Skeletonized versus Pedicled Internal Thoracic Artery Grafts in Coronary Artery Bypass Grafts of Diabetic Patients

Abstract

Patients with DM have a greater incidence of atherosclerosis and cardiovascular disease, which is associated with increased mortality and morbidity.Agrowing number of diabetic patients with multivesselCAD have recently beenreferred for CABGbecause of an unfavorable outcome of percutaneoustransluminal coronary angioplasty. The ITA has been the most reliable graft material used in CABG with an excellent long-term patency rate . The routine use of the LITA for CABG has been reported since the start of the 1980s.Traditionally, the ITA is harvested as a pedicle. The advantages of pedicled grafting include ease of handling, decreased harvesting time, and lower tendency for graft dissection. However, certain surgeons practice the ITA skeletonizationtechnique.This technique requires meticulous dissection and carries the risk of increased arterial injury.Numerous benefits of skeletonized ITA harvest have been proposed including increased flow and length, as well as a decreased sternal infection rates, and reduced pain. This is a prospective study was conducted at departments of cardiothoracic surgery in Ain Shams and Minia University hospitals.The study comprised, 170 diabetic patients undergoing CABG with the use of either skeletonized or pedicled LITA artery for revascularization of LAD coronary artery, from January 2011 to June 2014. The skeletonized group included 76(89.4%) male and 9(10.6%) female patients, with an average age of 57.83±10.21 years. The pedicledgroup included 73(85.9%) male and 12(14.1%) female patients, with an age average of 55.15±8.39 years. All patients were subjected to a careful history analysis, thorough clinical examination and complete investigatory profile. Results showed : Preoperative: The preoperative demographic and clinical data were comparable between the studied groups. There was no statistically significant difference between both groups regarding comparison of age, gender, frequency of obesity, smoking, family history of CAD, hypertension, dyslipidemia, and unstable angina. Intraoperative: The Intraoperative characteristics were comparable between both groups. In skeletonized group, bypass time(Bypass time Group I 101.61±4.04 min versus Group II 93.27±4.50 min p value 0.0001), ischemic time(Ischemic time Group I 68.04±7.02versus Group II 57.07±7. p value 0.0001), total operative time(Total operative time Group I 231.71±9.66 min versus Group II 195.07±9.11 min p value 0.0001), harvest time (ITA harvest time Group I 42.05±4.29 min versus Group II 24.72±2.76 min p value 0.0001)were significantly higher than the corresponding times in pedicled group. The internal thoracic artery flow rate(ITA flow (ml/min) Group I 80.98±4.55 versus Group II 74.98±7.88p value 0.0001)was significantly higher than the corresponding rate in pedicled group The number of grafts, use of inotropes, use of IABP, use of DC shock and use of antiarrhythmic were insignificantly different between both groups. Postoperative: Regarding postoperative comparison,there was statistically insignificant difference in duration of ventilation, ICU stay,amount of postoperative blood loss,arrhythmia, re-exploration, renal failure, hepatic failure, CVS complications, myocardial infarction and in-hospital deathbetween both groups, Regarding the hospital stay in pedicled group was significantly higher than stay in skeletonized group. (Hospital stay (days) Group I 6.51±1.26versus Group II 7.28±2.01 p value 0.004) In the skeletonized group, the overall morbidity rate was significantly lower than the corresponding rate in pedicled group which include. (Overall morbidity Group I 3(3.5%) versus Group II 12(12.9%) p value 0.01)