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Free-flap reconstruction for recurrence of head-and-neck cancer with vessel depletion is a technical challenge, and the literature is sparse. The present technical note describes the key-points of an approach harvesting the internal mammary pedicle. Results are reported in 3 patients, and pros and cons are discussed., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

Background: Current consensus has established the internal mammary vessels (IMV) over the thoracodorsal vessels (TDV) as the preferred recipients for microvascular breast reconstruction due to their superior flow rates and long-established outcomes. Yet, there are occurrences where the IMVs are not reliable and may subsequently prompt intraoperative decision-making. Several options exist, including the contralateral IMVs, thoracoacromial vessels, and TDVs. The appropriate sequence for vessel choice is not universally agreed upon. This study reevaluates the TDVs to highlight their viability as a second-line intraoperative alternative to the IMV and provide reference to the straightforward dissection required for harvest., Methods: A retrospective, single-institution, breast-level analysis examining 4754 breast free flaps from 2978 patients undergoing bilateral free flap reconstruction was conducted. Postoperative complications within 180 days were evaluated, and cohorts based on anatomic anastomosis (IMV vs. TDV) were created to compare outcomes. Subanalysis was conducted based on flap laterality as well as whether a flap was planned or converted intraoperatively., Results: Of 4754 breast free flaps, 4269 (89.8%) used the IMV while 485 (10.2%) used the TDV. Most complication rates between the TVD and IMV were not significantly different. Rates of flap loss were 1.0% and 1.2% for the IMV and TDV anastomosis (p = 0.59). IMV and TDV anastomosed flaps experienced similar rates of fat necrosis (6.3% vs. 6.2%, p = 0.915). However, multivariable analysis of all breasts regardless of laterality showed that skin necrosis was significantly less likely in TDV breasts (OR 0.45, 95% CI 0.29-0.71, p < 0.001)., Conclusions: Given the relative similarity in cohort outcomes, TDV anastomosis can be considered a viable alternative to the IMV when the IMV is unavailable or technically disadvantageous. The TDV artery remains a robust and reliable option in the present-day plastic surgeon's repertoire for breast reconstruction., (© 2024 The Author(s). Microsurgery published by Wiley Periodicals LLC.)

Objective: The effect of one-inflow and two-inflow coronary surgical revascularization techniques inclosing skeletonized double mammary artery (BIMA) as T-graft on outcome is studied., Methods: Early ad mid-term outcome of complete BIMA revascularization (C-T-BIMA) versus left-sided BIMA with right-sided aorto-coronary bypass (L-T-BIMA + R-CABG) is quantified and analyzed by multivariate logistic regression, Cox-regression, and Kaplan-Meier analysis in a series of 204 consecutive patients treated for triple-vessel coronary disease (3v-CAD)., Results: The L-T-BIMA + R-CABG technique (n = 104) enables higher number of total (4.02 ± 0.87 vs. 3.71 ± 0.69, p = 0.015) and right-sided (1.21 ± 0.43 vs. 1.02 ± 0.32, p = 0.001) coronary anastomoses, improves total bypass flow (125.88 ± 92.41 vs. 82.50 ± 49.26 ml, p < 0.0001) and bypass flow/anastomosis (31.83 ± 23.9 vs.22.77 ± 14.23, p = 0.001), and enhances completeness of revascularization (84% vs.69%, p = 0.014) compared to C-T-BIMA strategy (n = 100), respectively. Although the incidence of MACCE was comparable in the two groups (8% vs.1.2%, p = 0.055), the progression of functional mitral regurgitation (FMR) was significantly lower after L-T-BIMA + R-CABG, then after C-T-BIMA (47% vs.64%, p = 0.017). The use of C-T-BIMA-technique (HR = 4.2, p = 0.01) and preoperative RCA occlusion (HR = 3.006, p = 0.023) predicted FMR progression, whereas L-T-Graft + R-CABG technique protected against it (X 2  = 14.04, p < 0.0001) independent of the anatomic and clinical complexity (Syntax score I: HR = 16.2, p = 0.156, Syntax score II: HR = 1.901, p = 0.751), of early- (0.96% vs.2%, p = 0.617) and mid-term mortality (5.8% vs.4%, p = 0.748) when compared to C-T-BIMA, respectively., Conclusions: The two-inflow coronary revascularization by L-T-BIMA + R-CABG better protects against FMR progression without increasing MACCE and mortality. Older patients with RCA occlusion and reduced LV-EF benefit most from the two-inflow L-T-BIMA + R-CABG technique. Younger 3v-CAD patients with normal LV-EF can preferentially be managed with the one-inflow C-T-BIMA; however, long-term outcome remains to be revealed., (© 2024. The Author(s).)

Background: Coronary artery bypass grafting (CABG) surgery is a common procedure for managing multi-vessel coronary artery disease to revascularize the myocardium. Among the various conduits used, the left internal mammary artery (LIMA) is preferred due to its better long-term patency rate. However, CABG procedures involving LIMA may result in rare but serious complications, such as avulsion of the LIMA post-CABG, which leads to disruption of blood flow to the myocardium and the development of fatal cardiac tamponade., Case Presentation: We hereby present a unique case of spontaneous avulsion of a LIMA graft to the left anterior descending artery (LAD) away from the site of anastomosis, twenty-four hours following CABG surgery in a 67-year-old male patient. Emergency re-exploration and repair of the LIMA with interposition vein graft were performed and resulted in successful stabilization of the patient's critical condition. However, this was followed by a complicated recovery period involving atrial fibrillation, acute kidney injury, and wound infection., Conclusion: Avulsion of LIMA graft following CABG is rare, yet a fatal complication that requires high clinical suspicion and prompt management. Avulsion has been reported a few times in literature following both minimal invasive and conventional CABG. Understanding the etiology, clinical presentation, and management of this complication is crucial to avoid catastrophic outcomes., (© 2024. The Author(s).)

