title: The effect of bilateral internal thoracic artery harvesting on superficial and deep sternal infection: The role of skeletonization.
abstract: OBJECTIVE
  To determine the relative risk of sternal dehiscence in patients undergoing bilateral internal thoracic artery harvesting and to assess whether and to what extent the technique of artery skeletonization might reduce this risk.
  
  
  METHODS
  Prospectively collected data on patients undergoing coronary artery bypass operations with at least a single internal thoracic artery were reviewed. The last 450 patients receiving bilateral internal thoracic artery grafts were compared with 450 patients who received a single internal thoracic artery during the same period. The left internal thoracic artery was always harvested in a pedicled fashion. Among patients receiving a bilateral internal thoracic artery, both arteries were harvested in a pedicled fashion in 300 cases, whereas both internal thoracic arteries were skeletonized in the remaining 150 cases.
  
  
  RESULTS
  Compared with a single internal thoracic artery, harvesting both internal thoracic arteries either in a skeletonized or in a pedicled fashion increased the chance of deep (1.1% vs 3.3% vs 4.7%; P = .01) or superficial (4.8% vs 7.8% vs 12%; P = .002) sternal infection. However, the technique of artery harvesting (odds ratio, 4.1; 95% confidence interval, 1.4-12.1); the presence of peripheral arteriopathy (odds ratio, 3.1; 95% confidence interval, 1.2-8.5), and resternotomy for bleeding (odds ratio, 8.2; 95% confidence interval, 2.0-33.6) were the only independent predictors for deep sternal infection, whereas the technique of artery harvesting (odds ratio, 3.0; 95% confidence interval, 1.6-5.4), female sex (odds ratio, 2.2; 95% confidence interval, 1.2-4.2), and diabetes (odds ratio, 1.7; 95% confidence interval, 1.0-2.9) were the only independent predictors of superficial sternal infection. In diabetic patients, there was no difference in the incidence of deep sternal infection among patients receiving a single internal thoracic artery or double skeletonized internal thoracic arteries ( P = .4).
  
  
  CONCLUSIONS
  Bilateral internal thoracic artery harvesting carries a higher risk of sternal infection than harvesting a single internal thoracic artery. Skeletonization of both internal thoracic arteries significantly decreases this risk. A strategy of bilateral thoracic artery grafting can also be offered to patients at high risk for wound infection.
authors.affiliation: Division of Cardiac Surgery, University of Rome Tor Vergata, Italy. depauli@tin.it
authors.forename: Ruggero
authors.initials: R
authors.lastname: De Paulis
authors.forename: Stefano
authors.initials: S
authors.lastname: de Notaris
authors.forename: Raffaele
authors.initials: R
authors.lastname: Scaffa
authors.forename: Saverio
authors.initials: S
authors.lastname: Nardella
authors.forename: Jacob
authors.initials: J
authors.lastname: Zeitani
authors.forename: Costantino
authors.initials: C
authors.lastname: Del Giudice
authors.forename: Alfonso Penta
authors.initials: AP
authors.lastname: De Peppo
authors.forename: Fabrizio
authors.initials: F
authors.lastname: Tomai
authors.forename: Luigi
authors.initials: L
authors.lastname: Chiariello
mesh_terms: D000368:Aged; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D008323:Mammary Arteries / Q000637:transplantation*; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D018579:Patient Selection; D018570:Risk Assessment; D013529:Surgical Wound Dehiscence / Q000453:epidemiology*; D020858:Tissue and Organ Harvesting / Q000009:adverse effects / Q000379:methods*