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SECTION 6 Conduits forcoronary artery bypass graft surgery288

Cx marginal

PDA

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LITA

RITA

LAD

Fig.37.3 One convenient graft conﬁguration to accomplish all- arterial, no- aortic- touch CABG. Cx marginal, left circumﬂex coronary artery; LAD, left

anterior descending coronary artery; LITA, left internal thoracic artery; PDA, posterior descending coronary artery; RA, radial artery; RITA, right internal thoracic artery.

Guidelines forthe use oftotal arterial revascularization

e American College of Cardiology Foundation/ American Heart Association (classIIb) and European Society of Cardiology (ESC)/ European Association for Cardio- oracic Surgery (EACTS) (class IIa) Guidelines support the use of TAR for ‘young patients’ with ‘reasonable life expectancy’., e 2018 ESC/ EACTS Guidelines on myocardial revascularization emphasize complete revascularization, minimization of aortic manipulation, use of BITA and RA graing, and the skeletonized harvest of internal thoracic arteries and recommend ‘anaortic’ o- pump CABG by experienced operators. e STS clinical practice guidelines on arterial conduits for CABG do not specically mention TAR but do oer guidance for arterial graing. ey recommend the use of a second arterial

gra (RITA or RA) in appropriate patients (class of recommendation (COR) IIa, level of evidence (LOE) B), the use of BITA in patients without excessive risk of sternal complications (COR IIa, LOE B), and the use of the RA when graing coronary targets with severe stenoses (COR IIa, LOE B). e latest American, European, and Canadian guidelines on myocardial revascularization recommend the involvement of a Heart Team comprised of a non- interventional cardiologist, interventional cardiologist, cardiac surgeon, and other care providers.,, ey further emphasize that the use of arterial gras (specic targets, number, and type) should be part of the discussion of the Heart Team in determining the optimal approach to revascularization (COR I, LOE C). e right gastroepiploic artery may be considered in patients with poor conduit options or as an adjunct to more complete arterial revascularization (COR IIb, LOE B). ey further recommend the use of skeletonized BITA to reduce the risk of sternal infection (COR IIa, LOE B).

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Conclusion

ere is a large body of evidence that points to a benet of TAR compared with conventional CABG for most patients. ere are less conclusive data on the superiority of TAR compared to revascularization with two arterial gras plus SVGs, but most studies suggest a benet with TAR. Both diabetic and elderly subpopulations may benet from gra patency and reduction in stroke risk with TAR. For most diabetic patients, BITA harvest can be performed with adjunctive techniques to minimize sternal complications. Given the inherent bias in observational studies of surgical revascularization, highquality prospective studies with sucient long- term follow- up are needed.

REFERENCES

1. Loop FD, Lytle BW, Cosgrove DM, Stewart RW, Goormastic M, Williams GW, etal. Inuence of the internal- mammary- artery gra on 10- year survival and other cardiac events. N Engl J Med. 1986;314(1):1– 6.

2. Taggart DP, D’Amico R, Altman DG. Eect of arterial revascularisation on survival:a systematic review of studies comparing bilateral and single internal mammary arteries. Lancet. 2001;358(9285):870– 5.

3. Weiss AJ, Zhao S, Tian DH, Taggart DP, Yan TD. A meta- analysis comparing bilateral internal mammary artery with le internal mammary artery for coronary artery bypass graing. Ann Cardiothorac Surg. 2013;2(4):390– 400.

4. Taggart DP, Altman DG, Gray AM, Lees B, Nugara F, Yu LM, etal. Randomized trial to compare bilateral vs. single internal mammary coronary artery bypass graing:1- year results of the Arterial Revascularisation Trial (ART). Eur Heart J. 2010;31(20):2470– 81.

5. Taggart DP, Altman DG, Gray AM, Lees B, Gerry S, Benedetto U, etal. Randomized trial of bilateral versus single internal- thoracic artery gras. N Engl J Med. 2016;375(26):2540– 9.

6. Tranbaugh RF, Lucido DJ, Dimitrova KR, Homan DM, Geller CM, Dincheva GR, etal. Multiple arterial bypass graing should be routine. J orac Cardiovasc Surg. 2015;150(6):1537– 45.

7. Deb S, Cohen EA, Singh SK, Une D, Laupacis A, Fremes SE, etal. Radial artery and saphenous vein patency more than 5years aer coronary artery bypass surgery:results from RAPS (Radial Artery Patency Study). J Am Coll Cardiol. 2012;60(1):28– 35.

8. Hayward PA, Hare DL, Gordon I, Matalanis G, Buxton BF. Which arterial conduit? Radial artery versus free right internal thoracic artery:six- year clinical results of a randomized controlled trial. Ann orac Surg. 2007;84(2):493– 7.

9. Benedetto U, Caputo M, Vohra H, Bryan A, Angelini GD. State of the art in coronary revascularization:everolimus eluting stents versus multiple arterial graing. Int J Cardiol. 2016;219:345– 9.

