CARDIOVASCULAR
Benefit of Partial Right-Bilateral Internal Thoracic
Artery Harvesting in Patients at Risk of Sternal
Wound Complications
Jacob Zeitani, MD, Alfonso Penta de Peppo, MD, Ruggero De Paulis, MD,
Paolo Nardi, MD, Antonio Scafuri, MD, Saverio Nardella, MD, and Luigi Chiariello, MD
Division of Cardiac Surgery, Tor Vergata University, Rome, Italy, and Second University of Naples, Naples, Italy
Background. Excellent long-term patency of the inter-
nal thoracic artery (ITA) graft promotes use of bilateral
ITA bypass grafting; sternal devascularization, however,
increases the risk of wound complications. We hypothe-
sized that restricting right ITA (RITA) harvesting to a
short proximal skeletonized segment (3 to 5 cm) would
result in adequate residual blood supply to reduce that
risk.
Methods. Seventy-eight patients with numerous risk
factors for wound complications underwent composite
double ITA grafting, utilizing the RITA segment anasto-
mosed to the left skeletonized ITA and to the obtuse
marginal branch in Y fashion. Blood flow in the distal
RITA was assessed by parasternal transthoracic Doppler
ultrasonography. Comparisons were made with prospec-
tively collected data of patients undergoing pedicled
single (n 160) or skeletonized bilateral ITA grafting (n
143) during the same period.
E vidence of better long-term patency of internal tho-
racic artery (ITA) grafts, compared with vein grafts
[1], promotes the use of arterial grafts for myocardial
revascularization. Despite availability of various arterial
conduits, the ITA remains the ideal arterial graft [2], and
several investigations appear to confirm the benefit of
bilateral ITA (BITA) over single ITA (SITA) grafting for
myocardial revascularization [35]. Bilateral harvesting
implies, however, extensive devascularization of the ster-
num and increases the risk of postoperative tissue isch-
emia, leading to wound infection and dehiscence [6], in
particular in patients with additional risk factors of
wound complications as diabetes mellitus, obesity,
chronic obstructive pulmonary disease, or peripheral
arteriopathy [710]. As a consequence, although the tech-
nique of skeletonization of the ITA may limit the extent of
devascularization of the sternum and reduce the risk of
complications [1117], BITA harvesting is frequently
avoided in patients with multiple risk factors. To main-
tain the benefit of receiving two ITAs in those high-risk
Accepted for publication June 8, 2005.
Address correspondence to Dr Zeitani, Division of Cardiac Surgery, Tor
Vergata University, Via Oxford 85, Rome 00133, Italy; e-mail:
zeitani@hotmail.com.
2006 by The Society of Thoracic Surgeons
Published by Elsevier Inc
Results. Incidence of obesity, chronic obstructive pul-
monary disease, diabetes, and peripheral vascular dis-
ease was higher in study patients. Postoperative Doppler
ultrasonography detected reversed systolic dominant
flow pattern. Wound complications occurred in 2 of 78
(2.6%) patients, compared with 14 of 143 (9.8%) after
bilateral ITA (p 0.04) and 8 of 160 (5%) after single ITA
grafting (p ns). Technique of bilateral ITA harvesting
(partial right versus full length; odds ratio, 0.2; confi-
dence interval: 0.04 to 0.9) and diabetes mellitus (odds
ratio, 2.7; 95% confidence interval: 1.1 to 6.3) were inde-
pendent predictors of wound complications in the entire
series.
Conclusions. Substantial residual blood supply is de-
tectable after partial RITA harvesting and may prevent
wound complications in high-risk patients.
(Ann Thorac Surg 2006;81:139 44)
2006 by The Society of Thoracic Surgeons
patients, we proposed a method of partial right BITA
harvesting and composite arterial graft fashioning [18],
which seems to offer substantial residual blood flow to
the middle and distal portions of the right hemisternum.
The aim of this study was to assess the extent and pattern
of that residual blood flow and the occurrence of wound
complications in selected patients.
