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Pedicled or skeletonized bilateral internal mammary artery harvesting - a meta- analysis and trial sequential analysis

ABSTRACT Objective There is varying evidence on the role of skeletonization of internal mammary artery in reducing the risk of sternal wound infections and ischemia following bilateral internal mammary artery grafting. Post-operative clinical outcomes of skeletonized bilateral internal mammary artery versus pedicled bilateral internal mammary artery harvesting in patients undergoing coronary artery bypass surgery were compared. Methods A comprehensive electronic search was conducted using MEDLINE, Scopus, EMBASE, Cochrane database and Google Scholar from inception until 15 June 2020. All studies directly comparing skeletonized and pedicled bilateral internal mammary artery harvesting were included. Meta-analysis and trial sequential analysis were conducted. Results Nine studies (one randomized controlled trial and eight observational studies) consisting of 3649 patients (2050 patients with skeletonized bilateral internal mammary artery grafting and 1599 patients with pedicled bilateral internal mammary artery grafting) were included. Pooled effects analysis and trial sequential analysis reported significantly lower risk of sternal wound infection with skeletonized bilateral internal mammary artery harvesting (OR 0.27, 95% CI 0.20–0.51, p < 0.00001). Conclusions Skeletonization reduces the risk of sternal wound infections by preserving vasculature as much as possible. This facilitates its use in patients at high risk of sternal wound infection.