10. Buxton BF, Shi WY, Tatoulis J, Fuller JA, Rosalion A, Hayward PA. Total arterial revascularization with internal thoracic and radial artery gras in triple- vessel coronary artery disease is associated with improved survival. J orac Cardiovasc Surg. 2014;148(4):1238– 43.

11. Shi WY, Tatoulis J, Newcomb AE, Rosalion A, Fuller JA, Buxton BF. Is a third arterial conduit necessary? Comparison of the radial artery and saphenous vein in patients receiving bilateral internal thoracic arteries for triple vessel coronary disease. Eur J Cardiothorac Surg. 2016;50(1):53– 60.

12. Glineur D, D’hoore W, Price J, Dorméus S, de Kerchove L, Dion R, etal. Survival benet of multiple arterial graing in a 25- year single- institutional experience:the importance of the third arterial gra. Eur J Cardiothorac Surg. 2012;42(2):284– 90.

13. Grau JB, Kuschner CE, Johnson CK, Ferrari G, Zapolanski A, Brizzio ME, etal. e eects of using a radial artery in patients already receiving bilateral internal mammary arteries during coronary bypass graing:30- day outcomes and 14- year survival in a propensitymatched cohort. Eur J Cardiothorac Surg. 2016;49(1):203– 10.

14. Gaudino M, Puskas JD, Di Franco A, Ohmes LB, Iannaccone M, Barbero U, etal. ree arterial gras improve late survival:a meta- analysis of propensity matched studies. Circulation. 2017;135(11):1036– 44.

15. Yanagawa B, Verma S, Mazine A, Tam DY, Jüni P, Puskas JD, etal. Impact of total arterial revascularization on long term survival:a systematic review and meta- analysis of 130,305 patients. Int J Cardiol. 2017;233:29– 36.

16. Puskas JD, Sadiq A, Vassiliades TA, Kilgo PD, Lattouf OM. etal. Bilateral internal thoracic artery graing is associated with signicantly improved long term survival, even among diabetic patients. Ann orac Surg. 2012;94(3):710– 15.

17. Tatoulis J, Wynne R, Skillington PD, Buxton BF. Total arterial revascularization:a superior strategy for diabetic patients who require coronary surgery. Ann orac Surg. 2016;102(6):1948– 55.

18. Gaudino M, Bakaeen F, Benedetto U, Rahouma M, Di Franco A, Tam DY, etal. Use rate and outcome in bilateral internal thoracic artery graing:insights from a systematic review and metaanalysis. J Am Heart Assoc. 2018;7(11):e009361.

19. Tatoulis J. Total arterial coronary revascularization- patient selection, stenoses, conduits, targets. Ann Cardiothorac Surg. 2013;2(4):499– 506.

20. Muneretto C, Bisleri G, Negri A, Manfredi J, Metra M, Nodari S, etal. Total arterial myocardial revascularization with composite gras improves results of coronary surgery in elderly:a prospective randomized comparison with conventional coronary artery bypass surgery. Circulation. 2003;108(Suppl 1):II29– 33.

21. Bortolussi G, Bejko J, Gallo M, Comisso M, Carrozzini M, Guglielmi C, etal. Coronary artery bypass graing in elderly patients:insights from a comparative analysis of total arterial and conventional revascularization. J Cardiovasc Transl Res. 2016;9(3):223– 9.

22. Zhao DF, Edelman JJ, Seco M, Seco M, Bannon PG, Wilson MK, Byrom MJ, etal. Coronary artery bypass graing with and without manipulation of the ascending aorta:a network metaanalysis. J Am Coll Cardiol 2017;69(8):924– 36.

23. Albert, A, Ennker, J, Hegazy, Y, Ullrich, S, Petrov, G, Akhyari, P, etal. Implementation of the aortic no- touch technique to reduce stroke aer o- pump coronary surgery. J orac Cardiovasc Surg. 2018;156(2):544– 54.

24. Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, etal. 2011 ACCF/ AHA Guideline for Coronary Artery Bypass Gra Surgery. A report of the American College of Cardiology Foundation/ American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for oracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of oracic Surgeons. J Am Coll Cardiol. 2011;58:e123– 210.

25. Kohl P, Windecker S, Alfonso F, Collet JP, Cremer J, Falk V, etal. 2014 ESC/ EACTS Guidelines on myocardial revascularization:e Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardiooracic Surgery (EACTS). Developed with the special contribution

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of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J. 2014;35:2541– 619.

26. Neumann E- J, Sousa- Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, etal. 2018 ESC/ EACTS Guidelines on myocardial revascularization. Eur Heart J. 2019;40(2):87– 165.

27. Aldea GS, Bakaeen FG, Pal J, Fremes S, Head SJ, Sabik J, etal. e Society of oracic Surgeons clinical practice guidelines on

arterial conduits for coronary artery bypass graing. Ann orac Surg. 2016;101(2):801– 9.

