Skeletonized or Pedicled Harvesting of Left Internal Mammary Artery: A Systematic Review and Meta-analysis

We sought to compare clinical outcomes in skeletonized versus pedicled left internal mammary artery (LIMA) grafts in elective coronary artery bypass grafting through a systematic review and meta-analysis. A comprehensive electronic literature search of PubMed, Ovid, Embase, and Scopus was conducted from inception to January 2020. Only short-term (30 days) studies which compared both techniques have been included in our analysis. Primary outcomes were post anastomosis flow rate and sternal wound infection rate (SWI); secondary outcomes were conduit length, acute myocardial infarction and 30-day mortality. Thirteen articles with a total of 6222 patients met the inclusion criteria. Except for the prevalence of diabetes mellitus being significantly lower in the skeletonized cohort (odds ratio [OR] 0.77 95% confidence interval [CI] [0.61, 0.97], P = 0.03), there were no differences in the preoperative demographics between the 2 groups. The skeletonized LIMA conduit was significantly longer when compared to the pedicled conduit (weighted mean difference -2.64 cm 95% CI [-3.71, -1.56], P < 0.0001). SWI rates were not significantly different in the skeletonized versus pedicled LIMA group (OR 0.71 95% CI [0.47, 1.06], P = 0.10). New onset of acute myocardial infarction and 30-day mortality rate was similar in the 2 groups (OR 1.04 and 0.97, respectively, P > 0.05 in both). The postanastomoses flow rate was higher in skeletonized LIMA (Weighted Mean Difference -11.51 mL/min 95% CI [-20.54, -2.49], P < 0.01). Harvesting the LIMA using the skeletonized technique is associated with higher postanastomosis flow rates and longer conduit lengths; with no difference in SWI and mortality rates when compared to the pedicled technique. We suggest that this technique should be adopted, particularly for BITA harvesting. However, further research is needed to provide clearer indications for both methods.