Hostname: page-component-7b7567c8c-mnklg Total loading time: 0 Render date: 2026-11-12T16:50:15.072Z Has data issue: false hasContentIssue false
  • English
  • Français

Impact of surgical approach on development of surgical-site infection following internal mammary-artery, coronary-artery bypass graft procedures

Published online by Cambridge University Press:  02 May 2023

Polly H. van den BergOpen the ORCID record for Polly H. van den Berg[Opens in a new window],
Baevin Fesser,
Venkatachalam Senthilnathan,
Kamal R. Khabbaz and
Sharon B Wright
Polly H. van den Berg*
Affiliation:
Division of Infectious Diseases, Pennsylvania Hospital, Philadelphia, Pennsylvania
Baevin Fesser
Affiliation:
Division of Infection Prevention, Beth Israel Lahey Health, Cambridge, Massachusetts
Venkatachalam Senthilnathan
Affiliation:
Division of Cardiac Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
Kamal R. Khabbaz
Affiliation:
Division of Cardiac Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
Sharon B Wright
Affiliation:
Division of Infection Prevention, Beth Israel Lahey Health, Cambridge, MassachusettsDivision of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts
*
Corresponding author: Polly H. van den Berg, MD, Pennsylvania Hospital, 301 South 8th Street, Suite 1B, Philadelphia, PA 19106. E-mail: polly.vandenberg@pennmedicine.upenn.edu
Rights & Permissions [Opens in a new window]

Abstract

An abstract is not available for this content. As you have access to this content, full HTML content is provided on this page. A PDF of this content is also available in through the ‘Save PDF’ action button.

Information

Type
Research Brief
Information
Infection Control & Hospital Epidemiology , Volume 44 , Issue 11 , November 2023, pp. 1889 - 1890
Check for updates
Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution and reproduction, provided the original article is properly cited.
Copyright
© The Author(s), 2023. Published by Cambridge University Press on behalf of The Society for Healthcare Epidemiology of America

Deep incisional and organ-space surgical-site infections (SSIs) are infrequent but serious complications of coronary artery bypass graft (CABG) procedures. Arterial revascularization using internal mammary artery (IMA) grafts is associated with improved cardiac outcomes.Reference Rocha, Tam and Karkhanis1 The use of bilateral IMA (BIMA) grafting redirects sternal blood flow to the heart and may increase SSI risk due to lower sternal tissue perfusion. A skeletonized approach to IMA vessel harvest, wherein the IMA is dissected from surrounding tissue preserving collateral sternal blood flow, may decrease SSI risk compared with a pedicled approach, in which the IMA is mobilized within a tissue pedicle. It remains unclear whether the use of BIMA grafting compared with the use of a single IMA (SIMA) is an independent risk factor for SSI. It is also uncertain whether surgical approach to graft harvest, skeletonized versus pedicled, affects SSI development. Conflicting results have been reported on the impact of BIMA grafting and harvest technique on development of SSI.Reference De Paulis, de Notaris and Scaffa2–Reference Ji, Zhao and Liu5 In this study, we described the incidence of post-CABG SSI and assessed potential patient and procedural SSI risk factors, including IMA number and harvest technique.

Methods

We conducted a retrospective cohort study of consecutive adult patients who underwent a CABG procedure with at least 1 IMA graft at an academic tertiary-care center between July 2017 and June 2020, identified through the institution’s Society of Thoracic Surgeons database maintained by the Division of Cardiac Surgery. Data were electronically abstracted from hospital data records including demographics, comorbidities, graft number, surgical approach, surgeon, discharge location, and microbiological culture reports. Deep incisional and organ-space SSIs post-CABG within 90 days of procedure date were identified by infection preventionists using standard National Healthcare Safety Network definitions as part of routine surveillance. We calculated the incidence of post-CABG deep incisional and organ-space SSI. Bivariate analyses were performed using the Fisher exact test to identify potential patient and procedural risk factors for SSI, including surgical approach. Statistical analyses were performed using SAS version 9.4 software (SAS Institute, Cary, NC). All reported P values are 2-sided. This study was deemed exempt from review by the institutional review board.

Results

Overall, 1,591 CABG procedures with at least 1 IMA graft were performed; 550, 561, and 480 procedures were performed in each respective year of the study period. Furthermore, 1,244 CABGs (78.2%) were performed with a single IMA and 347 (21.8%) were performed using BIMA. In terms of surgical technique, 322 (92.8%) of BIMA CABGs were skeletonized versus 219 (17.6%) of SIMA CABGs. The baseline patient risk factors (Table 1) did not differ between IMA groups, except the SIMA group was more likely to meet criteria for extreme obesity (BMI ≥ 40 kg/m2; 5.3% vs 2.0%; P = .008).

Table 1.

Potential Risk Factors for Deep Incisional and Organ-Space Post-CABG SSI

Note. CABG, coronary artery bypass graft; SSI, surgical-site infection; BIMA, bilateral internal mammary artery.

