Simple Adaptations of Surgical Technique to Critically Reduce the Risk of Postoperative Sternal Complications in Patients Receiving Bilateral Internal Thoracic Arteries

Interact Cardiovasc Thorac Surg. 2013 Aug;17(2):378-82. doi: 10.1093/icvts/ivt089. Epub 2013 May 16.


Objectives: Limited blood supply to the thoracic chest wall is a known risk factor for sternal wound complications after CABG. Therefore, bilateral internal thoracic arteries are still rarely utilized despite their proven superior graft patency. The aim of our study was to analyse whether modification of the surgical technique is able to limit the risk of sternal wound complications in patients receiving bilateral internal thoracic artery grafting.

Methods: All 418 non-emergent CABG patients receiving bilateral internal thoracic artery CABG procedures (BITA) from January 2001 to January 2012 were analysed for sternal wound complications. Surgical technique together with known risk factors and relevant comorbidity were analysed for their effect on the occurrence of sternal wound complications by means of multivariate logistic regression analysis.

Results: Sternal wound complications occurred in 25 patients (5.9%), with a sternal dehiscence rate of 2.4% (10 patients). In multivariate analysis, diabetes (odds ratio [OR]: 4.8, 95% CI: 1.9-11.7, P=0.001), but not obesity (OR: 1.6, 95% CI: 0.7-4.2, P=0.28) or chronic obstructive pulmonary disease (OR: 2.2, 95% CI: 0.87-5.6, P=0.1) was a relevant comorbid condition for sternal complications. Skeletonization of ITA grafts (OR: 0.17, 95% CI: 0.06-0.5, P=0.001) and the augmented use of sternal wires (OR: 0.24, 95% CI: 0.06-0.95, P=0.04) were highly effective in preventing sternal complications. The use of platelet-enriched-fibrin glue (PRF) sealant, however, was associated with more superficial sternal infections (OR: 3.7, 95% CI: 1.3-10.5, P=0.02).

Conclusions: Adjusted for common risk factors, skeletonization of BITA grafts together with augmented sternal wires is effective in preventing sternal complications. The use of PRF sealant, however, increased the risk for superficial wound complications.

Keywords: Bilateral internal thoracic artery; Coronary artery bypass grafting; Sternal complications.

MeSH terms

  • Aged
  • Bone Wires / adverse effects
  • Chi-Square Distribution
  • Comorbidity
  • Diabetes Mellitus / epidemiology
  • Female
  • Fibrin Tissue Adhesive / adverse effects
  • Humans
  • Internal Mammary-Coronary Artery Anastomosis / adverse effects*
  • Logistic Models
  • Male
  • Middle Aged
  • Multivariate Analysis
  • Odds Ratio
  • Postoperative Complications / prevention & control*
  • Risk Factors
  • Sternotomy / adverse effects*
  • Sternotomy / instrumentation
  • Surgical Wound Dehiscence
  • Surgical Wound Infection / prevention & control
  • Treatment Outcome


  • Fibrin Tissue Adhesive