Wrapping of the Left Internal Thoracic Artery With

an Expanded Polytetrafluoroethylene Membrane

Eric Bezon, MD, Yasser A. Maguid, MD, Gildas Gueret, MD, Jean N. Choplain, MD,
Ahmed A. Aziz, MD, and Jean A. Barra, MD
Department of Cardiovascular and Thoracic Surgery, C.H.U. La Cavale Blanche, Brest, France

We describe the wrapping of the proximal segment of the
left internal thoracic artery graft in a polytetrafluoroeth-
ylene membrane. Two groups of patients were compared
(99 patients with wrapping, 70 patients as controls).
There were no statistical differences between the two
groups regarding the postoperative course. Three pa-
tients in the polytetrafluoroethylene group and 2 in the
control group underwent reoperation for valve surgery.
Exposure of the wrapped graft segment for clamping was
safer and more rapid than in the control group.
(Ann Thorac Surg 2006;81:3835)
2006 by The Society of Thoracic Surgeons

W ith improved long-term results of coronary artery Results

FEATURE ARTICLES
bypass grafts and the widespread use of internal
There were no significant differences between the two
thoracic artery (ITA) grafts, a growing number of older
groups in the postoperative course (Table 2). The re-
patients are likely to require reoperative cardiac surgery
exploration for bleeding in group 1 was not related to the
in the setting of a patent ITA graft [1]. In reoperation, a
PTFE membrane that was left in place. The sternal
patent ITA graft can be severely damaged [2]. The use of
wound infections in group 1 were treated without remov-
expanded polytetrafluoroethylene (PTFE) membrane re-
ing the PTFE membrane. Three-year freedom from re-
duces adhesions [3], but authors wrapped the ITA
currence of major cardiac events was 96% in group 1 and
throughout its whole length with a long PTFE vascular
97% in group 2.
prosthesis [35]. We propose a simpler approach by
In group 1, 3 patients underwent late reoperation (2
wrapping only the first 3 cm of the ITA pedicle with a
aortic valve replacements and 1 mitral valve repair at 6
PTFE membrane in order to locate and clamp the ITA in
months, 3 years, and 3 years of follow-up, respectively).
case of reoperation
In group 2, 2 patients underwent late reoperation (aortic
valve replacements at 2 years and 3 years of follow-up).
Technique In group 1, the localization and the surgical dissec-
tion of the PTFE tube were easy (Fig 2). There were
The proximal segment of the left ITA pedicle is wrapped
slight adhesions between the PTFE membrane and the
more than 3 cm in a PTFE membrane (Preclude Pericar-
surrounding tissues, although the surgical dissection
dial Membrane [WL Gore & Associates, Flagstaff, AZ]),
was guided by the stiffness and the white surgical
sized 3 by 4 cm, just before closing the sternum (Fig 1).
aspect of the PTFE membrane. It took 10, 12, and 9
The patch is transformed in a tube with an edge-to-edge
minutes, respectively in the first, second, and third
clipping, without tightening the ITA pedicle that should
be freely mobile inside the tube. Then the PTFE tube is
fixed to the surrounding mediastinal tissue in order to
avoid further displacements. In case of bilateral ITA
grafts, we use the Y procedure (reimplantation of the
right ITA into the left in situ ITA) to avoid crossing the
midline by the right ITA. In this case, only the proximal
segment of the left ITA is wrapped, which is located
above the reimplantation of the right ITA.
From 1998 to 1999, 169 consecutive patients were di-
vided in two groups and underwent coronary artery
bypass grafts (group 1, 99 patients with wrapping; group
2, 70 patients as controls). Preoperative and intraopera-
tive characteristics (Table 1) were similar in these groups.

Accepted for publication Oct 4, 2004.

Address correspondence to Dr Bezon, Service de Chirurgie Cardiaque,

Thoracique et Vasculaire, C.H.U. La Cavale Blanche, Brest, Cedex 29609 Fig 1. Proximal wrapping of the left internal thoracic artery pedicle
France; e-mail: eric.bezon@chu-brest.fr. with a polytetrafluoroethylene membrane.