28. Teo KK, Cohen E, Buller C, Hassan A, Carere R, Cox JL, etal. Canadian Cardiovascular Society/ Canadian Association of Interventional Cardiology/ Canadian Society of Cardiac Surgery position statement on revascularization— multivessel coronary artery disease. Can J Cardiol. 2014;30(12):1482– 91.

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Harvestingconduits

Open versus endoscopic

Alice Wang and Peter K. Smith

Harvesting saphenous vein grafts foruse incoronary bypasssurgery

e saphenous vein gra (SVG) remains the most commonly used conduit for circumex, right coronary, and diagonal coronary gras and is used in approximately 90% of patients undergoing coronary artery bypass graing (CABG) in the United States. Vein gra failure (VGF), however, remains a persistent disadvantage of the SVG compared to arterial conduits. Up to 15% of SVGs occlude within the rst year and up to half are occluded by 10years. VGF has serious clinical consequence as studies have found SVG occlusion to be associated with the need for repeat revascularization, myocardial infarction, and death. Consequently, much research has been dedicated to identifying causes of increased rates of VGF, particularly whether the method of harvest aects SVG patency.

In 1967, Rene Favaloro published the rst successful series using the SVG in CABG surgery. e greater saphenous vein was harvested in a completely open fashion using a long leg incision (Fig. 38.1). Disadvantages of this technique, however, included postoperative pain and wound complications in 2– 25% of patients. In 1996, surgeons began using an endoscopic vein harvesting (EVH) technique, which involves a 3cm incision above the medial aspect of the knee (Fig. 38.2). Up to 35cm of thigh saphenous vein can be harvested and if further length is needed, the lower leg saphenous vein can be harvested through the same knee incision and transected through a small incision above the medial malleolus. e most commonly used EVH system (Maquet/ Getinge, Sweden) utilizes carbon dioxide to inate a ‘closed’ tunnel around the vein, and under videoscopic visualization, the vein is bluntly dissected with collateral branches isolated and divided with electrocautery. Aer the SVG is removed, branches may be clipped or ligated and the vein is gently ushed to remove any residual clots. Other systems (Sorin LivaNova, Italy; Karl Storz, Tuttlingen, Germany) use manual mechanical force rather than carbon dioxide insuation to maintain an ‘open’ working tunnel. Vein branches may be divided with thermal or ultrasonic energy (Harmonic® scalpel, Ethicon, USA). Proponents of the latter believe that ultrasonic shears may expose the vein to

lower risk of thermal injury than electrocautery. However, the open technique may be more physically demanding for operators and thus far it has been less widely adopted than the closed, gas- inated technique.

Pathophysiology ofSVGharvest

EVH and open harvest involve very dierent surgical techniques. Unlike in open harvest, the most common technique for EVH requires electrocautery in close proximity to the SVG that may lead to thermal injury, involves greater mechanical contact with and

Completely open technique

Bridged technique

Bridged incisions

Saphenous vein harvest complete

Fig.38.1 Saphenous vein harvest:open and bridged techniques.

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Fig.38.2 Endoscopic saphenous vein harvest.

traction on the vein, and utilizes carbon dioxide to insuate the subcutaneous cavity. Ex vivo carbon dioxide pressure distention can damage gra endothelium, leading to a loss of antithrombotic factors and increased activity of prothrombotic factors. External pressure created by insuation can also lead to stasis and subsequent thrombosis. Clot strands have been found in EVH harvested SVGs and the mechanical manipulation needed to remove them may contribute to increased thrombogenicity. For these reasons, it is generally considered advisable to administer 2500 units of intravenous heparin systemically, prior to beginning EVH, to avoid intraluminal clots in SVGs, which may be dicult to detect and remove.

Molecular studies on the endothelial integrity of SVGs harvest by EVH compared to open harvest have varied. Grith etal. analysed 88 patients who underwent EVH and 82 patients who underwent open harvesting using a histological grading system that did not show a dierence between the two techniques. Rousou etal. examined portions of SVG from EVH and open harvest in ten patients shortly aer excision using epiuorescence multiphoton microscopy, a more sensitive technique, and found more damage to the endothelium in gras from the EVH group that may potentially lead to worse patency rates. Hussani etal. studied 19 patients who each underwent EVH and open harvesting, and analysed segments for cell viability, calcium mobilization, and nitric oxide generation. ey found similar viability, structure, and function in both groups but the EVH group had partially attenuated calcium mobilization and nitric oxide production that may cause increased occlusion rates. Whether this inconclusive evidence of dierences in endothelial integrity at the molecular level would lead to dierences in clinical outcomes, however, requires further investigation.

