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Internal thoracic artery harvesting without pleurotomy - Does smaller injury

mean a better outcome?

Article  in  Polish Journal of Cardio-thoracic Surgery · March 2012

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KARDIOCHIRURGIA DOROSŁYCH

Internal thoracic artery harvesting without pleurotomy

– does smaller injury mean a better outcome?

Pobranie tętnicy piersiowej wewnętrznej bez pleurotomii – czy mniejszy

uraz jest jednoznaczny z lepszymi wynikami operacyjnymi?

Rafał Nowicki1, Jakub Marczak1, Tomasz Bankowski1, Marcin Murmyło2, Grzegorz Bielicki1,
Maciej Rachwalik1, Wojciech Kustrzycki1

1Department of Cardiac Surgery, University of Medicine, Wroclaw, Poland

24th Department of Internal Medicine and Pulmonology, Lower Silesian Center for Thoracic Diseases, Wroclaw, Poland

Kardiochirurgia i Torakochirurgia Polska 2012; 1: 28–32

Abstract Streszczenie
Introduction: The internal thoracic artery (ITA) remains the Wstęp: Lewa tętnica piersiowa wewnętrzna utrzymuje pozy-
graft of choice for coronary artery bypass grafting (CABG). Ha- cję niekwestionowanego lidera wśród naczyń stosowanych
rvesting the ITA without pleurotomy may be a desirable appro- w pomostowaniu aortalno-wieńcowym (ang. coronary artery
ach if the technique is proven to decrease morbidity and mor- bypass graft – CABG). Pobieranie tętnic piersiowych bez na-
tality and improve the economic result. The aim of the study ruszania ciągłości jam opłucnowych może stanowić pożądane
was to evaluate the impact of different harvesting techniques podejście chirurgiczne, jeżeli metoda ta wpłynie korzystnie na
on postoperative blood loss, transfusion requirements and du- długość przeżycia, zachorowalność i aspekt ekonomiczny chi-
ration of postoperative therapy. rurgii wieńcowej.
Material and methods: We carried out a prospective study that Cel pracy: Celem badania była ocena wpływu techniki pobiera-
involved 115 patients who underwent on-pump CABG in our nia tętnicy piersiowej wewnętrznej na okołooperacyjną utratę
clinic. Patients were divided into two groups: those who under- krwi, zapotrzebowanie na transfuzję produktów krwiopochod-
went pleurotomy due to ITA harvesting (group A; n = 73) and nych oraz czas trwania poszczególnych etapów hospitalizacji.
the rest where pleura spearing technique was applied (group B; Materiał i metody: Do badania zakwalifikowano w  sposób
n = 42). Predicting factors for proposed end-points were asses- prospektywny 115 pacjentów, którzy zostali poddani zabie-
sed by stepwise forward regression. gowi CABG w Klinice Chirurgii Serca Akademii Medycznej we
Results: Postoperative chest tube drainage (CTD) at the 12th Wrocławiu. Pacjenci zostali losowo zakwalifikowani do dwóch
and the 24th hour as well as the hemoglobin level did not differ grup. Grupa A (n = 73) składała się z pacjentów, u których za-
statistically. Nonetheless, patients with pleurotomy required stosowano szerokie otwarcie jamy opłucnowej w procesie po-
significantly more units of packed red blood cells (RBC), fresh bierania lewej tętnicy piersiowej wewnętrznej; w grupie B (n =
frozen plasma (FFP) and packed platelets (PLT) than patients 42) zastosowano technikę polegającą na zachowaniu ciągłości
with intact pleural cavity (RBC = 0.94 ±1.4 vs. 0.5 ±0.9; p < opłucnej. Porównano przebieg okołooperacyjny pacjentów alo-
0.001; FFP = 0.6 ±1.5 vs. 0.4 ±1.1; p < 0.001; PLT = 0.3 ±1.5 vs. kowanych do obydwu grup pod względem okołooperacyjnej
0.1 ±0.8; p < 0.001). Regression analysis indicated that opening utraty krwi, ilości przetoczeń preparatów krwiopochodnych
of the pleural cavity was a prediction factor for higher CTD at oraz czasu trwania hospitalizacji na poszczególnych etapach
the 12th hour (β = 0.18; p = 0.03) and prolonged postoperative leczenia.
hospitalization (β = 0.17; p = 0.04). Group A patients were also Wyniki: Objętość drenażu pooperacyjnego w 12. i 24. godzinie
found to require a longer intensive care unit (ICU) stay than oraz poziom pooperacyjny hemoglobiny nie osiągnęły różnicy
those of group B (A: 1.5 ±1.0 vs. B: 1.3 ±0.6; p < 0.001). istotnej statystycznie. Tym niemniej pacjenci w grupie, w któ-
Conclusion: Spearing of pleura in the ITA harvesting procedure rej wykonywano pleurotomi����������������������������������
��������������������������������
, wymagali istotnie więcej trans-
decreases morbidity and improves the economic result for pa- fuzji koncentratów krwinek czerwonych, świeżo mrożonego
tients qualified for on-pump CABG. osocza oraz koncentratów krwinek płytkowych niż pacjenci