Background: Subclavian artery stenosis (SAS) occurs in 6% of patients undergoing coronary artery bypass grafting (CABG). Complications such as subclavian-coronary steal are common. Revascularization options in such cases remain debatable., Methods: In this case series, all patients with angina, had severe triple vessel disease on angiography. All tests including computed tomography (CT) angiography of neck vessels, were done as part of routine workup for CABG., Results: The patients, all males, had a mean age of 66.5 years with three of them having hypertension and diabetes. All were ex-smokers with mean ejection fraction (EF) of 60.1%. CT angiography of neck vessels revealed that two patients had moderate to severe while one had severe left SAS and another had severe proximal left internal mammary artery (LIMA) stenosis. Total arterial revascularization was performed, with an average of 3.5 distal grafts. The LIMA graft was employed in a Y graft configuration, anastomosed to in-situ right internal mammary artery (RIMA). All patients had uneventful postoperative stay and were discharged with a mean hospital stay of 3.8 days. There were no postoperative strokes, myocardial infarction, neurological symptoms, or change in EF. At 6-month follow-up, they were asymptomatic and doing well., Conclusion: The RIMA-LIMA-Y configuration can be a safe, viable option in CABG for patients with left SAS. It is challenging, with re-entry and judicious utilization of the length of LIMA being of paramount importance. The importance of CT angiography of neck vessels to detect SAS cannot be under-emphasized., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The internal mammary artery perforator (IMAP) flap has been widely used for chest wall and neck reconstruction. The color of its skin paddle closely resembles that of facial skin, making it attractive for facial reconstruction. However, there has been insufficient investigations reporting the use of free IMAP flap. Furthermore, even in such studies, somewhat invasive procedures, including rib cartilage resection, were employed to ensure sufficient pedicle length, potentially increasing donor morbidity. Our report presents two cases of successful facial defect reconstruction using a free IMAP flap harvested with minimal donor site damage, showing its feasibility. In the first case, a 48-year-old male underwent wide excision for a malignant melanoma on his right cheek, resulting in a 4 × 4.5 cm full-thickness defect. A free IMAP flap with a 2.5 cm pedicle, was harvested without rib cartilage resection, preserving IMA main trunk, and transferred with anastomosed to the angular vessels within the defect. The second patient presented with a 4.5 × 3.5 cm basal cell carcinoma on the left cheek, necessitating wide excision and leaving a 6 × 5 cm defect. A free IMAP flap was harvested with the same approach and successfully reconstructed the defect with connected to the superficial temporal vessels using vascular bridge. Both patients were discharged complication-free, with no recurrence during 24 and 15 months of follow-up, respectively. They were highly satisfied with the final skin color and texture outcomes. Harvesting a free IMAP flap while minimizing donor morbidity may offer an attractive option for facial reconstruction., (© 2024 Wiley Periodicals LLC.)

Background:  Composite T-grafts between left internal mammary artery (LIMA) and radial artery (RA) are a common concept in complete arterial myocardial revascularization. The aim of the present study was to investigate whether the use of the great saphenous vein (SV) instead of RA leads to comparably good results in terms of outcome in this context., Methods:  Patients who underwent myocardial revascularization with a T-graft using RA or a segment of SV to the right coronary artery or circumflex artery between the beginning of 2014 and the end of 2019 at the Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Campus Kiel were included. To minimize surgical variation, only patients were observed by a single senior surgeon in the department. Exclusion criteria were previous cardiac surgery, preoperative extracorporeal circulatory support, off-pump surgery, additional aortocoronary bypasses, and cardiac combination procedures., Results:  A total of 115 patients were studied. In 55 patients, the T-graft was placed between the LIMA and SV, and in 60 patients, the T-graft was placed between the LIMA and RA. Patients in the SV group were older (70.6 ± 7.8 vs. 58.5 ± 10.0 years; p  < 0.001), suffered more frequently from non-ST elevation myocardial infarction (12.7 vs. 1.7%; p  = 0.027), arterial hypertension (83.6 vs. 61.7%; p  = 0.009), and atrial fibrillation (18.2 vs. 1.7%; p  = 0.003). They were less likely to be active smokers (16.4 vs. 38.3%; p  = 0.009) and less likely to have a history of variceal surgery (0 vs. 15.0%; p  = 0.003). Calcification of the ascending aorta was also found more frequently in the saphenous group (18.2 vs. 3.3%, p  = 0.009). Operative times and number of distal anastomoses did not differ significantly between the two groups. Postoperative deliriums (16.7 vs. 5.0%; p  = 0.043) were observed more frequently in venous patients. Wound healing disorders of the leg (11.1 vs. 0%; p  = 0.011) did only occur in SV group and wound infections of the arm only in the RA group. Complete follow-up was achieved in 74.8% of cases. Median follow-up was 60.3 (39.6; 73.2) months. Serious adverse cardiac-cerebral events (19.0 vs. 22.7%; p  = 0.675) and mortality (14.5 vs. 6.7%; p  = 0.167) did not differ significantly between the groups at follow-up. Myocardial infarction (0 vs. 2.5%; p  = 1.000) and stroke (0 vs. 7.5%; p  = 0.245) were observed exclusively in RA group. Percutaneous coronary intervention was required in single patients of RA group (0 vs. 15.0%; p  = 0.028). No patient from either group underwent repeat coronary artery bypass grafting (CABG). The patients of SV group had angiographically competent grafts and open anastomoses. Graft failure was noted in a single patient in RA group, in which case both grafts and native coronary vessels were stented. Kaplan-Meier analysis revealed no significant survival disadvantage for SV group compared with RA group., Conclusion:  CABG with a composite T-graft between LIMA and a segment of SV may be comparable to bypass surgery with a composite T-graft between LIMA and RA. This might be true in terms of morbidity and mortality over an intermediate-term observation period. The results of our studies give rise to the hypothesis that the decision not to perform aortic bypass anastomosis may be more important than the choice of graft material., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: In breast reconstruction, arterial coupling has been reported to be more favorable in the thoracodorsal artery (TDA) than the internal mammary artery (IMA). This technique may help overcome anastomosis in a small, deep space. Understanding the arteries' mechanical properties is crucial for breast reconstruction's safety and success., Methods: Abdominal-based free flap breast reconstructions performed by a single surgeon between 2020 and 2022 were retrospectively analyzed. The patients were classified by microanastomosis technique (handsewn and coupler device) to compare the rate of vascular revision. Histomorphometric analysis of arterial coupling in TDA and IMA was performed in 10 fresh cadavers for comparing wall thickness and composition, including densities of elastic fiber, smooth muscle, and collagen., Results: A total of 309 patients (339 reconstructed breasts) were included. There were 29 patients in the TDA handsewn group (A), 38 patients in the TDA coupler group (B), and 242 patients in the IMA handsewn group (C). The rates of arterial revision in groups A, B, and C were 0.00% (95%CI: 0.00%-11.03%), 2.5% (95%CI: 0.44%-12.88%), and 1.49% (95%CI: 0.58%-3.77%), respectively, with no statistically significant differences (p-value = .694). Histologically, the thickness of the tunica media and adventitia between IMA and TDA showed no significant difference. The density of elastic fiber was significantly higher in IMA (16.70%) than in TDA (0.79%) (p-value <.001)., Conclusion: The histologic characteristics of TDA are more favorable for arterial coupling than those of IMA. Arterial coupling is a safe option in situations where TDA anastomosis must be performed through a narrow and deep incision., (© 2024 Wiley Periodicals LLC.)