Early studies ofEVH

Several early clinical studies demonstrated that EVH was associated with decreased wound complications, improved postoperative pain, and better patient satisfaction.–  Early studies also found similar VGF rates in patients who underwent EVH compared to those who had open harvest. In 2003, a prospective clinical trial randomized 112 patients to receive either EVH or open harvest and found in both groups similar rates of freedom from death, myocardial infarction, and recurrent ischaemia at 5- year follow- up (75% and 74%,

respectively). In 2005, Yun etal. completed a randomized clinical trial and compared 6- month angiography of 73 patients who underwent EVH against 71 patients who underwent open harvest and did not nd EVH to be a signicant predictor of gra occlusion. ese studies, however, were limited by either small sample size or short- term follow- up. Due to the signicant short- term benets of EVH and the lack of studies suggesting inferiority, the International Society for Minimally Invasive Cardiothoracic Surgery released a consensus statement in 2005 recommending EVH as the preferred technique. By 2008, EVH was used in 70% of CABG surgeries performed in the United States according to the Society of oracic Surgery National Database; in 2018, that proportion was 92.7%.

Contemporary studies ofEVH

While many short- term benets were observed with EVH, studies of long- term ecacy of EVH versus the open technique in large cohorts did not occur until aer the consensus statement was released. In 2009, Lopes etal. performed a post hoc analysis of the Project of Ex- Vivo Vein Gra Engineering via Transfection IV (PREVENT IV) clinical trial data and analysed vein gra patency with angiography at 1year. e study compared 1753 patients who underwent EVH against 1247 patients who underwent open harvest and found signicantly higher rates of VGF among patients who underwent EVH (27.2% vs 22.6%, respectively). Patients who underwent EVH also had a higher risk of death, myocardial infarction, or repeat revascularization. Zenati etal. followed this study and performed a post hoc analysis of the Randomized On/ O Bypass (ROOBY) trial, analysing 341 patients who underwent EVH and 553 who underwent open harvest. ey also found EVH to be associated with higher rates of VGF (41.3% vs 28.0%, respectively) and repeat revascularization (6.7% vs 3.4%, respectively) at 1- year follow- up. e major weakness of these studies, however, was that while both contained sizable cohorts, neither study randomized patients between EVH and open harvest; thus, these comparisons may contain unadjusted/ unknown bias.

ere have also been studies that have countered these ndings and reported no signicant dierences in long- term outcomes between EVH and open techniques. Williams etal. analysed 235,394 patients using a merged Centers for Medicare and Medicaid Services

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and Society of oracic Surgeons database and propensity- matched patients who underwent EVH versus open harvest with median 3year follow- up and found no signicant dierences in mortality rates (13.2% vs 13.4%, respectively) or the composite of death, myocardial infarction, and revascularization (19.5% vs 19.7%, respectively). Ameta- analysis by Deppe etal. analysed 16 randomized clinical trials, and 27 observational studies from 1998 to 2011 and found that while EVH had a signicantly higher incidence of VGF (26.9% vs 20.3%, respectively), this was not associated with increased myocardial infarction or mortality.

e Randomized Endo- Vein Gra Prospective (REGROUP) trial is the largest prospective randomized study comparing open harvest and EVH (ClinicalTrials.gov identier: NCT01850082). e trial was funded by the Veteran Aairs Medical Centers and enrolled 1150 patients from March 2014 to April 2017. At a mean follow- up of

2.7years, the composite primary outcome of major adverse cardiac events, including death from any cause, non- fatal myocardial infarction, and repeat revascularization, occurred in 89 patients (15.5%) in the open- harvest group and 80 patients (13.9%) in the EVH group (hazard ratio 1.12; 95% condence interval (CI) 0.83– 1.51; P=0.47). Leg- wound infections occurred signicantly more oen in the open- harvest group (relative risk 2.26; 95% CI 0.99– 5.15). is trial may be considered a denitive statement in support of EVH as

terms of wound infection and neurological decits. In contrast, Bisleri and co- authors found that open RA harvesting was associated with increased wound infection (7.3% vs 0.0%; P= 0.007), poorer wound healing on the Hollander scale (3.3 vs 4.7; P <0.001), and increased prevalence of paraesthesia at late- term follow- up (19.5% vs 3.6%; P <0.001).

Two metanalyses have compared endoscopic versus open harvesting techniques for the RA., However, both were limited by major methodological issues as they included mostly unmatched observational studies. In an attempt to overcome those limitations, Rahouma etal. recently used a meta- analytic approach limited to randomized controlled trials and propensity score- matched studies to investigate the impact of harvesting technique on RA gra patency and relevant clinical outcomes. e authors found that, overall, ERAH was associated with a signicantly lower risk of wound complication in comparison to open harvesting (odds ratio (OR) 0.33, 95% CI 0.14– 0.77; P=0.01). No dierences were found in RA patency rate (OR 1.36, 95% CI 0.91– 2.04; P=0.14) nor in early mortality (OR 0.78, 95% CI 0.10– 6.11; P=0.81) and in 5- year mortality (OR 0.59, 95% CI 0.18– 1.93; P=0.87) between the two groups.

