Technical aspects of double-skeletonized internal mammary artery grafting

Background. Bilateral internal mammary artery (IMA) grafting is performed t o provide complete arterial myocardial revascularization with the intention of decreasing postoperative return of angina and the need for reoperation. We present here technical views of double-skeletonized IMA grafting, and e valuate its clinical outcome. Methods. Skeletonized IMA is harvested gently with scissors and silver clip s, without use of cauterization, and embedded in a small syringe filled wit h papaverine. Three strategies for arterial revascularization were employed in 762 consecutive patients: (1) the cross arrangement (242 patients, 32%) , where the in situ right internal mammary artery (RIMA) is used for the le ft anterior descending artery (LAD), in situ left internal mammary artery ( LIMA) to circumflex marginal branches and the gastroepiploic artery for the right coronary artery ((RCA)); (2) the composite arrangement (476 patients , 62%), where free IMA is attached end-to-side to the other in situ IMA; an d (3) the natural arrangement (44 patients, 6%), where the in situ RIMA is connected to the RCA and in situ LIMA to LAD. Mean age was 66 years (range 30 to 92). Two hundred ninety-two patients (38%) were older than 70, and 22 9 (30%) were diabetic. Results. Operative mortality was 2.5% (n = 19). The mortality of urgent and elective cases was 1.2% (8 of 663), and that of emergency operation was 11 % (11 of 99). There were 9 (1.2%) perioperative myocardial infarctions, and 10 patients (1.3%) sustained strokes. Sternal wound infection occurred in 14 (1.8%). Conclusions. The three strategies described here provide the surgeon with t he versatility required for arterial revascularization with bilateral IMAs in most patients referred for coronary artery bypass grafting.