This study aims to evaluate the functional and prognostic outcomes associated with the internal mammary artery perforator (IMAP) flap in various head and neck defect repairs, given the current lack of clarity on its effectiveness. We performed a systematic review of various databases: PubMed, Embase, Scopus, Web of Science, and ScienceDirect using keywords such as "Internal mammary artery perforator flap" and "IMAP." Screening and data extractions were performed by two individual reviewers. Articles were considered eligible if they included sufficient information on IMAP flap features, their applications in the head and neck, and outcomes. From 264 articles analyzed, 24 studies were included for qualitative analysis. Out of which, 125 patients who received internal mammary artery perforator flaps were included. Most of the patients, 103 (88%), received pedicled IMAP flaps, and 22 (12%) received IMAP free flaps. The second internal mammary artery (IMA) was favored as the single perforator (81.5%), with the combination of the first and second IMA being the primary choice for dual perforators (92.5%). IMAP flaps were predominantly single perforator flaps (65%), with 35% being dual perforator flaps. Among various applications, IMAP flaps are commonly employed in the reconstruction of neck defects (25.5%), pharyngocutaneous fistula repair (20.8%), and burn scar contracture restoration (8%). Only seven (5.6%) patients had flap complications, including venous congestion (1.6%), partial necrosis (1.6%), complete necrosis (1.6%), and incision dehiscence (0.8%). Donor sites were predominantly closed by the primary closure (92%). 3.2% of donor sites had minor complications. The average follow-up was 12.6 (IQR: 6-18) months. This systematic review highlights the effectiveness and safety of IMAP flaps in head and neck reconstruction, with positive outcomes and minimal complications., (© 2024 Wiley Periodicals LLC.)

Background: An anomalous origin and inter-arterial course of the right coronary artery is a rare anomaly that can lead to sudden ischemic cardiac death if left untreated. We present a case of a patient with an anomalous right coronary artery originating from the left coronary sinus and an inter-arterial course that was managed with coronary artery bypass surgery using a suitable internal mammary artery conduit. The proximal right coronary artery was ligated to prevent competitive flow., Case Presentation: A 69 year-old-male with a ten-year history of intermittent chest pain and dyspnea with a negative workup underwent a cardiac catheterization, which showed an anomalous right coronary artery (RCA) originating from the left coronary sinus, with an inter-arterial course between the ascending aorta and pulmonary artery, and approximately 70% narrowing of the proximal RCA. The patient underwent an on-pump coronary artery bypass using the right internal mammary artery (RIMA) as a conduit, with segment 2 of the RCA being the target. The proximal RCA was ligated. Intra-operatively, there were no signs of ischemia or arrhythmia. The patient was successfully taken off cardiopulmonary bypass and eventually discharged home., Conclusion: Symptomatic anomalous origin of the right coronary artery with an inter-arterial course can be treated successfully with coronary artery bypass surgery with the internal mammary artery as a conduit. Ligation of the proximal right coronary artery is essential to minimize competitive flow through the bypass graft., (© 2024. The Author(s).)

Background: The advent of propeller flaps has permitted new and less invasive coverage solutions for thoracic defects compared to conventional flaps. Through a retrospective analysis of our cases, we would like to show the advantages of the internal mammary artery perforator (IMAP) flap for anterior chest wall reconstruction., Methods: We included patients who underwent anterior chest wall reconstruction with an IMAP propeller flap in the Toulouse University Hospital's plastic surgery department from January 2019 to December 2022. The data were collected on patient data, skin defects, and flap characteristics., Results: Twenty-three IMAP flaps were realized to cover locoregional defects. The skin paddle size of the IMAP flap averaged 15.6cm long (12-20)×6.7cm wide (4-10). The average arc of rotation of the flap was 113.5° (range 70-140°). In 3 cases, the IMAP flap was performed with a superior epigastric artery perforator flap (SEAP). In 3 cases out of 23, the flap partially necrotized, requiring surgical revision. In 1 case, the flap was fully necrotized and had to be removed., Discussion and Conclusion: Our series of 23 IMAP flaps on thoracic reconstruction is one of the largest published to date. Our series shows that the IMAP flap offers a simple and reliable solution with minor donor site morbidity for reconstructing small to medium-sized defects in the medial and paramedian regions of the chest wall., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

The internal mammary artery perforator (IMAP) flap is an evolution of the deltopectoral flap that is harvested based upon a single perforator from the internal mammary artery. Its favorable characteristics include pliability as a fasciocutaneous flap, ease of harvest, and minimal donor site morbidity. In this paper, we report our harvest technique and the versatility of the IMAP flap for pharyngoesophageal, cervical tracheal, and cutaneous neck defects. We seek to highlight the IMAP as a useful regional reconstructive option in both the primary and salvage reconstructive setting. As such, this flap is an important option in the head and neck reconstructive surgeon's armamentarium., (© 2024 Wiley Periodicals LLC.)

