title: Technical aspects of double-skeletonized internal mammary artery grafting.
abstract: BACKGROUND
  Bilateral internal mammary artery (IMA) grafting is performed to provide complete arterial myocardial revascularization with the intention of decreasing postoperative return of angina and the need for reoperation. We present here technical views of double-skeletonized IMA grafting, and evaluate its clinical outcome.
  
  
  METHODS
  Skeletonized IMA is harvested gently with scissors and silver clips, without use of cauterization, and embedded in a small syringe filled with papaverine. Three strategies for arterial revascularization were employed in 762 consecutive patients: (1) the cross arrangement (242 patients, 32%), where the in situ right internal mammary artery (RIMA) is used for the left anterior descending artery (LAD), in situ left internal mammary artery (LIMA) to circumflex marginal branches and the gastroepiploic artery for the right coronary artery (RCA); (2) the composite arrangement (476 patients, 62%), where free IMA is attached end-to-side to the other in situ IMA; and (3) the natural arrangement (44 patients, 6%), where the in situ RIMA is connected to the RCA and in situ LIMA to LAD. Mean age was 66 years (range 30 to 92). Two hundred ninety-two patients (38%) were older than 70, and 229 (30%) were diabetic.
  
  
  RESULTS
  Operative mortality was 2.5% (n = 19). The mortality of urgent and elective cases was 1.2% (8 of 663), and that of emergency operation was 11% (11 of 99). There were 9 (1.2%) perioperative myocardial infarctions, and 10 patients (1.3%) sustained strokes. Sternal wound infection occurred in 14 (1.8%).
  
  
  CONCLUSIONS
  The three strategies described here provide the surgeon with the versatility required for arterial revascularization with bilateral IMAs in most patients referred for coronary artery bypass grafting.
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Israel.
authors.forename: J
authors.initials: J
authors.lastname: Gurevitch
authors.forename: A
authors.initials: A
authors.lastname: Kramer
authors.forename: C
authors.initials: C
authors.lastname: Locker
authors.forename: I
authors.initials: I
authors.lastname: Shapira
authors.forename: Y
authors.initials: Y
authors.lastname: Paz
authors.forename: M
authors.initials: M
authors.lastname: Matsa
authors.forename: R
authors.initials: R
authors.lastname: Mohr
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007387:Internal Mammary-Coronary Artery Anastomosis / Q000379:methods*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies