title: Skeletonization of bilateral internal thoracic artery grafts lowers the risk of sternal infection in patients with diabetes.
abstract: OBJECTIVE
  Deep sternal wound infection is a dreaded complication of coronary artery bypass surgery, particularly in patients with diabetes. This study determines whether skeletonization of internal thoracic artery conduits compared with pedicled harvesting reduces the risk of deep sternal wound infection in patients with diabetes undergoing bilateral internal thoracic artery grafting.
  
  
  METHODS
  We reviewed prospectively gathered data on all patients who have undergone coronary artery bypass grafting and received bilateral internal thoracic artery grafts at our institution since 1990. We compared patients with diabetes who received skeletonized (n = 79) versus conventional pedicled (n = 36) internal thoracic artery conduits.
  
  
  RESULTS
  The proportion of patients taking insulin (19.0% vs 14.0% for skeletonized vs conventional grafts, respectively, P =.6) or oral hypoglycemic agents (68.4% vs 69.4%, P =.9), as well as the prevalence of type I diabetes (2.5% vs 8.3%, P =.18), were similar in both groups. Patients who received skeletonized grafts were more likely to receive a free rather than an in situ right internal thoracic artery graft (93.7% vs 30.6%, P <.001). The prevalence of deep sternal wound infection was significantly lower in patients who received skeletonized grafts compared with patients who received conventional grafts (1.3% vs 11.1%, P =.03). Patients in the skeletonized group were also less likely to develop any (superficial or deep) sternal wound infection postoperatively (5.1% vs 22.2%, P =.03). There was no significant difference in the prevalence of deep sternal wound infection between patients with diabetes who received skeletonized internal thoracic arteries and patients without diabetes who underwent conventional internal thoracic artery grafting (n = 578) (1.2% vs 1.6%, respectively, P =.8).
  
  
  CONCLUSIONS
  Skeletonization of internal thoracic artery conduits lowers the risk of deep sternal wound infection in patients with diabetes undergoing bilateral internal thoracic artery grafting. We no longer consider diabetes a contraindication to bilateral internal thoracic artery grafting, provided the internal thoracic arteries are skeletonized.
authors.affiliation: Division of Cardiac Surgery, Toronto General Hospital, and Department of Surgery, University of Toronto, Ontario, Canada.
authors.forename: Mark D
authors.initials: MD
authors.lastname: Peterson
authors.forename: Michael A
authors.initials: MA
authors.lastname: Borger
authors.forename: Vivek
authors.initials: V
authors.lastname: Rao
authors.forename: Charles M
authors.initials: CM
authors.lastname: Peniston
authors.forename: Christopher M
authors.initials: CM
authors.lastname: Feindel
mesh_terms: D000328:Adult; D000368:Aged; D015331:Cohort Studies; D001026:Coronary Artery Bypass / Q000009:adverse effects / Q000379:methods*; D003324:Coronary Artery Disease / Q000150:complications / Q000000981:diagnostic imaging / Q000601:surgery*; D003922:Diabetes Mellitus, Type 1 / Q000150:complications / Q000175:diagnosis; D003924:Diabetes Mellitus, Type 2 / Q000150:complications / Q000175:diagnosis; D005260:Female; D005500:Follow-Up Studies; D006085:Graft Survival; D006801:Humans; D007387:Internal Mammary-Coronary Artery Anastomosis; D016015:Logistic Models; D008297:Male; D008323:Mammary Arteries / Q000637:transplantation*; D008875:Middle Aged; D015995:Prevalence; D011446:Prospective Studies; D011859:Radiography; D018570:Risk Assessment; D012720:Severity of Illness Index; D013249:Sternum / Q000503:physiopathology; D013530:Surgical Wound Infection / Q000175:diagnosis* / Q000453:epidemiology*; D013908:Thoracotomy / Q000009:adverse effects / Q000379:methods; D020858:Tissue and Organ Harvesting; D016896:Treatment Outcome; D014654:Vascular Patency