Tracheoesophageal fistulas (TOF) following esophagectomy for esophageal cancer are rare but potentially fatal. There is no consensus on treatment between stenting and surgical repair, although the latter is associated with better distant survival. In surgical repair, the interposition of a flap improves healing by providing well-vascularized tissue and reinforcing the repair zone. The flaps described are usually muscular and decaying. We present the case of a malnourished fifty-year-old man who underwent intrathoracic surgical repair of symptomatic recurrent TOF using a skin flap based on the perforators of the internal thoracic artery (IMAP). The perforator flap was completely de-epidermized and tunneled under the sternum by a proximal and limited resection of the 3rd costal cartilage and placed at the posterior aspect of the trachea, with the excess tissue rolled up on either side. At 9 months, the patient showed no recurrence and improved general condition. The de-epidermized IMAP tunneled under the sternum intrathoracically is a reliable alternative to the conventional muscle flaps described in TOF management and an attractive additional tool in the plastic surgeon's surgical arsenal., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

Background: A pathological communication between the trachea and oesophagus - a tracheoesophageal fistula - may be congenital or acquired, benign or malignant, necessitating a multidisciplinary approach. Conservative attempts at closure of this abnormal connection are ineffective; the interposition of healthy vascular tissue offers the least chance of recurrence., Methods: Outcomes of an islanded fasciocutaneous internal mammary artery perforator flap applied for tracheoesophageal fistula management were assessed in four radiated patients with laryngeal carcinoma using retrospective records., Results: Four male patients, with an average age of 60.75 years, underwent tracheoesophageal fistula closure between September 2017 and February 2021. A left-sided second internal mammary artery perforator flap was used in all cases, with an average dimension of 10.5 × 4.5 cm. There were no complications of tracheoesophageal leak, flap issues or donor site morbidity on follow up., Conclusion: Recent advances in angiosomal territory mapping and microvascular dissection techniques, combined with an understanding of tracheoesophageal fistula pathology, have changed management perspectives in these difficult-to-treat patients.

Postpneumonectomy changes, including ipsilateral diaphragmatic elevation and rib crowding, mediastinal shifting of the heart and reduction of respiratory functional reserve by 45%-55%, make cardiac surgery challenging in terms of access to the heart and great vessels. There is a paucity of literature on coronary artery bypass graft (CABG) surgery in patients with a history of pneumonectomy. We report a case of a male in his 70s with a history of left pneumonectomy who underwent a successful on-pump CABG surgery using the left internal mammary artery graft and great saphenous vein graft. The patient was extubated postoperatively and discharged in a stable condition. With no consensus available for optimal preoperative, intraoperative and postoperative management for these high-risk patients, our case report adds to the rare literature regarding successful on-pump CABG after pneumonectomy., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: It is uncertain if the long-term biological behavior of the radial artery as a conduit for coronary bypass surgery has a similar resistance to the development of atherosclerosis as for the internal mammary artery. We aimed to examine long-term angiographic patency and disease-free patency (perfect patency) for internal mammary artery, radial artery, and saphenous vein grafts., Methods: A retrospective, single-center, individual patient cohort study of angiographic observations from patients' latest postoperative angiogram from 1997 to 2020 was performed. Analysis was per anastomosis and assessed for patency and perfect patency. A generalized linear mixed model premised upon logistic regression was used to minimize confounding bias., Results: A total of 983 patients with 3064 grafts were included, with a median follow-up of 8.6 (interquartile range, 4.4-12.6) years after the operation. Multivariable analysis revealed differences for radial (patency, 86.9%; perfect patency, 86.4%) and internal mammary artery (patency, 93.9%; perfect patency, 93.5%) versus saphenous vein graft (patency, 72.8%; perfect patency, 46.2%). There were no differences between the 2 arterial conduits for patency (odds ratio, 1.40; 95% CI, 0.85-2.33; P = .189) and perfect patency (odds ratio, 1.14; 95% CI, 0.71-1.84; P = .578). If a conduit was patent, then 99.4% of radial artery, 99.6% of internal mammary artery, and 63.5% of saphenous vein graft were reported as perfectly patent., Conclusions: Radial artery and internal mammary artery had similar patency and perfect patency while both were superior to saphenous vein graft., (Crown Copyright © 2022. Published by Elsevier Inc. All rights reserved.)

Background: Negative pressure wound therapy (NPWT) is traditionally used to treat postoperative wound infections. However, its use in closed wound sternotomy post cardiac surgery in high-risk patients has become increasingly popular. The potential preventive benefit of reducing sternal wound infections has been recently acknowledged. Bilateral internal mammary artery (BIMA) grafts are used in coronary artery bypass grafting but have been associated with an increased risk of sternal wound infections (SWIs)., Objectives: This systematic analysis examines whether NPWT can reduce the incidence of SWI following BIMA grafts, leading to more patients benefiting from the better survival outcome associated with BIMA grafting., Method: A comprehensive systematic search and meta-analysis were performed to identify studies on the use of NPWT in closed wound sternotomy. Ovid MEDLINE (in-process and other nonindexed citations and Ovid MEDLINE 1990 to present), Ovid EMBASE (1990 to present), and The Cochrane Library (Wiley), PubMed, and Google Scholar databases were searched from their inception to May 2022 using keywords and MeSH terms. Thirty-four articles from 1991 to May 2022 were selected., Result: Three studies reported on the outcome of NPWT following BIMA grafting. The pooled analysis did not show any significant difference in the incidence of sternal wound infection between NPWT and standard dressing (RR 0.48 95% CI 0.17-1.37; P = 0.17) with substantial heterogeneity (I 2  65%). Another seven studies were found comparing the outcome of SWI incidence of negative pressure closed wound therapy with conventional wound therapy in patients undergoing adult cardiac surgery. The pooled analysis showed that NPWT was associated with a low risk of SWIs compared to conventional dressing (RR 0.47 95% CI 0.36-0.59; P < 0.00001), with low heterogeneity (I 2  1%)., Conclusion: The literature identified that NPWT significantly decreased the incidence of sternal wound complications when applied to sutured sternotomy incisions in high-risk patients, and in some cases, it eliminated the risk. However, the inadequate number of randomized controlled trials assessing the effectiveness of NPWT in BIMA grafting emphasizes the need for further, robust studies., (© 2024. The Author(s).)