However, despite the use of a meta- analytic approach, due to the low event rate in both groups, even this analysis can be underpowered.

a standard for the harvest of SVGs during coronary bypass surgery. Nonetheless, it is both intuitively obvious and scientically proven that trauma to SVGs during harvest will reduce their patency and diminish the benet of CABG to the patient. Indeed, in other chapters in this textbook, the importance of atraumatic conduit harvest is emphasized and a growing literature supports a ‘no- touch’ technique for SVG harvest, resulting in outstanding short- and longterm patency of SVGs aer CABG. Whether performed by the open technique or by use of one of the various commercially available endoscopic systems, meticulous attention to minimizing trauma to the conduit during harvest is an essential element to optimizing clinical outcomes aer CABG.

Harvesting radial artery conduits foruse incoronary artery bypasssurgery

Debate exists as to the best approach for radial artery (RA) harvesting. Similarly to EVH, endoscopic RA harvesting (ERAH) has developed in order to minimize the trauma and improve patient satisfaction. ERAH oers the advantages of superior cosmetic and perioperative outcomes, whereas sceptics highlight the lack of robust clinical data on ERAH, especially with regard to gra patency.

Integrity of the endothelium is crucial for the normal function of vessels, with any intimal damage potentially leading to conduit failure. e RA is more fragile than the saphenous vein and endothelial integrity is of pivotal importance for the RA which is known for its early spastic tendency. For these reasons, the concerns regarding vessel damage are even higher for the RA when using an endoscopic approach.

e comparative studies of open versus endoscopic approaches yielded dierent results and no consensus about the ideal harvesting method currently exists. In a propensity score- matched study, Navia and colleagues found no dierence between the two techniques in

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2. Poston RS, Kwon MH, Gu J. Role of procurement- related injury in early saphenous vein gra failure aer coronary artery bypass surgery. Future Cardiol. 2006;2(4):503– 12.

3. Burris N, Schwartz K, Brown J, Kwon M, Pierson R, Grith B, Poston R. Incidence of residual clot strands in saphenous vein gras aer endoscopic harvest. Innovations (Phila). 2006;1(6):323– 7.

4. Grith GL, Allen KB, Waller BF, Heimansohn DA, Robison RJ, Schier JJ, etal. Endoscopic and traditional saphenous vein harvest:a histologic comparison. Ann orac Surg. 2000;69(2):520– 3.

5. Rousou LJ, Taylor KB, Lu XG, Healey N, Crittenden MD, Khuri SF, etal. Saphenous vein conduits harvested by endoscopic technique exhibit structural and functional damage. Ann orac Surg. 2009;87(1):62– 70.

6. Hussaini BE, Lu XG, Wolfe JA, atte HS. Evaluation of endoscopic vein extraction on structural and functional viability of saphenous vein endothelium. J Cardiothorac Surg. 2011;6:82.

7. Puskas JD, Wright CE, Miller PK, Anderson TE, Gott JP, Brown WM, etal. A randomized trial of endoscopic versus open saphenous vein harvest in coronary bypass surgery. Ann orac Surg. 1999;68(4):1509– 12.

8. Schurr UP, Lachat ML, Reuthebuch O, Kadner A, Mäder M, Seiert B, etal. Endoscopic saphenous vein harvesting for CABG— a randomized, prospective trial. orac Cardiovasc Surg. 2002;50(3):160– 3.

9. Athanasiou T, Aziz O, Skapinakis P, Perunovic B, Hart J, Crossman MC, etal. Leg wound infection aer coronary artery bypass

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graing:a meta- analysis comparing minimally invasive versus conventional vein harvesting. Ann orac Surg. 2003;76(6):2141– 6.

10. Allen KB, Heimansohn DA, Robison RJ, Schier JJ, Grith GL, Fitzgerald EB. Inuence of endoscopic versus traditional saphenectomy on event- free survival:ve- year follow- up of a prospective randomized trial. Heart Surg Forum. 2003;6(6):E143– 5.

11. Yun KL, Wu Y, Aharonian V, Mansukhani P, Pfeer TA, Sintek CF, etal. Randomized trial of endoscopic versus open vein harvest for coronary artery bypass graing:six- month patency rates. J orac Cardiovasc Surg. 2005;129(3):496– 503.

12. Lopes RD, Haey GE, Allen KB, Ferguson TB, Peterson ED, Harrington RA, etal. Endoscopic versus open vein- gra harvesting in coronary- artery bypass surgery. N Engl J Med. 2009;361(3):235– 44.

13. Zenati MA, Bhatt DL, Bakaeen FG, Stock EM, Biswas K, Gaziano JM, etal. Randomized trial of endoscopic or open vein- gra harvesting for coronary- artery bypass. N Engl J Med. 2019;380(2):132– 41.

14. Williams JB, Peterson ED, Brennan JM, Sedrakyan A, Tavris D, Alexander JH, etal. Association between endoscopic vs open vein- gra harvesting and mortality, wound complications, and cardiovascular events in patients undergoing CABG surgery. JAMA. 2012;308(5):475– 84.

15. Deppe AC, Liakopoulos OJ, Choi YH, Slottosch I, Kuhn EW, Scherner M, etal. Endoscopic vein harvesting for coronary artery bypass graing:a systematic review with meta- analysis of 27,789 patients. J Surg Res. 2013;180(1):114– 24.

