Skeletonized internal thoracic artery harvesting reduces chest wall dysesthesia after coronary bypass surgery

Markman, Phuong L.; Rowland, Michael A.; Leong, Jee-Yoong; Van Der Merwe, Juliana; Storey, Elsdon; Marasco, Silvana; Negri, Justin; Bailey, Michael; Rosenfeldt, Franklin L.

doi:10.1016/j.jtcvs.2009.03.066

« Previous Next »The Journal of Thoracic and Cardiovascular Surgery
Volume 139, Issue 3 , Pages 674-679, March 2010

Skeletonized internal thoracic artery harvesting reduces chest wall dysesthesia after coronary bypass surgery

Phuong L. Markman, MBBS, BMedSci (Hons)
- Cardiac Surgical Research Unit, CJ Officer Brown Cardiothoracic Unit, Alfred Hospital, Australia
Michael A. Rowland, FRACS
- Cardiac Surgical Research Unit, CJ Officer Brown Cardiothoracic Unit, Alfred Hospital, Australia
Jee-Yoong Leong, MBBS
- Cardiac Surgical Research Unit, CJ Officer Brown Cardiothoracic Unit, Alfred Hospital, Australia
Juliana Van Der Merwe, BCur, MPhil
- Cardiac Surgical Research Unit, CJ Officer Brown Cardiothoracic Unit, Alfred Hospital, Australia
Elsdon Storey, DPhil, FRACP
- Department of Neurology, Alfred Hospital, and Department of Medicine (Neuroscience), Monash University, Melbourne, Australia
Silvana Marasco, MS, FRACS
- Cardiac Surgical Research Unit, CJ Officer Brown Cardiothoracic Unit, Alfred Hospital, Australia
Justin Negri, FRACS
- Cardiac Surgical Research Unit, CJ Officer Brown Cardiothoracic Unit, Alfred Hospital, Australia
Michael Bailey, PhD, MSc (Stats)
- Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia
Franklin L. Rosenfeldt, MD, FRACS
- Cardiac Surgical Research Unit, CJ Officer Brown Cardiothoracic Unit, Alfred Hospital, Australia
- Address for reprints: Franklin Rosenfeldt, MD, FRACS, Cardiac Surgical Research Unit, The Alfred, PO Box 315, Prahran, Victoria 3181, Australia.

Received 17 December 2008; received in revised form 5 March 2009; accepted 29 March 2009. published online 23 September 2009.

Objective

A pain syndrome related to intercostal nerve injury during internal thoracic artery harvesting causes significant morbidity after coronary bypass surgery. We hypothesized that its incidence and severity might be reduced by using skeletonized internal thoracic artery harvesting rather than pedicled harvesting.

Methods

In a prospective double-blind clinical trial, 41 patients undergoing coronary bypass were randomized to receive either unilateral pedicled or skeletonized internal thoracic artery harvesting. Patients were assessed 7 (early) and 21 (late) weeks postoperatively with reproducible sensory stimuli used to detect chest wall sensory deficits (dysesthesia) and with a pain questionnaire used to assess neuropathic pain.

Results

At 7 weeks postoperatively, the area of harvest dysesthesia (percentage of the chest) in the skeletonized group (n = 21) was less (median, 0%; interquartile range, 0–0) than in the pedicled group (n = 20) (2.8% [0–13], P = .005). The incidence of harvest dysesthesia at 7 weeks was 14% in the skeletonized group versus 50% in the pedicled group (P = .02). These differences were not sustained at 21 weeks, as the median area of harvest dysesthesia in both groups was 0% (P = .89) and the incidence was 24% and 25% in the skeletonized and pedicled groups, respectively (P = 1.0). The incidence of neuropathic pain in the skeletonized group compared with the pedicled group was 5% versus 10% (P = .6) at 7 weeks and 0% versus 0% (P = 1.0) at 21 weeks.

Conclusions

Compared with pedicled harvesting, skeletonized harvesting of the internal thoracic artery provides a short-term reduction in the extent and incidence of chest wall dysesthesia after coronary bypass, consistent with reduced intercostal nerve injury and therefore the reduced potential for neuropathic chest pain.

CTSNet classification: 1, 5, 18, 23

Abbreviations and Acronyms: CABG, coronary artery bypass grafting, IQR, interquartile range, ITA, internal thoracic artery