Address for correspondence: Rafal Nowicki, epartment of Cardiac Surgery, Wroclaw Medical University, Borowska Street No. 213,
50-556 Wrocław, Poland, Email: [email protected]

28 Kardiochirurgia i Torakochirurgia Polska 2012; 9 (1)

 KARDIOCHIRURGIA DOROSŁYCH

Key words: CABG, LITA, pleurotomy, thoracic artery transplan- z zamkniętą jamą opłucnową (RBC = 0,94 ±1,4 vs 0,5 ±0,9; p <
tation, postoperative bleeding, postoperative complications. 0,001; FFP = 0,6 ±1,5 vs 0,4 ±1,1; p < 0,001; PPT = 0,3 ±1,5 vs 0,1
±0,8; p < 0,001). Analiza modelu regresji krokowej postępującej
wskazuje, iż otwarcie jamy opłucnowej stanowiło czynnik ry-
zyka zwiększonej objętości drenażu w 12. godzinie po zabiegu
(β = 0,18; p = 0,03) oraz przedłużonego czasu hospitalizacji
(β = 0,17; p = 0,04). Pacjenci z otwartą jamą opłucnową wy-
magali ponadto istotnie dłuższego pooperacyjnego pobytu na
oddziale intensywnej terapii niż pozostała grupa leczonych (A:
1,5 ±1,0 vs B: 1,3 ±0,6; p < 0,001).
Wnioski: Zachowanie ciągłości opłucnej ściennej podczas za-
biegu pobierania tętnicy piersiowej wewnętrznej skraca czas
trwania hospitalizacji, zmniejsza zakres powikłań krwotocz-
nych, przyczyniając się tym do redukcji kosztów chirurgicznego
leczenia zaawansowanej choroby wieńcowej.
Słowa kluczowe: pomostowanie aortalno-wieńcowe, lewa
tętnica piersiowa wewnętrzna, pleurotomia, przeszczepianie
tętnic klatki piersiowej, krwawienie, powikłania pooperacyjne.

Introduction Material and methods

According to the 2010 Annual Report of the Polish Heart Our study was conducted in a prospective manner. Ran-
Surgeons’ KROK Database, there were 13 285 isolated coro- domization was achieved by random allocation of patients
nary artery bypass grafting (CABG) procedures in Poland in to one of the two operating rooms (ORs) at our faculty (Mi-
2009 [1]. Owing to its anatomical availability, long standing crosoft Excel 2007, Microsoft Inc.): OR 1, where intact pleu-
patency and tremendous clinical outcome when used as ra technique was undertaken; and OR 2, where standard
a graft for coronary bypass surgery, the left internal tho- technique was implemented. The study group consisted
racic artery (LITA) serves as a gold standard in the surgical of 115 patients hospitalized in our faculty between January
treatment of coronary artery disease (CAD) [2]. It is not sur- 2007 and December 2008. The inclusion criteria were as
prising that many nuances emerged according to operative follows: elective surgery, isolated coronary artery disease
technique leading to a successful takedown of the vessel. (CAD), no previous cardiac surgery, no previous percutane-
Noera et al. demonstrated that pleurotomy during LITA ha- ous coronary intervention (PCI), negative history of chronic
rvest has a negative impact not only on lung function, but or acute pulmonary diseases, coagulopathy, major adverse
also on the blood loss measured as red blood cell (RBC) cerebro-vascular accidents, diabetes, chronic kidney dise-
units transfused postoperatively [3]. No evidence was given ase or malignancy. Patients requiring emergency surgery or
as far as other blood product requirements are concerned. suffering from significant left main stenosis as well as tho-
Length of intensive care unit (ICU) stay and overall hospi- se requiring intra-aortic balloon pump (IABP) both pre- and
talization time have been analyzed in this setting, altho- postoperatively were excluded from the study. In all sub-
ugh the evidence on this subject seems vague [4-8]. By far jects antiplatelet therapy was withdrawn in a safe interval
the most clear evidence was gathered on the superiority of of five days before the surgery.
Demographic structure, and medical history were ana-
lung function in patients with intact pleura over opening of
lyzed beforehand. Typical parameters of hemostasis and
the pleural cavity [4-8]. The aim of our study was to assess
postoperative bleeding were recorded at different stages
the utility of the extrapleural LITA harvesting technique, by
of the postoperative period. Postoperative blood product
means of blood loss, transfusion rates, pulmonary function
requirements were assessed as the unit of blood product
assessment and in-hospital therapy duration. This was
required per patient. The duration of overall hospital and
achieved by the comparison of post-operative outcome of
the ICU stay were analyzed as the difference in average time
patients with open pleural cavity and those whose pleura
spent in the ICU and in the cardiac surgery ward until ho-
remained intact.
spital discharge. The postoperative pulmonary function was
measured as the time needed to wean from the mechanical
Aim of study ventilatory support (orotracheal intubation time – ORT). All
The present study compared two LITA harvesting tech- postoperative complications were recorded and analyzed.
niques, with or without opening of the pleural cavity, in A total of 115 patients were divided into two groups. In
terms of their genuine safeness and postoperative out- group A (n = 73) a standard LITA harvesting technique was
come measured as postoperative blood loss, transfusion used. The surgical technique consisted of wide opening of
requirements, pulmonary complications and duration of the pleural cavity in order to achieve the best visualization
hospital stay. and the most surgeon friendly environment. In this setting

