Cardiac Surgical Research Unit, CJ Officer Brown Cardiothoracic Unit, Alfred Hospital, Australia.
J Thorac Cardiovasc Surg. 2010 Mar;139(3):674-9. doi: 10.1016/j.jtcvs.2009.03.066. Epub 2009 Sep 22.
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.
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.
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.
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.
与胸廓内动脉采集相关的肋间神经损伤引起的疼痛综合征会导致冠状动脉旁路手术后出现显著的发病率。我们假设，通过使用游离胸廓内动脉采集而非带蒂采集，可能会降低其发病率和严重程度。
在一项前瞻性、双盲临床试验中，41 例接受冠状动脉旁路手术的患者被随机分为单侧带蒂或游离胸廓内动脉采集。患者在术后 7（早期）和 21（晚期）周接受评估，使用可重复的感觉刺激来检测胸壁感觉缺失（感觉异常），并使用疼痛问卷来评估神经病理性疼痛。
在术后 7 周时，游离组（n = 21）的采集感觉异常区域（胸部的百分比）较小（中位数，0%；四分位距，0-0），低于带蒂组（n = 20）（2.8%[0-13]，P =.005）。游离组在 7 周时采集感觉异常的发生率为 14%，而带蒂组为 50%（P =.02）。这些差异在 21 周时并未持续，因为两组的采集感觉异常中位数均为 0%（P =.89），游离组和带蒂组的发生率分别为 24%和 25%（P = 1.0）。游离组与带蒂组相比，在术后 7 周时神经病理性疼痛的发生率分别为 5%和 10%（P =.6），而在术后 21 周时，发生率分别为 0%和 0%（P = 1.0）。
与带蒂采集相比，游离胸廓内动脉采集可在冠状动脉旁路手术后短期内降低胸壁感觉异常的程度和发生率，这与肋间神经损伤减少以及神经病理性胸痛的潜在风险降低一致。