Material and Methods
One thousand three hundred patients underwent iso-
lated myocardial revascularization at our institution from
January 2002 to December 2004; of those, 78 patients
requiring revascularization of the left anterior descend-
ing artery and of at least one large proximal obtuse
marginal branch, presenting two or more risk factors of
sternal wound complications (obesity, diabetes mellitus,
chronic obstructive pulmonary disease, peripheral vas-
cular disease, depressed left ventricular function), under-
went BITA bypass grafting by using the method of partial
right ITA (RITA) harvesting and assembling the compos-
ite graft in Y fashion. Ethical Review Board approval
(December 10, 2001) and individual patient informed
consent for surgical and additional radiologic procedures
were obtained.
0003-4975/06/$32.00
doi:10.1016/j.athoracsur.2005.06.025
 140 ZEITANI ET AL Ann Thorac Surg
CARDIOVASCULAR

PARTIAL RIGHT ITA HARVESTING 2006;81:139 44

Table 1. Data of Patients Who Received Skeletonized and second obtuse marginal branches. The sternum was
Bilateral Internal Thoracic Arteries (BITAs) or Pedicled reapproximated at the end of the procedure by using a
Single Internal Thoracic Artery (SITA) single stainless steal wire (A&E Medical Corporation,
Partial Right Full-Length Farmingdale, New Jersey) for each 10 kg of body weight.
BITAs BITAs SITA The fascia, subcutaneous layers and skin were closed
(n 78) (n 143) (n 160) with running absorbable sutures.
Sex (male/female) 56/22a 127/16 144/16
Ultrasonography and Radiography
Age (years) 69.5 5.7a 58.5 9.9c 62.2 8.5
NYHA class IIIIV 40 (51%)a 29 (20%) 23 (14%) To assess the preoperative blood flow in the distal RITA
Diabetes mellitus 40 (51%)a 43 (30%) 36 (22%) and the postoperative residual flow in the residual distal
COPD 40 (51%)a 20 (14%)c 6 (3.7%) RITA, a transthoracic color Doppler ultrasound scan
Peripheral vascular 20 (26%)a 16 (11%) 15 (9.3%) (Sonos 5500 and 7.5 MHz transducer; Hewlett Packard,
disease Andover, Massachusetts) was performed with intercostal
LVEF 50% 40 (51%)a 37 (26%) 39 (24%) approach at the fourth to fifth right parasternal space,
Obesity (body mass 20 (26%)b 15 (10%)c 37 (23%) obtaining two-dimensional images and pulsed Doppler
index 30 kg/m2) signals preoperatively and from the fourth to sixth post-
Reoperation for bleeding 2 (2.7%) 4 (2.8%) 3 (1.9%) operative day.
Bypass grafts 3.0 0.7 3.1 0.7 3.1 0.8 In 10 patients, an anteroposterior chest radiograph was
Distal ITA anastomoses 2.7 0.6a 2.1 0.6c 1.0 0.5 obtained in the operating room with portable equipment,
Cardiopulmonary bypass 81 28 82 27 85 26 protected by sterile drapes, after injection of 30 mL of
time (min) iodine solution through an 18G cannula inserted into the
Aortic crossclamp time 53 16c 54 18c 49 15 still unclipped end of the undissected distal RITA, to
(min)
visualize the residual vascular supply to the right hemis-
Sternal wound 2 (2.6%)b 14 (9.8%) 8 (5%)
complications ternum (the distal RITA and corresponding intercostal
Deep 0 (0%) 6 (4.2%)c 1 (0.6%) branches). On the fourth postoperative day, a multislice
Superficial 2 (2.6%) 8 (5.6%) 7 (4.4%) computed tomography (CT) scan was performed in the
same patients after injection of iodine solution in a
a
p 0.05 versus full-length BITA and SITA. b
p 0.05 versus peripheral vein, visualizing the distal RITA, veins, and
full-length BITA. c
p 0.05 versus SITA.
the corresponding intercostal branches.
COPD chronic obstructive pulmonary disease; LVEF left ventric-
ular ejection fraction; NYHA New York Heart Association.

Surgical Technique
Surgery was performed after skin preparation with pov-
idone-iodine solution and antibiotic administration (1 g
intravenous ceftizoxime) before incision; antibiotic pro-
phylaxis was continued for 48 hours postoperatively. The
partial right BITA harvesting technique and the method
of composite arterial graft fashioning have been de-
scribed previously [18]. Briefly, the left parasternal endo-
thoracic fascia is incised longitudinally, and the left ITA
(LITA) with the adjoining veins are visualized. The artery
is then harvested in a scheletonized fashion for the full
sternal length, by using titanium clips and scissors to
dissect collateral branches. Similarly, a proximal RITA
segment is dissected in a skeletonized fashion, from its
origin to the second or third intercostal space (3 to 5 cm)
Then, the free ends of the residual artery are clipped with
titanium clips, the segment is removed and anastomosed
as a free graft end-to-side to the in-situ LITA, in a
Y-graft configuration, approximately at the level where it
crosses the left pericardial border when distended to-
ward the left anterior descending artery. The RITA seg-
ment is anastomosed to the first obtuse marginal branch Fig 1. Postoperative multislice computed tomography scan of a pa-
and the in-situ LITA to the left anterior descending tient after harvesting of the proximal segment of the right internal
artery. In 45 patients the LITA was also sequentially thoracic artery, showing the residual artery (arrow), vein, and corre-
anastomosed to a diagonal branch, and in 7 patients the sponding intercostal branches (roman numerals indicate intercostal
RITA segment was sequentially anastomosed the first spaces).
Ann Thorac Surg
2006;81:139 44
Wound complications were observed during hospital-
ization or detected by physical examination at the outpa-
tient clinic during the first 2 postoperative months of
follow-up; they included instability of the sternum, with-
out evidence of tissue infection, or sternal wound infec-
tion, according to the guidelines for prevention of surgi-
cal site infection of the Hospital Infection Control
Practices Committee [19]. In particular, superficial infec-
tion was defined as wound erythema and purulent dis-
charge involving the skin and the subcutaneous layers
without involvement of sternal or mediastinal tissues;
deep infection was diagnosed in case of one of the
following: visual evidence of mediastinitis, isolation of an
organism from culture of mediastinal tissue or fluid, or
fever or instability of the sternum associated with puru-
lent drainage from the mediastinum. Patients character-
istics and occurrence of sternal wound complications
were compared with the prospectively collected data of
143 consecutive patients undergoing isolated bypass
grafting with skeletonized BITAs during the same period,
and of 160 patients submitted to pedicled SITA grafting
on the same dates (2 days before or after). The decision
for the number of ITAs and the method of harvesting was
taken by one of the four attending surgeons involved in
the series. Patients undergoing off-pump bypass or con-
comitant procedures were excluded.
Statistical Analysis
Comparisons of variables were performed by the un-
paired Students t test, 2 or Fishers exact test, as
appropriate. Influence of variables on wound complica-
tions was assessed by univariate analysis; factors poten-
tially affecting sternal wound complications included age,
sex, III to IV New York Heart Association functional class,
echocardiographic left ventricular ejection fraction lower
than 50%, diabetes mellitus, obesity (body mass index
30 kg/m2), chronic obstructive pulmonary disease, pe-
ripheral vascular disease, type of ITA harvesting (single
in pedicled fashion, skeletonized full-length bilateral,
skeletonized partial right bilateral), and time of cardio-
pulmonary bypass. Factors with a probability (p) value
less than 0.1 were then included in a stepwise logistic
regression prediction model. Variables are presented as
mean 1 SD. A p value less than 0.05 was considered
statistically significant. Statistical analysis was done by
SPSS statistical software package (SPSS, Chicago,
Illinois).
Results
Patients undergoing partial right BITA harvesting were
older and presented more risk factors of wound compli-
cations than patients undergoing SITA or full-length
BITA harvesting (Table 1). The preoperative transtho-
racic color Doppler ultrasonography detected antegrade
flow in the distal RITA with the normal pattern of a
peripheral artery. A shorter operative time was required
for dissection of the proximal segment than for dissection
of the full sternal length of the RITA (5.7 0.7 versus 19.8
2.6 minutes, p 0.001). Intraoperative chest radio-
ZEITANI ET AL 141
CARDIOVASCULAR
PARTIAL RIGHT ITA HARVESTING
Table 2. Predictors of Sternal Wound Complications
Univariate
Analysis Multivariate Analysis
Odds
Risk Factor p Value Ratio 95% CL p Value
Diabetes mellitus 0.04 2.7 1.16.3 0.02
Type of BITA harvesting 0.04 0.2 0.040.9 0.03
(partial right versus
full length)
COPD 0.46
Obesity 0.80
BITA bilateral internal thoracic artery; CL confidence limits;
COPD chronic obstructive pulmonary disease.
graphs after direct injection of iodine solution in the
residual distal RITA showed the artery and the corre-
sponding intercostal branches from the fourth to fifth
intercostal spaces; that residual vascular supply was also
well identified at postoperative CT scanning (Fig 1).
Aortic cross-clamp time was about 5 minutes longer
during BITA than SITA bypass grafting; among BITA
patients, an average of 2.7 distal ITA anastomoses were
performed with the composite Y grafting procedure, a
number significantly higher than with in situ BITAs
(Table 1). The postoperative Doppler analysis detected
systolic dominant inverted flow in the distal RITA.
Mediastinitis did not occur. Analysis of the entire
series of 381 patients showed that the rate of wound
complications was higher among patients with diabetes
mellitus (12 of 107, 10%, versus 12 of 250, 4.6%; p 0.04);
incidence of deep infection or dehiscence was also higher
in diabetic patients (5 of 114, 4.2%, versus 2 of 260, 0.8%;
p 0.02). Wound complications were less frequently
observed after partial right than after full-length BITA
harvesting (2.6% versus 9.8%, p 0.03). Instability of the
sternum without evidence of tissue infection occurred in
2 patients (1.4%) in the full-length BITA group; deep
wound infection was diagnosed in 4 more patients (2.8%)
in that group, in 1 patient (0.6%) in the SITA group, and
in no patient in the partial right BITA group. Incidence of
deep wound complications was higher in the full-length
than in the partial right BITA group, although at low
statistical power (4.2% versus 0%, p 0.06); nevertheless,
comparisons with patients receiving a SITA demon-
strated a significantly higher rate of deep wound prob-
lems after full-length but not after partial right BITA
harvesting (4.2% versus 0.6%, p 0.03, and 0% versus
0.6%, p not significant; Table 1). A multivariate analysis
in the entire series was then performed, showing that
both diabetes and technique of BITA (partial versus
full-length RITA) harvesting were independent predic-
tors of wound complications (Table 2).
All patients with deep wound complications under-
went reoperation for debridement of necrotic and devas-
cularized tissue and direct closure of the sternum, fascia,
and superficial layers, associated with intravenous anti-
biogram-guided antibiotic therapy in patients with pos-
itive cultures or wide-spectrum antibiotic prophylaxis in
 142 ZEITANI ET AL
CARDIOVASCULAR
PARTIAL RIGHT ITA HARVESTING
aseptic sternal dehiscence. They experienced complete
wound healing. Patients with superficial wound compli-
cations were also treated by surgical debridement, pri-
mary closure of wound dehiscence and antibiotic treat-
ment, as described previously [20]; one procedure failed
and was crossed over to conventional topical treatment
until secondary wound healing.