Kardiochirurgia i Torakochirurgia Polska 2012; 9 (1) 29

Internal thoracic artery harvesting without pleurotomy – does smaller injury mean a better outcome?

the LITA was taken down as a pedicle with surrounding tis- tegrade according to the Calafiore protocol in normother-
sue, e.g. endothoracic fascia, internal thoracic veins and mia. Activated clotting time (ACT) was maintained between
surrounding adipose tissue. Group B (n = 42) consisted of 100 and 120 seconds shortly after cardiopulmonary bypass
patients in whom extrapleural LITA harvesting technique termination. All patients were given tranexamic acid i.v. 1.0
was applied; hence no pleural cavity was opened. In this g preoperatively and 1.0 g shortly before leaving the OR.
case, the LITA was harvested in a semi-pedicled manner, e.g. This protocol was implemented in all patients regardless of
artery surrounded by two internal thoracic veins and encirc- their coagulation status.
ling adipose tissue but without the endothoracic fascia. All
patients were operated on by a single cardiac surgeon (R.N.) Statistical analysis
In all cases harvesting of the LITA was performed using bi- The study was approved by the Institutional Review
polar electrocautery (Force FX™, Valleylab, Colorado, USA). Committee. The statistical analysis was performed with the
All side branches were ligated with hemaclips. aid of Statistica 9.0 software, StatSoft Inc. Before any fur-
ther analysis all data were tested for normal distribution by
Surgical protocol Shapiro-Wilk test and Leven test for variance homogeneity.
The routine on-pump CABG protocol of our clinic was Results were displayed as mean and standard deviation.
applied to all patients. Premedication was admitted one The Student T-test, Wald-Wolfowitz and Chi-squared tests
hour before the operation with morphine 0.1 mg/kg and were applied for univariate analysis. Stepwise forward re-
midazolam 7.5 mg orally. Anesthesia was induced with pro- gression was used to reveal the prediction factors of studied
pofol TCI 2-4 μg/ml and fentanyl 5-7.5 μg/kg. Intubation end-points. Statistical significance was assumed at p < 0.05.
was facilitated with pancuronium 0.1 mg/kg. To maintain
anesthesia propofol TCI 2-3 μg/ml and fentanyl 5-10 μg/ Results
kg/h as a continuous intravenous infusion was used. Ven- The two groups did not differ as far as demographic
tilation was controlled artificially with a mixture of air and data and preoperative morbidity are concerned. There was
oxygen (initially FiO2 of 1.0 and 0.6 thereafter). All patients an inequality in left ventricular ejection fraction (LVEF) be-
underwent surgical revascularization by a standard me- tween groups, in favor of group B (58.6 ±9.0 vs. 57.1 ±10.9;
dian sternotomy. All patients were supported by a cardio- p = 0.047). No differences were found as far as preoperative
pulmonary bypass with non-pulsatile flow (2.2-2.4  l/min/ parameters of hemostasis are concerned. Average number
m2) using a Dideco Compacflo ECC device when arrested. of neither arterial nor venous grafts differed between gro-
Warm blood cardioplegia protection was administered an- ups. All patients had comparable time of aorta cross-clamp,
cardiopulmonary bypass (CPB) time, and requirements for
Tab. I. Preoperative baseline variables inotropic support intraoperatively (Tab. I and Tab. II).
Group A (n = 73) Group B (n = 42) p Although one patient in each group suffered cardiac
Age 66.3 ±8.9 63.7 ±9.0 NS arrest, there was no in-hospital mortality in either group.
Sex W: 19, M: 54 W: 7, M: 35 NS There was one major coronary and one cerebral adverse
event, both in group A, which consisted of perioperative
Body mass index 28.1 ±4.7 28.7 ±5.5 NS
myocardial infarction (CKMB > 10% of total CK, new q wa-
LVEF [%] 57.1 ±10.9 58.6 ±9.0 0.047
ves and loss of R forces over an anatomical region of the
aPTT [s.] 32.0 ±6.5 31.8 ±3.7 NS lateral aspect of the anterior wall) and stroke. This did not
INR 1.04 ±0.06 1.06 ±0.09 NS reach statistical significance. No development of chronic or
HGB [mg%] 13.9 ±1.4 14.2 ±1.7 NS acute kidney disease was observed (Tab. III).
PLT [x103] 211.2 ±61.7 217.9 ±58.9 NS
LVEF – left ventricular ejection fraction, aPTT – partial thromboplastin time, INR –
Blood loss
international normalized ratio, HGB – hemoglobin, PLT – platelets. Neither 12 nor 24 hour chest tube drainage differed
Tab. II. Operative outcome
significantly between groups, although in group A  it was
higher by approximately 70 ml per patient. No significant
Group 1 (n = 73) Group 2 (n = 42) p
difference in postoperative level of hemoglobin was noted,
No. of SV grafts 1.68 ±0.7 1.7 ±0.7 NS
No. of LITA grafts 73 (100%) 42 (100%) NS
Tab. III. Postoperative complications (in-hospital follow-up)
No. of RA grafts 1 (1.4%) 0 (0%) NS
Group 1 (n = 73) Group 2 (n = 42) p
CPB time [min] 68.2 ±30.4 71.0 ±30.4 NS
Major adverse
Aorta cross clamp 1 (1.4%) 0 (0%) NS
31.04 ±15.13 33.6 ±14.8 NS cerebral events
time [min]
Perioperative my-
Inotropic support 1 (1.4%) 0 (0%) NS
ocardial infarction
during bypass 18 (24.7%) 8 (19.5%) NS
weaning [pts] Cardiac arrest (all
1 (1.4%) 1 (2.4%) NS
in VF mechanism)
SV – saphenous vein, LITA – left internal thoracic artery, RA – radial artery, CPB –
cardiopulmonary bypass. VF – ventricular fibrillation.

