Benedetto Umberto, Altman Douglas G, Gerry Stephen, Gray Alastair, Lees Belinda, Pawlaczyk Rafal, Flather Marcus, Taggart David P
Bristol Heart Institute, University of Bristol, School of Clinical Sciences, Bristol, United Kingdom.
Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom.
J Thorac Cardiovasc Surg. 2016 Jul;152(1):270-6. doi: 10.1016/j.jtcvs.2016.03.056. Epub 2016 Apr 6.
The question of whether skeletonized internal thoracic artery harvesting reduces the incidence of sternal wound complications in comparison with the pedicled technique, in the context of single or bilateral internal thoracic arteries, remains controversial. We studied the impact of the internal thoracic artery harvesting strategy on sternal wound complication in the Arterial Revascularization Trial.
Patients enrolled in the Arterial Revascularization Trial (n = 3102) were randomized to coronary artery bypass grafting with single or bilateral internal thoracic arteries. Sternal wound complication rates were examined according to the harvesting technique that was documented in 2056 patients. The internal thoracic artery harvesting technique, based on the surgeon's preference, resulted in 4 groups: pedicled single internal thoracic artery (n = 607), pedicled bilateral internal thoracic artery (n = 459), skeletonized single internal thoracic artery (n = 512), and skeletonized bilateral internal thoracic artery (n = 478). Propensity scores weighting was used to estimate the impact of the harvesting technique on sternal wound complications.
A total of 219 of 2056 patients (10.6%) experienced a sternal wound complication within 1 year from the index operation. Of those, only 25 patients (1.2%) required sternal wound reconstruction. Pedicled bilateral internal thoracic artery (odds ratio [OR], 1.80; 95% confidence interval [CI], 1.23-2.63) but not skeletonized bilateral internal thoracic artery (OR, 1.00; 95% CI, 0.65-1.53) or skeletonized single internal thoracic artery (OR, 0.89; 95% CI, 0.57-1.38) was associated with a significantly increased risk of any sternal wound complications compared with pedicled single internal thoracic artery.
The present Arterial Revascularization Trial substudy suggests that, with a skeletonization technique, the risk of sternal wound complication with bilateral internal thoracic artery grafting is similar to that after standard pedicled single internal thoracic artery harvesting, whereas skeletonized single internal thoracic artery harvesting did not add any further benefit when compared with pedicled single internal thoracic artery harvesting.
在单支或双支胸廓内动脉的情况下，与带蒂技术相比，采用骨骼化胸廓内动脉获取技术是否能降低胸骨伤口并发症的发生率，这一问题仍存在争议。我们在动脉血运重建试验中研究了胸廓内动脉获取策略对胸骨伤口并发症的影响。
纳入动脉血运重建试验的患者（n = 3102）被随机分配接受单支或双支胸廓内动脉冠状动脉旁路移植术。根据2056例患者记录的获取技术检查胸骨伤口并发症发生率。根据外科医生的偏好，胸廓内动脉获取技术分为4组：带蒂单支胸廓内动脉（n = 607）、带蒂双支胸廓内动脉（n = 459）、骨骼化单支胸廓内动脉（n = 512）和骨骼化双支胸廓内动脉（n = 478）。采用倾向评分加权法来评估获取技术对胸骨伤口并发症的影响。
2056例患者中共有219例（10.6%）在初次手术后1年内发生胸骨伤口并发症。其中，仅25例患者（1.2%）需要进行胸骨伤口重建。与带蒂单支胸廓内动脉相比，带蒂双支胸廓内动脉（比值比[OR]，1.80；95%置信区间[CI]，1.23 - 2.63）与任何胸骨伤口并发症风险显著增加相关，但骨骼化双支胸廓内动脉（OR，1.00；95% CI，0.65 - 1.53）或骨骼化单支胸廓内动脉（OR，0.89；95% CI，0.57 - 1.38）并非如此。
目前的动脉血运重建试验子研究表明，采用骨骼化技术时，双支胸廓内动脉移植的胸骨伤口并发症风险与标准带蒂单支胸廓内动脉获取后的风险相似，而与带蒂单支胸廓内动脉获取相比，骨骼化单支胸廓内动脉获取并未带来更多益处。
