Effect of Skeletonization of Bilateral Internal Thoracic Arteries on Deep Sternal Wound Infections
Thomas A Schwann1, Mario F L Gaudino2, Daniel T Engelman1
1Department of Surgery, University of Massachusetts-Baystate, Springfield, Massachusetts.
Insights
Skeletonized bilateral internal thoracic arteries (BITA) grafting may reduce deep sternal wound infections (DSWIs) after coronary bypass surgery. This technique showed a protective role against DSWIs, especially in high-risk patients.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Surgical Outcomes
Background:
- Bilateral internal thoracic arteries (BITA) coronary bypass grafting is linked to improved long-term outcomes.
- However, BITA grafting is also associated with an increased risk of deep sternal wound infections (DSWIs).
- The impact of BITA harvesting technique on DSWIs and operative mortality (OM) requires investigation.
Purpose of the Study:
- To analyze the effect of BITA skeletonization on the incidence of DSWIs and OM.
- To compare DSWI and OM rates between skeletonized BITA (ssBITA) and non-skeletonized BITA (Non-ssBITA) techniques.
Main Methods:
- Analysis of The Society of Thoracic Surgeons Adult Cardiac Surgery Database (July 2017-December 2018).
- Patients were divided into ssBITA and Non-ssBITA groups.
- Comparison of observed-to-expected (O/E) ratios for DSWI and OM, using multivariable logistic regression and propensity score matching.
Main Results:
- 11,269 patients were analyzed; 42.8% underwent ssBITA.
- ssBITA was associated with a statistically significant decrease in DSWIs (adjusted odds ratio, 0.66; P = .05).
- No significant difference in operative mortality was observed between groups.
Conclusions:
- The skeletonization technique for BITA harvesting is associated with a reduced risk of DSWIs.
- This finding supports the protective role of skeletonization in mitigating DSWI risk after BITA coronary bypass grafting.
- DSWI risk increases with patient risk factors, underscoring the importance of surgical technique.
Background:
Bilateral internal thoracic arteries (BITA) coronary bypass grafting may improve long-term outcomes but is associated with increased deep sternal wound infections (DSWIs). We analyzed whether BITA skeletonization impacts DSWIs and operative mortality (OM) using The Society of Thoracic Surgeons Adult Cardiac Surgery Database.
Methods:
Primary, isolated, nonemergent/nonsalvage BITA patients (July 2017 to December 2018) in The Society of Thoracic Surgeons Adult Cardiac Surgery Database were divided into groups based on BITA harvesting technique: both skeletonized (ssBITA) and ≥1 nonskeletonized (Non-ssBITA). DSWI and OM observed-to-expected (O/E) ratios were compared using The Society of Thoracic Surgeons Perioperative Risk Models. ssBITA versus Non-ssBITA DSWI and OM adjusted odds ratios were calculated by multivariable logistic regression and corroborated by propensity score matching.
Results:
We analyzed 11,269 patients (42.8% ssBITA, 57.2% Non-ssBITA, 770 hospitals, 1448 surgeons). The ssBITA group had a higher incidence of comorbidities and off-pump surgery. Overall incidences of DSWIs and OM were 0.98% (O/E ratio, 5.1) and 1.72% (O/E ratio, 1.4), respectively, and were 28% (P = .129) and 23% (P = .096) lower in ssBITA. The DSWI O/E ratio was highest (5.9) in Non-ssBITA and lowest in ss-BITA (4.1). After multivariable adjustment, ssBITA was associated with a decreased risk of DSWIs (adjusted odds ratio, 0.66; 95% confidence interval, 0.44-1.00; P = .05), with no difference in OM. These results were confirmed among 3884 propensity score-matched pairs. DSWIs increased sharply with increasing number of risk factors for DSWIs regardless of harvesting technique, with a trend for higher DSWIs among Non-ssBITA for all risk categories.
Conclusions:
The observed high O/E ratio indicates that BITA grafting is associated with increased risk of DSWIs. Risk-adjusted DSWI rate and a lower O/E ratio in ssBITA support the protective role of skeletonization.
Related Concept Videos
01:26Flail Chest-II
Assessment:
1. Clinical Evaluation:
History:
01:17The Thoracic Cage: Sternum
The sternum is the elongated bony structure on the anterior side of the thoracic cage. It consists of three parts: the manubrium, the body, and the xiphoid...