Comment
Different surgical strategies have been developed during
the last decade to achieve the optimal myocardial revas-
cularization for each patient. It is now well documented
that the ITA graft compares favorably with other con-
duits, owing to the relatively large vessel diameter and
the physiologic properties of the arterial wall, which
provide for high flow and long-term patency [1, 2]. Use of
BITAs has been recently reported to improve survival
and freedom from recurrent angina [35] but, at the same
time, to cause extensive devascularization of the ster-
num, increasing the risk of wound infection and dehis-
cence [6]. That risk appears to increase seriously in
patients with additional known risk factors as diabetes
mellitus or chronic obstructive pulmonary disease [710].
Recently, for example, Molina and colleagues [10] re-
ported an high incidence of wound infection in obese
patients, with a high mortality rate, and questioned
whether BITA harvesting should be performed in these
patients. Unlike pedicled ITA harvesting, the technique
of skeletonization reduces the extent of devascularization
of the chest wall, leaving veins, muscle and surrounding
endothoracic tissue in place and is, therefore, potentially
associated with fewer postoperative wound complica-
tions: indeed, occurrence of sternal wound infection
appears consistently low after routine use of bilateral
skeletonized ITAs [1517]. For example, the 2.8% rate of
deeper wound infection in the present series is similar to
the recently reported rates of 1.7% by Matsa and associ-
ates (13), 2.2% by Pevni and colleagues [21], or 2.4% by
Sauvage and coworkers [22]. Other recently published
investigations in patients with diabetes also report a very
moderate prevalence of wound problems after BITA
skeletonization, with deep sternal infection rates from
1.3% to 4% [11, 13, 23].
Previous observations at our institution [14] also sug-
gest a lower rate of wound infections after skeletoniza-
tion of BITAs than after harvesting both arteries in a
pedicled fashion; indeed, skeletonization may preserve a
number of sternal and intercostal branches arising as a
common trunk from the ITA [24], maintaining some
collateral flow to the sternum. Also, implantation of
bilateral in-situ ITAs has the advantage of maintaining
two separate blood supplies to the myocardium, avoiding
additional anastomoses to fashion a composite graft.
Nonetheless, we also found that the risk of wound
complications seemed to increase greatly in patients with
several risk factors for wound infection; the present study
suggests that the proposed method of partial right BITA
harvesting and skeletonization may further improve re-
Ann Thorac Surg
2006;81:139 44
sidual blood supply, and therefore wound healing, in
those high-risk patients.
We hypothesized that a proximally limited dissection
of the RITA would leave a residual vascular supply to the
right hemisternum through the distal RITA, promoting
more efficient wound healing, in particular in patients
presenting with numerous risk factors for complications.
Although use of the distal arterial segment would result
in residual antegrade perfusion to the chest wall, the
proximal ITA segment was preferred as it presents a
larger diameter, which facilitates fashioning of the com-
posite graft. Interestingly, postoperative Doppler analy-
sis of blood flow in the distal RITA, which could now be
considered as the terminal branch of the right superior
epigastric artery, showed inverted systolic dominant flow
pattern, as previously reported [18]. Connections to the
lower intercostal branches and to the inferior epigastric
artery appear to provide, therefore, for a persistent blood
supply to the middle and distal portions of the right
hemisternum that should be advantageous to promote
wound healing. Indeed, owing to the inclusion criteria,
patients selected for the described technique presented
several potential risk factors of wound complications; yet,
sternal wound problems rarely occurred in these pa-
tients, showing a significantly lower rate of wound com-
plications all together when compared with control BITA
graft patients. Also, fewer deep wound complications
were observed in the former group, but at a low statistical
power, possibly as result of the several inclusion criteria
selecting a homogeneous but relatively small group of
coronary patients for the partial right BITA harvesting
procedure; nevertheless, occurrence of deep complica-
tions after full-length, but not partial right, BITA harvest-
ing compared unfavorably with single ITA harvesting,
thus enhancing the clinical significance of these observa-
tions in that subset of complications and underlining the
overall benefit of the proposed technique in preventing
wound problems. Findings were confirmed by a multi-
variate analysis of the potential risk factors in the entire
series of 381 patients, still showing that type of BITA
harvesting (partial versus full-length RITA) and diabetes
mellitus were independent predictors of wound
complications.
