Open vs Intact Pleura During Internal Thoracic Artery Harvesting: A Meta-Analysis of Randomized Trials

The pleura is typically opened during internal thoracic artery (ITA) harvesting, but closed pleura technique has also been described. Preserving pleural integrity may reduce the risk of postoperative pulmonary complications. A meta-analysis was performed of all randomized controlled trials (RCTs) comparing outcomes of open vs closed pleura techniques during ITA harvesting.

Systematic review through November 4, 2025 was conducted to identify RCTs comparing open vs closed pleura techniques during ITA harvesting. The primary outcome was pleural effusion. The secondary outcomes were changes in spirometry findings, pulmonary atelectasis, chest tube output, cardiac tamponade, changes in blood gas results, ventilation time, operative mortality, myocardial infarction, sternal wound infection, return to the operating room, intensive care unit stay, and hospital length of stay. Outcomes were pooled using an inverse variance random effects model.

Nine RCTs including 1869 patients (1015 with an open pleura technique, 854 with a closed pleura technique) were analyzed. Compared with the open pleura technique, the closed pleura technique was associated with less pleural effusion (odds ratio [OR], 0.35; 95% CI, 0.25-0.48), less pulmonary atelectasis (OR, 0.35; 95% CI, 0.28-0.43), less impairment of forced expiratory volume in 1 second (mean difference [MD], 13.0; 95% CI, 7.3-18.7), and shorter ventilation time (MD, -1.0 hours; 95% CI, -0.1 to -2.0 hours). The closed pleura technique was also associated with lower chest tube output after 24 hours (MD, -150 mL; 95% CI, -71 to -230 mL) and lower operative mortality (OR, 0.37; 95% CI, 0.20-0.66) but more cardiac tamponade (OR, 11.05; 95% CI, 1.14-106.82).

Maintaining pleural integrity during ITA harvesting was associated with fewer pulmonary complications, more cardiac tamponade, and lower operative mortality.