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Left Internal Mammary Artery Skeletonization Reduces Bleeding-A Randomized Controlled Trial
Piotr Mazur1, Radosław Litwinowicz2, Vakhtang Tchantchaleishvili3
1Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow, Poland; Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland.
Insights
Skeletonized left internal mammary artery (LIMA) harvesting significantly reduces mediastinal drainage after coronary artery bypass grafting (CABG) compared to pedicled LIMA. This technique also lowered blood transfusions and myocardial necrosis markers.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Surgical Techniques
Background:
- Coronary artery bypass grafting (CABG) is a common cardiac procedure.
- Left internal mammary artery (LIMA) is frequently used as a graft in CABG.
- Harvesting techniques for LIMA, skeletonized versus pedicled, may impact surgical outcomes.
Purpose of the Study:
- To compare the impact of skeletonized versus pedicled LIMA harvesting on postoperative bleeding in CABG patients.
- To evaluate the effect of LIMA harvesting technique on myocardial necrosis markers.
Main Methods:
- A randomized, single-blinded trial with parallel group design was conducted.
- 62 patients undergoing primary elective CABG were assigned to either skeletonized or pedicled LIMA dissection.
- Postoperative cumulative drainage at 12 hours and myocardial necrosis markers were monitored.
Main Results:
- Skeletonized LIMA harvesting resulted in a 28% reduction in 12-hour mediastinal drainage compared to pedicled LIMA (P = .02).
- Patients receiving pedicled LIMA required more fresh-frozen plasma transfusions (P = .03).
- Skeletonized LIMA was associated with significantly lower creatine kinase levels post-surgery.
Conclusions:
- Skeletonized LIMA harvesting leads to less mediastinal drainage after CABG compared to pedicled LIMA harvesting.
- The skeletonized technique appears to be associated with improved short-term outcomes regarding bleeding and myocardial injury.
Background:
The objective of this study was to compare the impact of skeletonized versus pedicled left internal mammary artery (LIMA) harvesting on bleeding after coronary artery bypass grafting (CABG).
Methods:
In a randomized, single-blinded trial with a parallel group design and equal allocation, we randomly assigned 62 patients undergoing primary elective CABG in a tertiary cardiac center to skeletonized or pedicled LIMA dissection. Before surgery, all aspects of coagulation were assessed. Patients were blinded to LIMA dissection technique and monitored for cumulative drainage at 12 hours (primary outcome) as well as myocardial necrosis markers.
Results:
With recruitment complete, there were 31 patients in each group; all patients were analyzed. Median postoperative drainage was 395 mL at 12 hours in all patients; it was lower by 28% at 12 hours (P = .02) in patients with skeletonized LIMA (Cohen's d, 0.6; 95% confidence interval (CI), 0.09-1.11). Patients with a LIMA pedicle received more fresh-frozen plasma transfusions than did the skeletonized LIMA group (Median 3; interquartile range 3-5 versus median 3; interquartile range 3-3; P = .03). Study arms did not differ in blood coagulation. Left internal mammary artery skeletonization (odds ratio = 0.04; 95% CI, 0.003-0.44; P = .009) and higher body mass index (odds ratio = 0.63; 95% CI, 0.45-0.89; P = .008) decreased the odds of being in the top drainage quartile at 12 hours (≥550 mL). Creatine kinase was lower in skeletonized LIMA directly after surgery (median 218 U/L; interquartile range 175-310 U/L versus median 424 U/L; interquartile range 256-510 U/L; P < .001), at 6 hours (median 324 U/L; interquartile range 239-424 U/L versus median 529 U/L; interquartile range 374-707 U/L; P < .001), and 12 hours after surgery (median 351 U/L; interquartile range 277-552 U/L versus median 695 U/L; interquartile range 509-1067 U/L; P < .001).
Conclusions:
Left internal mammary artery skeletonization results in lower mediastinal drainage after CABG than pedicled LIMA harvesting.