16. Gaudino M, Antoniades C, Benedetto U, Deb S, Di Franco A, Di Giammarco G, etal. Mechanisms, consequences, and prevention of coronary gra failure. Circulation. 2017;136(18):1749– 64.

17. Schwann TA, Gaudino M, Baldawi M, Tranbaugh R, Schwann AN, Habib RH. Optimal management of radial artery gras in CABG:patient and target vessel selection and anti- spasm therapy. J Cardiovasc Surg. 2018;33(5):205– 12.

18. Navia JL, Olivares G, Ehasz P, Gillinov AM, Svensson LG, Brozzi N, etal. Endoscopic radial artery harvesting procedure for coronary artery bypass graing. Ann Cardiothorac Surg. 2013;2(4):557– 64.

19. Bisleri G, Giroletti L, Hrapkowicz T, Bertuletti M, Zembala M, Arieti M, etal. Five- year clinical outcome of endoscopic versus open radial artery harvesting:a propensity score analysis. Ann orac Surg. 2016;102(4):1253– 9.

20. Wu HB, Hu R, Wang ZW, Hu ZP, Li LC, Wu ZY, etal. Endoscopic radial artery harvesting does not compromise gra patency for coronary artery bypass gra:a meta- analysis of 2782 patients. Heart Lung Circ. 2014;23(11):1084– 90.

21. Cao C, Tian DH, Ang SC, Peeceeyen S, Allan J, Fu B, Yan TD. A meta- analysis of endoscopic versus conventional open radial artery harvesting for coronary artery bypass gra surgery. Innovations (Phila). 2014;9:269– 75.

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Harvesting arterial conduits

Skeletonized versus pedicle versus semi- skeletonized

Umberto Benedetto, Brian F. Buxton, and David P. Taggart

Internal thoracicartery

e use of bilateral internal thoracic arteries (BITAs) has been associated with an increased occurrence of sternal wound infections aer coronary artery bypass graing (CABG). e increased risk of sternal wound complications appears to be caused by sternal ischaemia and/ or venous congestion occurring aer BITA harvesting. Traditionally, the internal thoracic artery (ITA) has been dissected as a pedicle that includes the artery and accompanying veins, endothoracic fascia, a part of the parietal pleura, and, distally, the transversus thoracis muscle. Electrocautery has commonly been used to divide the branches aer the application of clips on the artery side. Several techniques have been developed to reduce sternal ischaemia aer ITA dissection. Askeletonizing technique of the ITA harvest is one such method in which the ITA is dissected as an isolated artery rather than as a pedicle, and electrocautery is either avoided or used in very low- power settings. Some of the sternal branches and anterior intercostal arteries of the ITA can arise from the ITA as a common trunk. If these common trunks are preserved during ITA dissection, the sternal collateral blood supply may be better preserved aer ITA dissection (Fig. 39.1). Dissecting the le ITA as a pedicle gra reduces blood ow to the sternum more than does dissecting the ITA in a skeletonized fashion., Although skeletonized harvesting is technically demanding, it is associated with excellent ow and patency rates at least comparable to those observed with pedicled ITA gras. Moreover, it may reduce the incidence of neuropathic pain following surgery. Finally, many authors believe that additional conduit length provided by skeletonization improves the ease of arterial graing, facilitates sequential graing, and increases the number of possible arterial distal anastomoses.

Sternal woundcomplications

In a large randomized trial comparing BITA versus single ITA graing, 10.7% of patients presented with a sternal wound complication of some degree within 1year from the index operation. However, only 3.6% had severe sternal wound complications, with

2.4% requiring antibiotic therapy and 1.2% requiring sternal wound reconstruction. Pedicled BITAs (16.1%) but not skeletonized BITAs

(9.6%) increased the risk of any sternal wound complication when compared to the standard pedicled single ITAs (9.5%). e rate of sternal wound reconstruction in this trial was particularly low and no signicant dierences were found between pedicled (1.5%) and skeletonized (2.1%) BITAs.

A meta- analysis conducted by Sá etal., involving 4817 patients (2424 skeletonized and 2393 pedicled), showed a statistically signicant dierence in the incidence of sternal infections between the two types of graing. Skeletonized graing (xed eect model:odds ratio (OR) 0.443, 95% condence interval (CI) 0.323– 0.608; P <0.001; random eect model: OR 0.443, 95% CI 0.323– 0.608; P <0.001) was associated with a reduction in the incidence of postCABG sternal infection, with diabetes having a major inuence. Notably, the rate of sternal complications has been shown to be associated with the centre’s experience in the use of BITA gras.