2006 by The Society of Thoracic Surgeons 0003-4975/06/$32.00

Published by Elsevier Inc doi:10.1016/j.athoracsur.2004.10.024
 384 HOW TO DO IT BEZON ET AL Ann Thorac Surg
WRAPPING OF THE LEFT ITA 2006;81:3835

Table 1. Preoperative and Intraoperative Characteristics

Group 1 Group 2
(99 Patients) (70 Patients)

Age (y) Mean SD 57 10 60 8

Female sex n (%) 23 (23%) 12 (17%)
Three vessels disease n (%) 77 (78%) 55 (79%)
Left main disease n (%) 14 (14%) 10 (14%)
Diabetes n (%) 19 (19) 16 (23)
Obesity n (%) 11 (11) 8 (11)
Euroscore Mean SD 2.7 0.7a 3.6 0.6a
CABG with one ITA n (%) 54 (54)b 8 (11)b
CABG with two ITAs n (%) 45 (45)c 62 (89)c
Combined valvular n (%) 5 (5) 2 (3)
surgery
a
p 0.05 (Students t test); b,c
p 0.05 (chi-square test).
CABG coronary artery bypass graft; group 1 patient with wrap- Fig 2. Wrapped left internal thoracic artery pedicle at the reopera-
ping of the left internal thoracic artery pedicle; group 2 patient tion (arrow).
without wrapping of the left internal thoracic artery pedicle; ITA
internal thoracic artery; SD standard deviation.
FEATURE ARTICLES

patient, after re-sternotomy, to control the wrapped territory but requires graft dissection with the risk of ITA
ITA, keeping in mind that we search the wrapped ITA injury, which could be fatal [2]. Systemic deep hypother-
before starting the dissection of the heart. The mia allows leaving the ITA unclamped [6], but deep
wrapped graft was clamped without removing the hypothermia has potential deleterious side effects [7]. We
PTFE tube, just after clamping the aorta. Then contin- have chosen to clamp the ITA to secure the retrograde
uous 20C retrograde blood cardioplegia was deliv- cardioplegia, which is a good myocardial protection in
ered. At the end of the operation, the PTFE membrane reoperation.
was left in place. The postoperative follow-up was In the reported studies, all the length of the ITA
simple in the three cases. In group 2, the dissection was pedicle was passed inside a ringed PTFE vascular
quite difficult due to the presence of severe adhesions. prosthesis before performing the distal coronary anas-
In one case the external muscular layers of the ITA wall tomoses [4, 5]. In case of bleeding with this technique,
were damaged, but fortunately without compromising the hemostasis of the ITA pedicle is impossible without
the ITA patency, which was assessed by intraoperative
removing the vascular prosthesis. It is also difficult to
Doppler. Twenty-nine minutes were required in the
eliminate twisting or kinking of the graft inside it. In
first case to control the ITA pedicle and 38 in the
our technique, proximal wrapping performed after
second case after re-sternotomy. The postoperative
protamine perfusion and safe hemostasis avoids these
follow-up was simple.
disadvantages. In addition, less synthetic material is
implanted.
Comment Our results show that the proximal wrapping does not
In case of reoperation, temporary occlusion of the ITA increase surgical risks during the primary intervention
graft reduces cardioplegia washout in the ITA grafted and allows ITA clamping without tedious ITA dissection
during the reoperation. Operative time is saved without
Table 2. Postoperative Coursea risk of ITA injury.
For economic reasons, we use the proximal
Group 1 Group 2 wrapping in patients who are younger than 60 years of
(99 Patients) (70 Patients)
age and when there is a foreseeable risk of late
Mortality n (%) 1 (1%) 2 (3%) reoperation.
Myocardial infarction n (%) 3 (3%) 2 (3%)
Use of inotropic drugs n (%) 11 (11%) 10 (14%)
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