30 Kardiochirurgia i Torakochirurgia Polska 2012; 9 (1)

 KARDIOCHIRURGIA DOROSŁYCH

even though patients of group A required reoperation for Comments

bleeding five times more often than those of group B. As Postoperative blood loss. Normothermic cardiopulmo-
shown by stepwise forward regression for both groups, the nary bypass is known to cause fewer coagulation deran-
factors having the most significant impact on CTD at 12 ho- gements than the moderate hypothermic one, yet platelet
urs after the surgery were as follows: preoperative partial mechanical activation, systemic inflammatory response
thromboplastin time (aPTT) (β = 0.39; p < 0.001), internatio- caused by blood exposure to artificial materials, and unfrac-
nal normalized ratio (INR) (β = 0.51; p = 0.001), preoperative tionated heparin use have long been the attributed disa-
platelet count (β = 0.17; p = 0.04) preoperative LVEF (β = dvantages of on-pump CABG [9-12]. The operative tech-
–0.19; p = 0.02), age (β = –0.17; p = 0.04), aorta cross-clamp nique should also be appreciated as an important factor
time (β = –0.17; p = 0.03), and, most importantly, opening limiting or aggravating the postoperative drainage capacity
of left pleural cavity while harvesting LITA (β = 0.18; p = [3, 6, 10-12]. An extensive tissue resection while harvesting
0.03). As for CTD 24 hours postoperatively the most signi- the LITA as a pedicle might contribute to the above state-
ficant factors were alike: preoperative aPTT (β = 0.56; p < ment as well. The literature has little or no evidence on
0.001), INR (β = 0.31; p = 0.04), postoperative INR (β = 0.45; how the postoperative blood loss impacts the postoperati-
p < 0.001), hemoglobin level 12 hours postoperatively (β = ve transfusion requirements and causes the need for pro-
–0.21; p = 0.003), age (β = –0.26; p < 0.001) and female longed hospitalization in the ICU. Similarly to the existing
gender (β = –0.19; p < 0.001) (Tab. IV). body of evidence, we conclude that opening of the pleural
cavity during LITA harvest is associated with more pronoun-
Blood product requirements ced blood loss, a bigger drop in postoperative hemoglobin
Patients of group A were found to require more blood and higher rates of reoperation for bleeding [3, 6]. In our
products than those of group B. That concerned not only opinion insertion of even the softest chest tube into the
packed red blood cells, but also packed platelets, and fresh pleural cavity might have the ability to cause mechanical ir-
frozen plasma. We did not find any significant differences ritation and consequently fluid secretion, which adds to the
between the coagulation tests and the platelet count po- total drainage capacity. The pleural tube is also found to
stoperatively (Tab. V). cause pulmonary function infringements and is associated
with greater postoperative pain and higher need for opioid
Time of therapy, ICU stay and indirect analgesia in the ICU [4].
assessment of pulmonary function Transfusion requirements. In comparison with other au-
thors we have gone further in the analysis of perioperative
The time of ventilatory support, preoperative INR and blood product requirements [3, 6]. There is clear evidence