Flow and patency rate withskeletonized versus pedicled ITAgrafts

e rate of sternal wound infections is higher when both ITAs are used but appears to decrease when the ITAs are skeletonized. For this reason, skeletonization is gaining popularity and is a classI(level of evidence B) recommendation in the 2018 European Society of Cardiology/ European Association for Cardio- oracic Surgery Guidelines on myocardial revascularization for patients at increased risk of sternal wound problems. However, skeletonization may increase the risk of damaging an ITA during harvest compared to preparing a pedicled gra, especially in regard to intramural haematoma. Moreover, the skeletonized ITA is partially denuded of the adventitia and its vasa vasorum during skeletonization and there have been theoretical concerns that this might potentially aect its ow and long- term patency rate. However, several studies did not conrm this hypothesis. Sasajima and co- workers found no histological evidence of detrimental eects in skeletonized ITAs harvested in dogs. In an immunohistochemical study that used polyclonal antibody to factor VIII to assess the integrity of the endothelial layer aer surgical preparation, Gaudino and colleagues concluded that there was no dierence between skeletonized and pedicled ITAs in 40 randomized patients.

Sternum

Internal thoracic artery

taken as a pedicle

taken as a skeleton

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SECTION 6 Conduits forcoronary artery bypass graft surgery296

Anterior intercostal

artery

Fig.39.1 Skeletonized (blue) versus pedicled (red) harvesting.

Posterior intercostal

artery

Research regarding ow and patency rate of skeletonized versus pedicled ITAs is limited. Available studies reveal that both skeletonized and pedicled gras are associated with outstanding early and mid- term patency. One meta- analysis on intraoperative ow capacity of the gras including eight studies found a statistically signicant dierence in favour of the skeletonized ITA compared with the pedicled ITA in terms of ow capacity (additional 20.8 mL/ min; 95% CI 6.6– 35.0; P=0.004). However, no dierence was found when randomized studies only were included (additional 13.2 mL/ min; 95% CI −1.1 to 27.6; P=0.071). One reason for conicting results regarding ITA ows may be due to variation in skeletonization techniques and in the type of vasodilator used. With regard to patency rate, a pooled analysis of ve studies involving 1764 evaluated conduits (1145 skeletonized; 619 pedicled) showed that the two techniques were comparable in terms of risk of occlusion (OR

1.351, 95% CI 0.408– 4.471; P=0.801). In addition, sensitivity analysis showed no dierence in patency between the le and right ITA.

Post- CABG pain withskeletonized versus pedicledITA

e ITA syndrome is a triad consisting of pain, allodynia, and dysesthesia subsequent to ITA. Skeletonization of ITA gras has consistently been demonstrated to reduce post- CABG pain and the incidence of major sensory decits at 1- month and 3- month followup., e generally accepted reason for reduced incidence and severity of post- CABG pain when the ITA is harvested in a skeletonized fashion is that skeletonized harvesting preserves the anterior branch of the intercostal nerve. However, patients do not usually detect any signicant dierence in post- CABG pain between skeletonized and non- skeletonized sides immediately aer surgery; this dierence may be noted later aer surgery, when competing sources of pain from the midline skin incision and sternotomy have subsided.

Semi- skeletonized ITAharvesting

Despite its relative advantages, skeletonized harvesting is more technically demanding and time- consuming than pedicled harvest. An alternative technique, named ‘semi- skeletonization’, may combine advantages of both the conventional technique and the skeletonization technique. e ITA can be prepared with its

maximum length without major alteration of the conventional pedicled technique. In the semi- skeletonized technique, a single initial incision is made in the endothoracic fascia longitudinally along the medial side of the accompanying vein just as in the conventional pedicled fashion. Rather than making a second lateral incision in the endothoracic fascia and harvesting a strip of the fascia along with the vessels, the ITA pedicle with accompanying veins and surrounding thin tissue is mobilized from the endothoracic fascia and harvested without removing endothoracic fascia or muscle tissue. is manoeuvre is like scraping the ITA o the endothoracic fascia with a cold cautery tip or scissors. Branches can be divided with either lowpower cautery or clips and scissors; many surgeons clip the branch on the ITA side and use low- power cautery on the peripheral side. Another modication of the pedicled harvesting technique is the preservation of the communicating musculophrenic and superior epigastric arteries to the chest wall; this is accomplished by dividing the harvested ITA above its terminal bifurcation and leaving the distal bifurcation intact on the inferior chest wall near the xiphoid. In addition, preservation of the pericardiacophrenic artery and the sternal intercostal trunks of the ITA possibly promotes the collateral circulation to the sternum and presternal tissues aer BITA harvest. Both techniques have been found to be associated with a lower incidence of sternal wound infection, although the evidence is very limited, and concern for potential steal phenomena motivates many surgeons to divide these branches routinely.

Radial artery and right gastroepiploic arteryharvesting

Ever since Keeley rst reported skeletonization of the ITA in 1987, there has been interest in the potential benets of skeletonization of other conduits such as the radial artery and right gastroepiploic artery. Concerns have been raised regarding vessel spasm and luminal diameter in these arterial conduits. Both the radial artery and the right gastroepiploic artery have more smooth muscle cells in the wall and consequently a higher tendency to spasm when compared to the ITA.