Purpose: To compare the outcomes of left circumflex artery (LCx) revascularization using an internal thoracic artery (ITA) or radial artery (RA) as the second arterial graft., Methods: Patients who underwent primary isolated coronary artery bypass grafting with left anterior descending artery revascularization using an ITA and LCx revascularization using another bilateral ITA (BITA group) or an RA (ITA-RA group) were included. All-cause mortality (primary endpoint), cardiac death, major adverse cardiac events, in-hospital death, and deep sternal wound infection (secondary endpoints) were evaluated., Results: Among 790 patients (BITA, n = 548 (69%); ITA-RA, n = 242 (31%)), no significant difference in all-cause mortality between the groups was observed (hazard ratio (HR): 0.87; 95% confidence interval (CI): 0.67-1.12; p = 0.27) during follow-up (mean, 10 years). Multivariate analysis revealed that the BITA group exhibited significantly lower rates of long-term all-cause mortality (HR: 0.63; 95% CI: 0.48-0.84; p = 0.01). In the propensity-matched cohort (n = 480, 240 pairs), significantly fewer all-cause deaths occurred in the BITA group (HR: 0.66; 95% CI 0.47-0.93; p = 0.02). There were no significant differences in secondary outcomes., Conclusions: When used as second grafts for LCx revascularization, ITA grafts may surpass RA grafts in reducing all-cause mortality 10 years postoperatively.

Background: The selection of reliable recipient vessels is essential for successful free tissue transfer. The use of internal mammary intercostal perforators (IMAPs), instead of the internal mammary vessels as the recipient vessels, has been described in breast reconstruction. Debates exist regarding the reliability of these perforators as recipient vessels because of their variability in location and caliber. The aim of this paper was to conduct a systematic literature review and meta-analysis to determine the reliability of the IMAPs as recipient vessels., Methods: A systematic literature review was performed on the "PubMed," "Medline," "Ovid," and "Cochrane library" databases for articles published from January 1990 to March 2021. Exclusion criteria were non-English studies, reports with case number less than 5, cadaveric or animal studies, and studies with incomplete postoperative outcomes. The reliability of using IMAPs for breast reconstruction was determined by assessing the reported rates of partial or complete flap failure and other complications (fat necrosis, skin necrosis, and requirement for revision surgery)., Results: Three hundred and sixteen cases in 13 studies were included for further analysis with more than 85% of the IMAPs suitable for anastomosis being located in the second and third intercostal spaces. Partial or total flap failure was reported in three of 316 patients (0.95%). The rate of other complications such as fat necrosis, skin necrosis, and requirement for revision surgery were all less than 5%., Conclusion: With deliberate preoperative planning, delicate perioperative manipulation, and meticulous microvascular anastomosis, the internal mammary perforators can be used as reliable recipient vessels in microvascular breast reconstruction., (© 2023 Wiley Periodicals LLC.)

Background: To maximize arterial grafts, left internal mammary (LIMA) sequential and Y grafts are used. The aim is to compare the angiographic patency of the LIMA in these configurations., Methods: Between 2002 and 2020, angiography was performed on 1000 patients who either had a single (570), sequential (100), or LIMA y (129) graft. The LIMA was divided into segments (S); S1: LIMA inflow to the first anastomosis, S2: terminal portion of the LIMA to left anterior descending (LAD), and S3; the y-limb anastomosis to a coronary. S1 and S2 patency analysis was carried out with logistic regression., Results: Failure of the S1 and S2 was 3.7% single, 9% sequential, and 6.2 Y graft (P = .049). Segment 1 failed in 3.7% in single, 5% in sequential, and 0.8% in Y grafts (P = .049). Segment 3 failure was 10.3%. Regression revealed female sex and sequential grafts were associated with decreased S1 and S2 patency., Conclusions: Single grafts have the best patency. Failure in sequential grafts leads to increased occlusion of the LIMA inflow, whereas Y-graft failure tends to occlude the y limb. When arterial conduit is sparse, a Y graft should be considered., (Crown Copyright © 2022. Published by Elsevier Inc. All rights reserved.)

Objectives: We explored the current evidence on the best second conduit in coronary surgery carrying out a double meta-analysis of propensity score matched or adjusted studies comparing bilateral internal thoracic artery (BITA) versus single internal thoracic artery plus radial artery., Methods: PubMed, Embase, and Google Scholar were searched for propensity score matched or adjusted studies comparing BITA versus single internal thoracic artery plus radial artery. The end point was long-term mortality. Two statistical approaches were used: the generic inverse variance method and the pooled meta-analysis of Kaplan-Meier-derived individual patient data., Results: Twelve matched populations comparing 6450 patients with BITA versus 9428 patients with single internal thoracic artery plus radial artery were included in our meta-analysis. The generic inverse variance method showed a statistically significant survival benefit of the BITA group (hazard ratio, 0.84; 95% CI, 0.74-0.95; P = .04). The Kaplan-Meier estimates of survival at 1, 5, 10, and 15 years of the BITA group were 97.0%, 91.3%, 80.0%, and 68.0%, respectively. The Kaplan-Meier estimates of survival at 1, 5, 10, and 15 years of the single internal thoracic artery plus radial artery group were 97.3%, 91.5%, 79.9%, and 63.9%, respectively. The Kaplan-Meier-derived individual patient data meta-analysis applied to very long follow-up time data, showed that BITA provided a survival benefit after 10 years from surgery (hazard ratio, 0.77; 95% CI, 0.63-0.94; P = .01). No differences in terms of survival between the 2 groups were detected when the analysis was focused on the first 10 years of follow-up (hazard ratio, 0.99; 95% CI, 0.91-1.09; P = .93)., Conclusions: The present meta-analysis suggests that double internal thoracic artery may provide, compared with single internal thoracic artery plus radial artery, a statistically significant survival advantage after 10 years of follow-up, but not before. VIDEO ABSTRACT., (Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

