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Eur J Cardiothorac Surg 2004;25:142
© 2004 Elsevier Science NL
Letter to the Editor |
Department of Cardiothoracic Surgery, University Hospital of Wales, Cardiff, UK
Received 16 August 2003; received in revised form 26 August 2003; accepted 28 September 2003.
* Corresponding author. University Hospital of Wales, Heath Park, Cardiff, CF14 4XW, UK. Tel.: +44-29-2074-2944; fax: +44-29-2074-5439
e-mail: uvonopp{at}cardiffandvale.wales.nhs.uk
Key Words: Coronary artery bypass graft • Complications • Infection • Internal mammary artery
We would like to congratulate Lu and co-workers on their analysis of risk factors for sternal wound infection [1]. However, we note that their definition of ‘a sternal wound infection’ (both superficial and deep) required evidence of mediastinal infection in all of their three criteria. Our understanding therefore would be that there was evidence of mediastinitis (deep sternal wound infection) in all cases. There is no further clarification as to how the authors then separated these patients into ‘superficial’ or ‘deep’ sternal infections!
The risk factors identified were similar to those in other reports and the authors have discussed various strategies to reduce sternal wound infection. The authors, however, make no reference to the proven method of harvesting the internal mammary artery (IMA) by a skeletonized method. As the authors did not mention their technique of harvesting the IMA, we presume that it was by the usual ‘pedicle technique’, which has been shown to result in a significant compromise to the sternal blood supply [2]. In contrast, the skeletonized technique of harvesting the IMA, by either low power electrocautery or ultrasonically [3], has been shown to maintain better sternal blood supply [4]. The skeletonized IMA has a higher free blood flow and is associated with a lower incidence of sternal wound infection including bilateral IMA use in diabetics [3]. The use of bilateral skeletonized IMAs in diabetics is not associated with an increased incidence of infection except possibly in the diabetic woman who is also obese [5].
In 786 consecutive coronary artery bypass graft±valve patients (October 2001–March 2003) at our institution in whom single or bilateral IMAs were harvested, the trend for deep sternal wound infection is lower at 0.4% with the skeletonized technique vs. 1.0% with the pedicle harvesting technique. We do not yet have sufficient patient numbers for our results to reach statistical significance.
Nevertheless, based on the aforementioned publications we would suggest that an alternative conclusion to that of ‘avoiding using bilateral internal mammary arteries in diabetic or obese patients’ is to modify the technique of harvesting the IMAs to a skeletonized method along with attention to the multiple other influencing variables [3].
References
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