence of SWC in the skeletonised (12/141, 8.5%) compared to the non-skeletonised group (82/414, 19.8%) [odds ratio 0.46, 95% confidence interval (0.23;0.88), p = 0.019] as well as a lower grade [0.45 (0.24;0.871), p = 0.018]. There was no significant effect on overall survival [0.67 (0.19;2.32), p = 0.529]. Subanalysis of this population revealed that the observed effects were most prominent in patients receiving BIMA grafts, with 6/56 (10.7%) SWC in the skeletonised and 62/252 (24.6%) in the non-skeletonised group [0.37 (0.15;0.90), p = 0.028 for incidence], as well as a lower grade [0.36 (0.15;0.88), p = 0.025]. These advantages were not significant in diabetic patients receiving SIMA grafts nor in the full study population.
Conclusions:
This study, using a more sensitive classification of SWC, shows in a large group of patients that, in combination with optimized wound management, the skeletonisation technique is associated with a clear reduction in the incidence and grade of SWC in diabetic patients receiving BIMA grafts. This encourages the extension of BIMA use in OPCAB to this risk population.
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