The internal mammary artery has become the primary conduit for the surgical revascularisation of the left anterior descending artery. Large side branches of internal mammary artery are typically ligated during cardiac surgery to avoid a potential coronary steal phenomenon. However, ligation of side branches can be unsuccessful due to the technically difficult surgical exploration of internal mammary artery branches. In this article, we present a case of a man who suffered from exertion angina pectoris despite successful surgical revascularisation of occluded left anterior descending artery by the internal mammary artery bypass. The coronary steal syndrome caused by the mighty side branch of internal mammary artery, that is, lateral costal artery was concluded as the reason of exertional angina. The endovascular procedure was performed and the lateral costal artery was successfully occluded using vascular plug. The occlusion of lateral costal artery has led to a complete disappearance of the exertional angina., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Perivascular adipose tissue (PVAT) surrounding human internal mammary artery (IMA) possesses anticontractile property. Its function under pathological conditions is barely studied. We previously reported that homocysteine impairs the vasodilator function of IMA through endothelium and smooth muscle-dependent mechanisms. This study investigated the effect of homocysteine on the function of PVAT and the associated mechanisms., Methods: Residual IMA tissues were collected from patients undergoing coronary artery bypass grafting. Vasoreactivity was studied using myograph. Adiponectin was measured by ELISA. Expressions of adiponectin receptors (AdipoRs), eNOS and p-eNOS were determined by RT-qPCR and Western blot., Results: Exposure to homocysteine augmented the contractile responses of PVAT-intact IMA to U46619 and potassium chloride, regardless with or without endothelium. Such augmentation was also observed in skeletonized IMA with transferred, homocysteine-exposed PVAT. Homocysteine attenuated the relaxant response of PVAT-intact while endothelium-denuded vessels to acetylcholine. Homocysteine lowered adiponectin content in the PVAT, downregulated the expression of AdipoR1 and AdipoR2 as well as eNOS and p-eNOS in skeletonized IMA. The relaxant response of skeletonized IMA to AdipoR agonist AdipoRon was blunted by homocysteine or eNOS inhibitor, and homocysteine significantly attenuated the inhibitory effect of eNOS inhibitor on AdipoRon-induced relaxation., Conclusions: Homocysteine impairs the anticontractile/vasorelaxing activity of PVAT surrounding the IMA through inhibiting adiponectin/AdipoR/eNOS/nitric oxide signalling pathway., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Surgical approaches of minimally invasive direct coronary artery bypass and left atrial appendage exclusion are different, and issues may arise in cases of concomitant surgery. Moreover, the safety of concomitant procedures has not been established. A man in his 80s with a history of stroke required minimally invasive coronary artery bypass grafting and left atrial appendage closure for the stenosis of the left anterior descending artery and atrial fibrillation. He suffered from bladder bleeding, which required early reduction of anticoagulant and antiplatelet medication. Therefore, he wished for surgical treatment. A lateral incision was necessary for left atrial appendage closure in minimally invasive surgery. We performed totally endoscopic harvest of the internal thoracic artery without a robotic system. This method allowed the incision to be made more laterally. Combining the endoscopic harvest of the internal mammary artery with left atrial appendage closure via lateral incision may be a reasonable technique., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Data on bilateral internal mammary artery (BIMA) versus single internal mammary artery (SIMA) on diabetics were analyzed; This is the only meta-analysis, the last 7 years., Methods: Medline through PubMed/EMBASE/CINHAL and the Cochrane Central Register of Controlled Trials; 179 articles were studied; 19 studies deemed suitable and were included in the analysis., Results: The mortality was 2.41% for BIMA versus 1.71% for SIMA (odds ratio [OR] =  0.95; 95% confidence interval [CI]: 0.74-1.22). Postoperative reopening for bleeding was higher at 3.75% for BIMA versus 2.91% for SIMA (OR =  1.49; 95% CI: 1.15-1.93). The incidence of MI was 0.87% for BIMA versus 0.83% for SIMA (OR =  0.73; 95% CI: 0.37-1.44). Deep sternal wound infection was 3.02% for BIMA and 1.95% for SIMA (OR =  1.57; 95% CI: 1.26-1.95). When skeletonized, the incidence of DSWI was 2.5% for BIMA versus 2.41% for SIMA. There was a significant difference at 5-year survival favoring the BIMA, 85.15% BIMA versus 80.77% SIMA (OR =  1.79; 95% CI: 1.60-2.01). The 10-year overall survival was 74.04% BIMA versus 61.57% SIMA (OR =  1.79; 95% CI: 1.61-1.98). The 15-year survival was 47.08% for BIMA versus 37.06% for SIMA (OR =  1.69; 95% CI: 1.52-1.88)., Conclusions: Postoperative bleeding was higher in BIMA group. Bilateral internal mammary artery in diabetic patients should be carried out in a skeletonize fashion, to reduce DSWI. There is a survival benefit of using BIMA in diabetics within 5 years of surgery; it remains significant up to 15 years., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Competing Interests: Funding Support and Author Disclosures Dr Allana has received consulting fees from Boston Scientific and Abiomed. Dr Brilakis has received consulting/speaker honoraria from Abbott Vascular, the American Heart Association (associate editor Circulation), Amgen, Asahi Intecc, Biotronik, Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), CSI, Elsevier, GE Healthcare, IMDS, Medicure, Medtronic, Siemens, and Teleflex; has received research support from Boston Scientific and GE Healthcare; is an owner of Hippocrates LLC; and is a shareholder of MHI Ventures, Cleerly Health, and Stallion Medical.

