Comparison of Long-term Clinical Outcomes of Skeletonized vs Pedicled Internal Thoracic Artery Harvesting Techniques in the Arterial Revascularization Trial
Authors: Mario Gaudino, Katia Audisio, Mohamed Rahouma, David Chadow, Gianmarco Cancelli, Giovanni J. Soletti, Alastair Gray, Belinda Lees, Stephen Gerry, Umberto Benedetto, Marcus Flather, David P. Taggart, David Taggart, Stan Wos, Marek Jasinski, Marek Deja, Vipin Zamvar, Brian Buxton, Siven Seevanayagam, Peter O’Keefe, The late Andy Forsyth, Uday Trivedi, Stephen Clark, Andrzej Bochenek, Ragheb Hasan, Jatin Desai, Andy Ritchie, Chris Choong, Sukumaran Nair, Catherine Sudarshan, Alexander Cale, Tom Spyt, The late Anthony Gershlick, Jullien Gaer, Jerzy Sadowksi, Boguslaw Kapelak, Jerzy Pacholewicz, Fernando Moraes, John Pepper, Venkatachalam Chandrasekaran, Rafal Pawlaczyk, Gopi Mannam, Lokeswara Rao Sajja, Norman Briffa, Riccardo Casabona, Gugliemo Actis Dato, Walid Dihmis, Manoj Kuduvali, Lech Anisimowicz, Bruno Podesser, Naresh Trehan, ZS Meharwal, Marian Zembala, Kaz Widenka
Journal: JAMA Cardiology (2021)

<h3>Importance</h3> Recent evidence has suggested that skeletonization of the internal thoracic artery (ITA) is associated with worse clinical outcomes in patients undergoing coronary artery bypass surgery (CABG). <h3>Objective</h3> To compare the long-term clinical outcomes of skeletonized and pedicled ITA for CABG. <h3>Design, Setting, and Participants</h3> The Arterial Revascularization Trial (ART) was a 2-group, multicenter trial comparing the use of a bilateral ITA vs a single ITA for CABG at 10 years. Patients in the ART trial were stratified by ITA harvesting technique: skeletonized vs pedicled. Data were collected from June 2004 to December 2017, and data were analyzed from June to July 2021. <h3>Interventions</h3> In this analysis, the 10-year clinical outcomes were compared between patients who received skeletonized vs pedicled ITAs. <h3>Main Outcomes and Measures</h3> The primary outcome was all-cause mortality. The secondary outcomes were a composite of major adverse cardiac events (MACE) including all-cause mortality, myocardial infarction, and repeated revascularization and a composite including MACE and sternal wound complication (SWC). Cox regression and propensity score matching were used. <h3>Results</h3> Of 2161 included patients, 295 (13.7%) were female, and the median (interquartile range) age was 65.0 (58.0-70.0) years. At 10 years, the risk of all-cause mortality was not significantly different between the pedicled and skeletonized groups (hazard ratio [HR], 1.12; 95% CI, 0.92-1.36;<i>P</i> = .27). However, the long-term risks of the secondary outcomes were significantly higher in the skeletonized group compared with the pedicled group (MACE: HR, 1.25; 95% CI, 1.06-1.47;<i>P</i> = .01; MACE and SWC: HR, 1.22; 95% CI, 1.05-1.43;<i>P</i> = .01). The difference was not seen when considering only patients operated on by surgeons who enrolled 51 patients or more in the trial (MACE: HR, 1.07; 95% CI, 0.82-1.39;<i>P</i> = .62; MACE and SWC: HR, 1.04; 95% CI, 0.80-1.34;<i>P</i> = .78). <h3>Conclusions and Relevance</h3> While the long-term survival of patients was not different between groups, the rate of adverse cardiovascular events was consistently higher in the skeletonized group and the difference was associated with surgeon-related factors. Further evidence on the outcome of skeletonized ITA is needed.