It has to be noted that the observed rate of 4.2% of deep
wound complications after full-length BITA skeletoniza-
tion appears relatively high when compared with preva-
lence of deep sternal infection, the more frequently
reported wound problem, in the literature; that may
account for the statistical significance of that figure in the
present study. It should be considered, however, that
postoperative sternal instability without evidence of in-
fection is potentially related, as sternal infection, to the
extent of sternal devascularization and therefore to the
technique of harvesting, thus validating our definition of
deep wound complication that was anyhow adopted for
all observations in the series.
Feasibility of the described composite Y grafting pro-
cedure requires a favorable coronary anatomy, with a
large and proximally located obtuse marginal branch; in
that case, a rather short proximal segment of the RITA
Ann Thorac Surg
2006;81:139 44
appears adequate, as part of the composite Y graft, to
reach the first and sometimes the second marginal
branches. Otherwise, should further sternal devascular-
ization be required to harvest a longer segment, other
arterial grafts, as the radial artery, may replace the RITA
as second conduits to reach the circumflex territory,
accomplishing complete arterial revascularization of the
left ventricle with, one hopes, a good patency rate. In our
technique, the proposed length of the RITA segment may
vary from 3 to 5 cm, depending on the number and
location of the marginal branches needing revasculariza-
tion; that aspect can usually be assessed preoperatively,
after evaluation of coronary angiograms. Intraoperative
inspection of the obtuse marginal branches is also rec-
ommended before RITA harvesting. Furthermore, the
proposed composite Y-graft technique provides the pos-
sibility of sequential grafting of the LITA to the left
anterior descending artery and diagonal branches; con-
sequently, more arterial distal anastomoses per patient
were performed with that technique than with bilateral
in-situ ITA grafting.
In conclusion, the proposed method of BITA grafting,
preserving substantial vascular supply to middle and
distal sternal tissues, appears to prevent wound compli-
cations in selected patients at high risk of this complica-
tion, who may therefore benefit from receiving two or
more grafts by means of the two ITAs at acceptable risk.
Limitations of the Study
Patients selected for partial right BITA harvesting pre-
sented more numerous risk factors for wound complica-
tions than control patients. That observation could be
expected to strengthen the positive influence of that
method on occurrence of wound complications; never-
theless, comparisons among groups carry a potential
selection bias. To better define this aspect, however, type
of harvesting was also assessed in a multivariable model
including data from the entire series, demonstrating that
type of harvesting (partial versus full-length RITA) as
well as diabetes mellitus were independent predictors of
wound complications. It should also be mentioned that
the present investigation implies the limitations of non-
randomized studies; more observations are therefore
required to confirm the reported findings.
References
1. Cameron A, Davis K, Green G, Schaff HV. Coronary bypass
surgery with internal-thoracic-artery grafts: effect on sur-
vival over a 15-year period. N Engl J Med 1996;334:216 9.
2. Barener H. The continuing evolution of arterial conduits.
Ann Thorac Surg1999;68(Suppl):1 8.
3. Endo M, Nishida H, Tomizawa Y, Kasanuki H. Benefit of
bilateral IMA grafts over single IMA graft for multiple
coronary artery bypass grafting. Circulation 2001;104:2164
70.
4. Stevens LM, Carrier M, Perrault LP, et al. Single versus
bilateral internal thoracic artery grafts with concomitant
saphenous vein grafts for multivessel coronary artery bypass
ZEITANI ET AL 143
CARDIOVASCULAR
PARTIAL RIGHT ITA HARVESTING
grafting: effects on mortality and event-free survival.
J Thorac Cardiovasc Surg 2004;127:1408 15.
5. Lytle BW, Blackstone EH, Loop FD, et al. Two internal
thoracic artery grafts are better than one. J Thorac Cardio-
vasc Surg 1999;117:85572.
6. Seyfer AE, Shriver CD, Miller TR, Graeber GM. Sternal
blood flow after median sternotomy and mobilization of the
internal mammary arteries. Surgery 1988;104:899 904.