Background: The use of internal mammary perforator (IMP) vessels as recipients for free flap breast reconstruction was first described in 1999. Despite numerous advantages over the internal mammary (IM) and thoracodorsal recipient vessels, their widespread use remains mired in concern. This paper describes our method of IMP vessel preparation and outcomes with regard to safety and reliability., Methods: To support the reliability of the IMP vessel preparation, a retrospective study on prospectively collected data of all free flap breast reconstruction patients between 1 July 2016 and 31 July 2019 was performed. Data were collected on patient demographics, type of reconstruction operative details and complications., Results: Out of the 450 flaps performed, the IMP vessels were used in 36% of the cases. Of these cases, 18% had received neo-adjuvant chemotherapy and 15% had a history of radiotherapy to the chest wall. In total, 161 flaps were performed to reconstruct 138 breasts (115 single and 23 stacked flaps). Three patients required a return to theatre, with one needing recipient vessel revision from the IMP to the IM vessels due to calibre mismatch. No mastectomy skin flap necrosis, free flap loss or significant fat necrosis were encountered., Conclusion: This article describes an IM vessel preparation method that results in predictable outcomes in both single and stacked flap reconstructions with a low complication rate. Due to their reliability and versatility, we consider the IMP vessels a valuable attribute to the recipient vessel arsenal of any breast reconstruction microsurgeon., Competing Interests: Declaration of Competing Interest The authors have no conflict of interest to declare., (Copyright © 2023 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: In autologous tissue breast reconstruction, recipient vessels are important for artery perfusion and venous drainage to ensure free flap survival. There are insufficient clinical outcomes to select efficient recipient vessels in bi-pedicled deep inferior epigastric perforator (DIEP) flap reconstruction., Methods: We presented a retrospective observational series of 108 patients regarding the diameter, anastomosis time, and re-anastomosis rate in internal mammary (IM), circumflex scapular (CS), thoracodorsal (TD), thoracoacromial (TA), lateral thoracic (LT), and internal mammary perforator (IMP) vessels of bi-pedicled DIEP flaps for breast reconstruction after mastectomy. The outcomes were the vessel re-anastomosis rate, flap failure rate, vessel anastomosis time, and complications. Data were gleaned from the chi-square test, Fisher's test, and analysis of variance using Scheffe's test as a post hoc analysis. The level of significance was p < 0.05., Results: There were no significant differences in the diameters of the artery, first vein, and second vein across the recipient vessels (p > 0.05). However, the anastomosis time was longer in IM and TA than in CS, TD, and LT (p < 0.001). Also, there were no significant differences for re-anastomosis, flap necrosis, and fat necrosis among different recipient vessels (p > 0.05)., Conclusions: Because of the altered mastectomy incisions, this study provides complete anatomical vascular properties and suggests that altering recipient vessel selection for bi-pedicled DIEP flaps can shorten anastomosis time and better conceal scars., Competing Interests: Declaration of Competing Interest The authors declare that they have no competing financial interests. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. This paper was not based on previous communications with society or conferences., (Copyright © 2023 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: The internal mammary artery (IMA) is the preferred recipient vessel for microvascular anastomosis in immediate autologous breast reconstruction following skin-sparing mastectomy (SSM). Although the IMA accounts for approximately 60% of the blood supply to the breast, the exact contribution to the mastectomy skin flap perfusion is unclear. The aim of this observational study was to investigate the impact of using the IMA as a recipient vessel on medial mastectomy skin flap perfusion assessed with indocyanine green angiography (ICGA)., Methods: This observational study included ten consecutive women who underwent immediate autologous breast reconstructions following SSM. Two intraoperative indocyanine green (ICG) assessments were performed to assess tissue perfusion of the upper and lower part of the medial mastectomy skin flap: the first following the SSM and the second after clamping the IMA. During a 120-second angiography, three additional images were made after 60, 90, and 120 s. The ICG inflow time and mean, minimum, and maximum fluorescence intensities (FIs) were obtained., Results: Four unilateral and six bilateral autologous breast reconstructions were included. There was no difference in tissue perfusion when comparing the inflow time (24.1 s vs. 23.0 s, P = 0.348), the mean FI (131.4 vs. 124.0, P = 0.126), minimum FI (28.6 vs. 33.4, P = 0.086), and maximum FI (253.1 vs. 247.6, P = 0.166) before and after clamping the IMA., Conclusion: According to this study, the use of the IMA as a recipient vessel does not reduce medial mastectomy skin flap perfusion in patients undergoing immediate autologous breast reconstructions following SSM., Competing Interests: Declaration of Competing Interest The authors have no relevant financial or non-financial interests to disclose., (Copyright © 2023 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Competing Interests: Disclosures Dr Chu has received Speaker’s honoraria from Medtronic, Edwards, Terumo Aortic, and Artivion.

The minimally invasive repair of pectus excavatum (MIRPE), or Nuss procedure, is regarded as the gold standard technique for the treatment of symptomatic pectus excavatum. Minimally invasive repair of pectus excavatum is regarded as a low-risk operation with a reported life-threatening complication rate estimated at around 0.1%. Presented are three cases of right internal mammary artery injury (RIMA) after MIRPE resulting in massive hemorrhage in both the acute and chronic postoperative setting and subsequent management strategies. Exploratory thoracoscopy and angioembolization were utilized which achieved prompt hemostasis and allowed for complete patient recovery.

Aim: The most versatile recipient vessels for breast reconstruction are the internal mammary artery and vein. For microvascular anastomosis, one or two costal cartilages are often dissected to increase the length of the vessel and the degree of freedom. In some cases, the resection of the rib cartilage causes long-term depression at the dissected site, compromising its cosmetic appearance., Patients and Methods: A total of 101 patients were examined, with 111 sides in which the internal mammary artery and vein were used as the recipient vessels. The patients were followed up for at least 6 months., Results: A total of 37 of 38 patients with complete rib cartilage preservation had no depression, and 1 patient had a slight depression. In the case of partial resection of the rib cartilage, 37 of the 46 sides had no depression, 8 sides had mild depression, and 1 side had an obvious depression. When more than one rib cartilage was removed, 11 of the 27 sides had no depression, 11 had mild depression, and 5 had an obvious depression. The Spearman rank correlation coefficient was 0.4911936., Conclusion: This study reported the relationship between rib cartilage resection and postoperative concave deformity in breast reconstruction surgery using free flap transfer and the internal mammary artery and vein as the recipient vessels. A strong correlation was found between the extent of rib cartilage resected and the degree of depression. Minimizing rib cartilage resection when using the internal mammary artery and veins may minimize postoperative chest recession deformity and provide a well-dressed breast reconstruction., Competing Interests: Declaration of Competing Interest None declared., (Copyright © 2023 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

An 82-year-old woman with past history of pulmonary nontuberculous mycobacterial infection complained of hemoptysis and was pointed out the strongly stained nodule in the middle lobe of the right lung on chest enhanced computed tomography (CT), which was suggested to be peripheral pulmonary artery aneurysm. Angiography of the right internal thoracic artery (RITA) revealed the peripheral pulmonary artery aneurysm with the shunt from the branch of the RITA, which was considered to be the cause of hemoptysis. Transcatheter arterial embolization was performed for the branch of the RITA 2 times, however, the hemoptysis recurred again after 5 months. Therefore, after the third embolization for the RITA, the right middle lobectomy with amputation of the shunt vessel was performed. The patient has been well without hemoptysis for one year and 6 months after the surgery.

Although performing total arterial coronary artery bypass revascularisation, using internal thoracic arteries as in situ grafts is not always feasible. The implantation of an internal thoracic artery on the aorta could be necessary, in a situation rarely planned preoperatively. Herein, we describe a simple and original way to perform this anastomosis. A 2-cm length of extra radial artery graft ended by a clip is anastomosed to the aorta in a standard fashion. The internal thoracic artery is then sown on the radial dome. We obtain a wide arterial anastomotic chamber using a standard technique, safe and easily reproducible.