LVEF on admission were the factors influencing the dura- that for every unit of packed red blood cells transfused in
tion of postoperative ICU stay (respectively: β = 0.21; p = the intact pleural cavity group, two units were transfused
0.02, β = 0.52; p = 0.002, β = –0.17; p = 0.03). The time in those with an opened pleural cavity. We hypothesize that
spent on the ICU was significantly longer for those of gro- higher rates of FFP and PLT transfused in patients with ope-
up A, although overall time of hospital stay did not dif- ned pleura did not have to be caused by greater coagula-
fer among the groups. Opening of the pleural cavity had tion derangements in this group. This might be due to the
a negative impact on the overall hospital stay (β = 0.17;
p = 0.04), hence committing to prolonged hospitalization.
The very same trends were observed for high body mass Tab. V. Postoperative CBC and blood product requirements
index (β = 0.25; p = 0.003) and advanced age (β = 0.26; Group 1 Group 2
p
(n = 73) (n = 42)
p = 0.005), which were also strong predictors of prolonged
hospital stay (Tab. VI). PLT [x103] 137.2 ±55.3 145.3 ±50.4 NS
aPTT [s.] 39.9 ±10.7 40.8 ±14.3 NS
INR 1.5 ±0.2 1.4 ±0.1 NS
Tab. IV. Postoperative blood loss
Packed red blood cells (u.) 0.94 ±1.4 0.5 ±0.9 < 0.001
Group 1 (n = 73) Group 2 (n = 42) p
Fresh frozen plasma (u.) 0.6 ±1.5 0.4 ±1.1 < 0.001
CTD at 12th hour
590.2 ±427.0 518.1 ±292.5 NS Packed platelets (u.) 0.3 ±1.5 0.1 ±0.8 < 0.001
postoperatively [ml]
CTD at 24th hour
809.2 ±530.9 708.6 ±368.3 NS Tab. VI. Time of therapy and pulmonary complications.
postoperatively [ml]
Hemoglobin level po- Group A  Group B
9.8 ±1.2 10.6 ±1.3 NS p
stoperatively [mg%] (n = 73) (n = 42)

Hemoglobin level 12 Time of ICU stay [days] 1.5 ±1.0 1.3 ±0.6 < 0.001
hours postoperati- 9.6 ±1.4 10.3 ±1.4 NS Time of hospitalization [days] 9.3 ±5.4 10.9 ±8.4 NS
vely [mg%]
Ventilatory support time [h] 8.2 8.2 NS
Reoperation for
5 (6.8%) 1 (2.4%) NS Prolonged intubation 0 (0%) 1 (2.4%) NS
bleeding
Reintubation 1 (1.4%) 0 (0%) NS
CTD – chest tube drainage.

Kardiochirurgia i Torakochirurgia Polska 2012; 9 (1) 31

 Internal thoracic artery harvesting without pleurotomy – does smaller injury mean a better outcome?

additional space opened for fluid retention in the pleural The paper was presented during the 5th Congress of the
cavity, which does not take place when the pleura remains Polish Society for Cardiothoracic Surgery, Poznan, 20-22
closed. Residual bleeding that might be left behind, beyond May 2010.
the ability of the surgeon to be cauterized or ligated, may
be stopped by the elements of the parietal pleura when it
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Conclusions
Considering the above we conclude as follows:
Opening of the pleural cavity is associated with worse
operative outcome in terms of post-operative blood pro-
duct requirements, prolonged orotracheal intubation and
longer hospitalization in the ICU. Before applying the open
harvesting technique one should bear in mind that this is
linked to a detrimental impact on pulmonary function and
postoperative blood loss.

32 Kardiochirurgia i Torakochirurgia Polska 2012; 9 (1)

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