Int J Clin Exp Med 2019;12(6):7683-7691 www.ijcem.com /ISSN:1940-5901/IJCEM0073668 Original Article Advantages of using skeletonized ITA vs. pedicled ITA in CABG Aiman Khan * , Huangmengjie Zhang * , Merveesh L Auchoybur, Yueyue Xu, Wei Qin, Zhibing Qiu, Wen Chen, Xin Chen Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Jiangsu, People’s Republic of China. * Equal contributors. Received January 29, 2018; Accepted October 12, 2018; Epub June 15, 2019; Published June 30, 2019 Abstract: Background: Despite various observational studies having been performed regarding the supposed ad- vantages of skeletonization of the internal thoracic artery (ITA), its impact, especially on reducing the microscopic injury, remains unclear. Methods: Sixty patients (45 males, mean age 67.2 ± 8.6 years) undergoing isolated CABG surgery were enrolled into the study and randomized into skeletonized (n = 33) and pedicled (n = 37) groups. Intra- operatively, the left ITA was harvested according to the group to which the patient was assigned to, and ITA free fow was assessed directly with an ultrasonic fow meter both before and after anastomosis was completed. ITA harvest time and conduit length were also recorded. A blinded assessment of pain and dysesthesia was performed. Sternal perfusion was assessed preoperatively and during the 6-month follow-up using SPECT fusion imaging (n = 33), by measuring active microcirculation in the Volume of Interest (VOI). Results: The harvest time was longer for skeleton- ized ITA (27.1 versus 24.1 minutes; P = 0.06). There was a trend toward increased ITA length in the skeletonized group (18.2 ± 0.3 versus 17.7 ± 0.3 cm; P = 0.09). In situ ITA fow was higher in skeletonized arteries upon direct measurement (10.1 ± 1.0 versus 7.4 ± 0.9 mL/min; P = 0.01) upon harvesting, but not on post-anastomotic ultra- sonic fow meter measurement (7.1 ± 0.8 versus 6.3 ± 1.7 mL/min; P = 0.19) after anastomosis was completed. Skeletonization was associated with decreased pain at the 6-month follow-up (0.79 ± 0.17 versus 1.47 ± 0.25; P = 0.05) and a reduction in major sensory defcits at the 6-month follow-up (17% versus 50%; P = 0.002). There was no signifcant difference between either group in the baseline adjusted sternal perfusion. Conclusions: Skeletonization results in reduced postoperative pain and dysesthesia, improved conduit free fow and graft length, while signif- cantly increasing the duration required for ITA harvest. Additionally, there was no signifcant difference in the extent of damage to the microcirculation of the sternum between both pedicled and skeletonized groups, suggesting that skeletonization is not advantageous for maintaining sternal circulation. Keywords: Coronary artery bypass graft surgery, internal thoracic artery, skeletonization, pedicle, sternal perfusion Introduction It is well established that the internal thoracic artery (ITA) is the most reliable graft in patients undergoing coronary artery bypass grafting (CABG) due to its excellent long-term patency rate [1, 2]. Despite these long-term benefts, certain characteristics of the ITAs limit their use in certain settings. Harvest of the ITAs is asso- ciated with impairment in sternal perfusion [5] and increased deep sternal wound infections [6], particularly in diabetic patients receiving bilateral ITAs. The length of usable conduit av- ailable can be limited in the setting of sequen- tial grafting. In addition, ITA harvest has been associated with increased and persistent post- operative pain [7-9]. The skeletonization of the ITA, frst described by Keeley [10] in 1987, has been proposed as a solution to many of the problems associated with ITA harvesting, such as decreasing the in- cidence of sternal infection [11, 12]. Although this technique requires meticulous dissection and carries the theoretical risk of increased arterial injury, studies have not demonstrated any differences in microscopic injury or vascu- lar function when skeletonized and pedicled ITAs are compared [13, 14]. Proposed benefts of skeletonization include increased fow [15]