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Eur J Cardiothorac Surg 2005;28:780-781
© 2005 Elsevier Science NL

Letter to the Editor

Skeletonized bilateral internal mammary arteries in unstable angina: a paradigm shift

Department of Cardiac Surgery, Royal Hospital for Sick Children, Yorkhill NHS Trust, Dalnair Street, Glasgow G3 8SJ, UK

Received 11 July 2005; accepted 10 August 2005.

^_* Corresponding author. Tel.: +44 141 201 0269; fax: +44 141 201 9204. (Email: drrajashahzad{at}hotmail.com).

Key Words: Bilateral internal mammary arteries • Coronary artery bypass grafting • Unstable angina • Skeletonized internal mammary artery

Bonacchi et al. [1] deserve credit for presenting their experience of using skeletonized bilateral internal mammary arteries (BIMA) for urgent/emergent surgical revascularization in unstable angina (UA). Their study is significant not only for advocating urgent or emergent surgical intervention in UA but more importantly for validating the safety and efficacy of the use of skeletonized BIMA in this potentially high-risk scenario.

Several studies have been reported over the past few years showing survival benefit, lower reintervention rate, and better angina-free survival after BIMA grafting when compared with the use of a single IMA [2]. However, concerns about sternal wound infection [3] and the suboptimal use of pedicled right IMA as a free graft, because it is not always long enough to reach the branches of the left or right coronary artery without tension [2], led to the development of a surgical technique in which the IMA is dissected as a skeletonized vessel [4]. This harvesting technique bestowed the advantages of greater length and greater spontaneous blood flow of a skeletonized vessel compared to pedicled IMA [2]. The use of skeletonized BIMA allows the use of both IMAs as grafts to practically all coronary vessels requiring surgical revascularization, thus obtaining complete arterial revascularization without the need for harvesting additional conduits [2]. Furthermore, preservation of collateral blood supply to the sternum and decreased risk of infection, decreased postoperative chest wall pain, better judgment of graft length with thorough visual inspection to identify spastic or damaged areas that can, otherwise, be obscured by perivascular fat, are some of the additional advantages [2] that make skeletonized BIMA a highly attractive technique in nearly all types of patients presenting for surgical myocardial revascularization.

Surgical myocardial revascularization in UA is indicated when the conservative therapies fail or when the clinical-anatomical situations necessitate the surgical alternative such as in cases with left main coronary artery disease, large atherosclerotic burden and diffuse disease involving all the coronary arteries or unstable hemodynamics unresponsive to intra aortic balloon pump. However, very little is known about the timing of surgical intervention, optimal revascularization strategy and techniques of myocardial protection in this high-risk subset of patients. More importantly, there is a reluctance to use arterial conduits/BIMA in UA patients undergoing non-elective surgery secondary to longer harvesting IMAs' time vs saphenous vein [5]. The study by Bonacchi et al. [1] provides useful insight into these unresolved issues. Their BIMA harvesting as well as myocardial protection and revascularization strategies can be adopted as a standard approach for surgical revascularization in UA.

For skeptics who have always objected to the use of arterial conduits let alone skeletonized BIMA in non-elective surgery, owing to the longer dissection time, the potential for cardioplegia maldistribution, the longer cross clamp time, and initial inadequacy of flow, the message from Bonacchi et al. [1] is loud and clear. It is time for a pardigm shift.

References

1. Bonacchi M, Prifti E, Maiani M, Giunti G, Leacche M. Skeletonized bilateral internal mammary arteries for non-elective surgical revascularization in unstable angina. Eur J Cardiothorac Surg 2005;28:120-126.[Abstract/Free Full Text]
2. Raja SG, Haider Z, Zaman H. Skeletonized bilateral internal mammary arteries for total arterial myocardial revascularization. Heart Lung Circ 2004;13:395-398.[CrossRef][Medline]
3. Kouchoukos NT, Wareing TH, Murphy SF, Pelate C, Marshall Jr WG. Risks of bilateral internal mammary artery bypass grafting. Ann Thorac Surg 1990;49:210-217.[Abstract]
4. Cunningham JM, Gharavi MA, Fardin R, Meek RA. Considerations in the skeletonization technique of internal thoracic artery dissection. Ann Thorac Surg 1992;54:947-950.[Abstract]
5. Bonacchi M, Prifti E, Giunti G, Frati G, Sani G. Urgent surgical revascularization of unstable angina. Influence of double mammary arteries. Eur J Cardiothorac Surg 2001;20:747-754.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Shahzad G. Raja Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Raja, S. G. Search for Related Content PubMed PubMed Citation Articles by Raja, S. G.