7. Kouchoukos NT, Wareing TH, Murphy SF, Pelate C, Mar-
shall WG. Risks of bilateral internal mammary artery bypass
grafting. Ann Thorac Surg 1990;49:210 9.
8. Ridderstolpe L, Gill H, Granfeldt H, Ahlfeldt H, Rutberg H.
Superficial and deep sternal wound complications: inci-
dence, risk factors and mortality. Eur J Cardiothorac Surg
2001;20:1168 75.
9. Loop FD, Lytle BW, Cosgrove DM, et al. Sternal wound
complication after isolated coronary artery bypass grafting:
early and late mortality, morbidity and cost of care. Ann
Thorac Surg 1990;49:179 87.
10. Molina JE, Lew RS, Hyland KJ. Postoperative sternal dehis-
cence in obese patients: incidence and prevention. Ann
Thorac Surg 2004;78:9127.
11. Peterson MD, Borger MA, Rao V, Peniston CM, Feindel CM.
Skeletonization of bilateral internal thoracic artery grafts
lowers the risk of sternal infection in patients with diabetes.
J Thorac Cardiovasc Surg 2003;126:1314 9.
12. Parish MA, Asai T, Grossi EH, et al. The effects of different
techniques of internal mammary artery harvesting on ster-
nal blood flow. J Thorac Cardiovasc Surg 1992;104:13037.
13. Matsa M, Paz Y, Gurevitch J, et al. Bilateral skeletonized
internal thoracic artery grafts in patients with diabetes.
J Thorac Cardiovasc Surg 2001;121:668 74.
14. De Paulis R, de Notaris S, Scaffa R, et al. The effect of
bilateral internal thoracic artery harvesting on superficial
and deep sternal infection: the role of skeletonization. J Tho-
rac Cardiovasc Surg 2005;129:536 43.
15. Calafiore AM, Vitolla G, Iaco AL, et al. Bilateral internal
mammary artery grafting: midterm results of pedicled ver-
sus skeletonized conduits. Ann Thorac Surg 1999;67:1637 42.
16. Gummert JF, Mohr FW. Deep sternal wound infection and
risk analysiswhat do we really know? Thorac Cardiovasc
Surg 2003;51:109 10.
17. Athanasiou T, Crossman M, Asimakopoulos G, et al. Should
the internal thoracic artery be skeletonized? Ann Thorac
Surg 2004;77:2238 46.
18. Zeitani J, Penta de Peppo A, De Paulis R, et al. Partial right
internal thoracic artery harvesting is sufficient for obtuse
marginal branch bypass grafting. Ann Thorac Surg 2005;79:
3612.
19. Mangram AJ, Horan TC, Pearson ML, et al. Guideline for
prevention of surgical site infection, 1999. Hospital Infection
Control Practices Advisory Committee. Infect Control Hosp
Epidemiol 1999;20:250 78.
20. Zeitani J, Bertoldo F, Bassano C, et al. Superficial wound
dehiscence after median sternotomy: surgical treatment ver-
sus secondary wound healing. Ann Thorac Surg 2004;77:
6725.
21. Pevni D, Mohr R, Lev-Run O, et al. Influence of bilateral
skeletonized harvesting on occurrence of deep sternal
wound infection in 1,000 consecutive patients undergoing
bilateral internal thoracic artery grafting. Ann Thorac Surg
2003;237:277 80.
22. Sauvage LR, Rosenfeld JG, Roby PV, et al. Internal thoracic
artery grafts for the entire heart at a mean of 12 years. Ann
Thorac Surg 2003;75:501 4.
23. Lev-Ran O, Mohr R, Amir K, et al. Bilateral internal thoracic
artery grafting in insulin-treated diabetics: should it be
avoided? Ann Thorac Surg 1995;59:163 8.
24. De Jesus RA, Acland RD. Anatomic study of the collateral
blood supply of the sternum. Ann Thorac Surg
1995;59:163 8.