Background:  Breast reconstruction (BR) using autologous free flaps has been shown to have numerous psychosocial and quality-of-life benefits. Unfortunately, the microsurgical learning curve is quite steep due to some unique operative challenges. Currently, there is no realistic simulation model that captures real-life respiratory excursion and the depth of internal mammary vessels within the compact recipient site. The purpose of this study was to delineate intraoperative measurements of depth and motion, describe the resulting simulation model, and conduct a pilot study evaluating the simulator as an educational resource., Methods:  This is a single-center, ethics-approved study. For the intraoperative measurements, all consecutive patients undergoing free flap BR using internal mammary vessels as recipients were recruited. Patient and intraoperative factors as well as intraoperative measurements were recorded. A dynamic model was developed based on intraoperative parameters. For the pilot study, plastic and reconstructive surgery trainees were recruited to complete a hand-sewn internal mammary artery (IMA) anastomosis using the new simulator and completed objective questionnaires pre- and postsimulation. Subjective feedback was recorded and themes determined., Results:  Fifteen operative sites were analyzed. Flap pocket was found to be between 4 and 5 cm in depth with vertical excursion of 3.7 ± 1.0mm and a respiratory rate of 9 to 14 breaths/minute. Previous radiation, rib space, body mass index (BMI), blood pressure, heart rate, tidal volume, and respiratory rate showed no correlation to vessel depth/excursion. Laterality, rib space, BMI, radiation, vitals, and tidal volume had no correlation with vessel movement. Twenty-two trainees were included in the pilot. An increase in confidence and mixed results for anxiety was reported., Conclusion:  This study reports a novel microsurgical simulation model that provides a realistic deep inferior epigastric perforator free flap BR IMA anastomosis experience. It replicates movement of vessels in situ with real-time respiratory excursion and similar physical structures of the internal mammary system. This model shows promising results for increased use in microsurgical education., Competing Interests: None declared., (Thieme. All rights reserved.)

An internal mammary artery to pulmonary artery (IMA-PA) fistula is a very rare vascular abnormality. Patients with this disease are often asymptomatic, but they may develop symptoms such as heart failure and hemoptysis. A 60-year-old woman was incidentally diagnosed with left IMA-PA fistula by chest computed tomography (CT) during an examination for colon cancer. She was asymptomatic, but we determined that surgery was indicated because of the presence of an aneurysmal change. We performed complete surgical resection of the IMA-PA fistula and aneurysm under cardiopulmonary bypass. Her postoperative course was uneventful. Although a specific management strategy for IMA-PA fistula has not yet been established, surgical treatment should be performed to prevent rupture in cases with aneurysmal change.

Rationale and Objectives: Noninvasive diagnostic imaging of subclavian artery (SCA) and internal thoracic artery (ITA) is crucial to the patients planning to use ITA for coronary artery bypass grafting (CABG). The guidelines have not yet provided guidance on screening high-risk groups. The present study aimed to evaluate the contribution of ultrasonography in the assessment of SCA and ITA, especially for the patients referred for CABG who planned to use ITA graft., Materials and Methods: Patients diagnosed with multivessel coronary heart disease were enrolled and some of them planned CABG. Bilateral SCAs and ITAs were routinely evaluated by color Doppler ultrasound (CDUS) before operation. The luminal diameter and the peak systolic velocity of the proximal and distal parts of SCA and ITA were measured. Depending on the Doppler waveform, the lumen narrowing rate was calculated., Results: The final analysis was carried out in 572 patients. Thirty-five patients had moderate (50%-69%), severe (70%-99%) stenosis or occlusion in the SCA (left-sided in 21 and right-sided in 14). One patient had severe proximal stenosis in left ITA and one patient had no flow in left ITA due to the occlusion in left SCA. One patient had anatomic variation of isolated right aortic arch with aberrant left SCA. All of those cases were confirmed with multidetector computed tomography angiography., Conclusion: CDUS could be used for the evaluation of SCA and ITA before CABG as part of presurgical vascular assessment and provide an import basis for the imaging diagnosis and surgical plan., (Copyright © 2022 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.)

Objective: Harvest of the left internal mammary artery (LIMA) is a technically demanding element of minimally invasive coronary surgery. We aimed to evaluate the learning curve of thoracoscopic, nonrobotic LIMA harvest during endoscopic coronary artery bypass (Endo-CAB) surgery., Methods: Eighty patients undergoing Endo-CAB surgery were included. LIMA harvest was performed using commonly available video-assisted thoracoscopic instruments. Time from incision until heparin administration was defined as total LIMA harvest time (this includes opening of the pericardium and identification of coronary targets). LIMA harvest times ( N = 80) and total procedure times for single-vessel grafting ( n = 51) were analyzed., Results: The mean LIMA harvest time was 58 ± 19 min, ranging from 15 to 113 min. The mean procedure time was 150 ± 39 min. Significant reductions in both LIMA harvest and total Endo-CAB procedure times were observed with increasing experience (logarithmic regression Y = 109 - 14.9*log(x), P < 0.001; Y = 227 - 24.4*log(x), P < 0.001, respectively). No damage to the LIMA occurred during thoracoscopic harvesting., Conclusions: Total thoracoscopic (nonrobotic) LIMA harvest is an efficient technique with a steep learning curve using routine instruments. More patients might benefit from minimally invasive coronary surgery using thoracoscopic LIMA harvest techniques.

Purpose: In this article, we reported on the up-to-date literature regarding skeletonized bilateral internal mammary artery (BIMA) flow and the effect on sternal perfusion. We also reviewed the pros and cons of the skeletonization technique versus the conventional pedicle technique for harvesting the BIMA., Methods: We performed an up-to-date review using the PubMed database, with a specific focus on the contemporary published literature., Results: BIMA skeletonization can preserve the sternal microcirculation, minimize tissue damage, and maintain blood supply to the chest wall at the tissue level. This effect is also apparent in diabetics. Deep sternal wound infection (DSWI) rates are significantly less with skeletonization versus the conventional pedicle technique and are comparable to single internal mammary artery harvesting., Conclusions: Contemporary large-scale studies demonstrate that skeletonization of the BIMA increases conduit length, provides superior flow, reduces the incidence of DSWIs, and improves late survival. Hopefully, this review will increase awareness of the compelling evidence in favor of using skeletonized internal mammary arteries and stimulate increased uptake of BIMA revascularization surgery.