Initially, both the radial and gastroepiploic arteries were harvested as pedicles. However, recent reports indicate that radial and gastroepiploic arteries are also being harvested

gastroepiploic artery skeletonization argue that it facilitates surgical manipulation, increases gra luminal diameter, reduces gra spasm, and reduces the incidence of early gra stenosis (string sign). On the other hand, critics of the skeletonization technique argue that the method is more technically demanding and therefore more likely to lead to vessel damage both macroscopically and microscopically and that microscopic endothelial damage may predispose to early gra stenosis.

e highest quality study assessing vessel endothelial damage was performed by Rukosujew etal. ey used scanning electron microscopy to look for possible endothelial damage in surplus conduit pieces. Minor endothelial damage was consistently observed in all vessels, regardless of harvesting technique, and dierences between harvesting techniques were therefore considered to not be clinically signicant.

39 Harvesting arterial conduits 297

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Fukata etal. assessed the eect of skeletonized harvest techniques on the vessel wall by looking at the maximum depth of thermal degeneration. is study demonstrated that thermal degeneration was limited to the vessel’s connective tissue and did not aect the media or intima in vessels used in a clinical setting. Skeletonization of both radial artery and gastroepiploic artery does not have an adverse effect on angiographic patency; in fact, some report it may improve patency, presumably by allowing greater dilation and ow and avoiding tension due to the longer length of the harvested conduit.,

Conclusion

In conclusion, skeletonization is generally safe for the internal thoracic, radial, and gastroepiploic arteries and may improve gra ow and angiographic patency. Skeletonization may also increase the length of the conduit, and so facilitate a larger number of sequential gras. Importantly, skeletonized harvest of ITAs mitigates the increased risk of sternal wound infection that accompanies BITA graing. Indeed, skeletonized harvest of even a single ITA reduces the risk of sternal wound complications compared to pedicled harvest. Many dedicated coronary surgeons therefore use skeletonized harvest routinely for all ITAs; most of these surgeons also preserve the distal bifurcation of the ITA, leaving it intact on the chest wall to facilitate healing. However, skeletonized harvest techniques are somewhat more demanding than traditional pedicled harvest techniques and meticulous attention to detail is necessary to optimize the quality of conduits harvested and thus optimize clinical outcomes aer CABG.

REFERENCES

1. Benedetto U, Altman DG, Gerry S, Gray A, Lees B, Pawlaczyk R, etal. Pedicled and skeletonized single and bilateral internal thoracic artery gras and the incidence of sternal wound complications:insights from the Arterial Revascularization Trial. J orac Cardiovasc Surg. 2016;152(1):270– 6.

2. Kamiya H, Akhyari P, Martens A, Karck M, Haverich A, Lichtenberg A. Sternal microcirculation aer skeletonized versus pedicled harvesting of the internal thoracic artery:a randomized study. J orac Cardiovasc Surg. 2008;135(1):32– 37.

3. Boodhwani M, Lam BK, Nathan HJ, Mesana TG, Ruel M, Zeng W, etal. Skeletonized internal thoracic artery harvest reduces pain and dysesthesia and improves sternal perfusion aer coronary artery bypass surgery:a randomized, double blind, within- patient comparison. Circulation. 2006;114(8):766– 73.

4. Sá MP, Ferraz PE, Escobar RR, Vasconcelos FP, Ferraz AA, Braile DM, etal. Skeletonized versus pedicled internal thoracic artery and risk of sternal wound infection aer coronary bypass surgery:meta- analysis and meta- regression of 4817 patients. Interact Cardiovasc orac Surg. 2013;16(6):849– 57.

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13. Keeley SB. e skeletonized internal mammary artery. Ann orac Surg. 1987;44(3):324– 5.

14. Suma H. Spasm of the gastroepiploic artery gra. Ann orac Surg. 1990;49(1):168– 9.

15. Taggart DP, Mathur MN, Ahmad I. Skeletonization of the radial artery:advantages over the pedicled technique. Ann orac Surg. 2001;72(1):298– 9.

16. Gagliardotto P, Coste P, Lazreg M, Dor V. Skeletonized right gastroepiploic artery used for coronary artery bypass graing. Ann orac Surg. 1998;66(1):240– 2.

17. Rukosujew A, Reichelt R, Fabricius AM, Drees G, Tjan TD, Rothenburger M, etal. Skeletonization versus pedicle preparation of the radial artery with and without the ultrasonic scalpel. Ann orac Surg. 2004;77(1):120– 5.

18. Fukata Y, Horike K, Kano M. Histological study on the inuences of an ultrasonic scalpel on skeletonized vessel wall. Ann orac Cardiovasc Surg. 2002;8(5):291– 7.

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20. Kamiya H, Watanabe G, Takemura H, Tomita S, Nagamine H, Kanamori T. Skeletonization of gastroepiploic artery gra in o pump coronary artery bypass graing:early clinical and angiographic assessment. Ann orac Surg. 2004;77(6):2046– 50.

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