title: Skeletonized internal thoracic artery harvest reduces pain and dysesthesia and improves sternal perfusion after coronary artery bypass surgery: a randomized, double-blind, within-patient comparison.
abstract: BACKGROUND
  Observational studies suggest that skeletonization of the internal thoracic artery (ITA) can improve conduit flow and length and reduce deep sternal infections and postoperative pain. We performed a randomized, double-blind, within-patient comparison of skeletonized and nonskeletonized ITAs in patients undergoing coronary surgery.
  
  
  RESULTS
  Patients (n = 48) undergoing bilateral ITA harvest were randomized to receive 1 skeletonized and 1 nonskeletonized ITA. Intraoperatively, ITA flow was assessed directly and with a Doppler flow probe before and after topical application of papaverine. ITA harvest time and conduit length were recorded. A blinded assessment of pain (visual analog scale) and dysesthesia (physical examination) was performed at discharge, at 2 weeks, and at a 3-month follow-up. Sternal perfusion was assessed with nuclear imaging (n = 7). Skeletonization required longer ITA harvest times (27 +/- 1 versus 24 +/- 1 minutes; P = 0.04). There was a trend toward increased ITA length in the skeletonized group (18.2 +/- 0.3 versus 17.7 +/- 0.3 cm; P = 0.09). In situ ITA flow was lower in skeletonized arteries (7.4 +/- 0.9 versus 10.1 +/- 1.0 mL/min; P = 0.01) and increased significantly after ITA division and papaverine application. Postanastomotic flows were similar between groups. Skeletonization was associated with decreased pain at the 3-month follow-up and a reduction in major sensory deficits at the 4-week and 3-month (17% versus 50%; P = 0.002) follow-ups. Baseline adjusted sternal perfusion was significantly greater by 17 +/- 6% (P = 0.03) on the skeletonized side.
  
  
  CONCLUSIONS
  Skeletonization results in reduced postoperative pain and dysesthesia and increased sternal perfusion at follow-up but does not produce increased conduit flow. ITA skeletonization may be a strategy for reducing morbidity after CABG.
authors.affiliation: Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
authors.forename: Munir
authors.initials: M
authors.lastname: Boodhwani
authors.forename: B Khanh
authors.initials: BK
authors.lastname: Lam
authors.forename: Howard J
authors.initials: HJ
authors.lastname: Nathan
authors.forename: Thierry G
authors.initials: TG
authors.lastname: Mesana
authors.forename: Marc
authors.initials: M
authors.lastname: Ruel
authors.forename: Wanzhen
authors.initials: W
authors.lastname: Zeng
authors.forename: Frank W
authors.initials: FW
authors.lastname: Sellke
authors.forename: Fraser D
authors.initials: FD
authors.lastname: Rubens
mesh_terms: D001026:Coronary Artery Bypass / Q000379:methods*; D004311:Double-Blind Method; D005260:Female; D006801:Humans; D008297:Male; D008323:Mammary Arteries / Q000601:surgery*; D008875:Middle Aged; D010149:Postoperative Pain / Q000517:prevention & control*; D010292:Paresthesia / Q000517:prevention & control*; D018579:Patient Selection; D018401:Sample Size; D013249:Sternum / Q000601:surgery; D020858:Tissue and Organ Harvesting / Q000379:methods*