Overall, 19 deep incisional and organ-space SSIs occurred during the study period. The overall post-CABG SSI incidence rate was 1.2 per 100 procedures, with 1.0 and 1.7 SSIs per 100 procedures following SIMA and BIMA approaches, respectively. Over the 3-year study period, the proportion of CABG procedures using SIMA grafting increased (from 77.5% to 76.1% to 81.5%) and skeletonized grafting increased (from 29.1% to 34.2% to 39.4%). Over the same period, overall SSI incidence decreased (from 1.8 to 1.1 to 0.6 SSI per 100 procedures). Staphylococcus spp caused 8 infections (ie, 3 coagulase-negative staphylococci, 3 methicillin-resistant S. aureus, 2 methicillin-susceptible S. aureus) and Pseudomonas aeruginosa caused 4.

Diabetes, female sex, discharge to a rehabilitation facility, age ≥75 years, and BMI ≥40 kg/mReference De Paulis, de Notaris and Scaffa2 (ie, extreme obesity) were significant predictors of post-CABG SSI on bivariate analysis (Table 1).

Discussion

In our study, the incidence of deep incisional and organ-space SSI following CABG with at least 1 IMA was 1.2%, which is similar to the range of 1%–4% reported in the literature.Reference De Paulis, de Notaris and Scaffa2–Reference Biancari, Gatti and Rosato8

Potential patient risk factors for SSI were diabetes,Reference Rubens, Chen and Bourke3,Reference Benedetto, Altman and Gerry4,Reference Risnes, Abdelnoor, Almdahl and Svennevig6–Reference Biancari, Gatti and Rosato8 female sex,Reference Rubens, Chen and Bourke3,Reference Benedetto, Altman and Gerry4,Reference Meszaros, Fuehrer and Grogg7,Reference Biancari, Gatti and Rosato8 older age,Reference Risnes, Abdelnoor, Almdahl and Svennevig6 and obesity,Reference Rubens, Chen and Bourke3,Reference Benedetto, Altman and Gerry4,Reference Risnes, Abdelnoor, Almdahl and Svennevig6–Reference Biancari, Gatti and Rosato8 matching findings from other studies. In addition, we found that discharge to a rehabilitation facility was associated with post-CABG SSI, which is likely explained by confounding patient comorbidities requiring discharge to a facility instead of home.

In terms of procedural risk factors, use of a BIMA graft, compared with use of a SIMA graft, and surgical graft harvest technique (pedicled vs skeletonized) were not significant predictors of SSI (Table 1). We observed an increase in the use of SIMA and skeletonized grafts over time, which appeared to be accompanied by a decrease in SSI incidence. Notably, no other practice changes were implemented during this period.

This study had several limitations. It had a retrospective single-center design. Given that the number of deep incisional and organ-space SSIs was low, we had insufficient power to detect differences between groups. Another limitation of this study was that surgeon preference and perception of patient risk for infection likely influence method of revascularization, which may have affected surgical outcome and SSI development. BIMA utilization and IMA vessel skeletonization are associated with longer operative time, which may have affected surgical approach.

This study provides preliminary data on the impact of surgical technique to reduce deep incisional and organ-space SSIs following CABG procedures utilizing at least 1 IMA. The overall incidence of SSI following BIMA-skeletonized CABGs was similar compared to SIMA-pedicled CABGs (1.6% vs 1.3%), suggesting that BIMA-skeletonized CABGs may be performed safely. Because surgical approach and number of IMA vessels are potentially modifiable factors, even in patients with more traditional risk factors for SSI, additional research is needed to validate the significance of these findings.

Acknowledgments

Financial support

No financial support was provided relevant to this article.

Conflicts of interest

All authors report no conflicts of interest relevant to this article.

References

Rocha, RV, Tam, DY, Karkhanis, R, et al. Long-term outcomes associated with total arterial revascularization vs non-total arterial revascularization. JAMA Cardiol 2020;5:507–514.10.1001/jamacardio.2019.6104CrossRefGoogle ScholarPubMed
De Paulis, R, de Notaris, S, Scaffa, R, et al. The effect of bilateral internal thoracic artery harvesting on superficial and deep sternal infection: the role of skeletonization. J Thorac Cardiovasc Surg 2005;129:536–543.10.1016/j.jtcvs.2004.07.059CrossRefGoogle ScholarPubMed
Rubens, FD, Chen, L, Bourke, M. Assessment of the association of bilateral internal thoracic artery skeletonization and sternal wound infection after coronary artery bypass grafting. Ann Thorac Surg 2016;101:1677–1682.10.1016/j.athoracsur.2015.10.031CrossRefGoogle ScholarPubMed
Benedetto, U, Altman, DG, Gerry, S, et al. Pedicled and skeletonized single and bilateral internal thoracic artery grafts and the incidence of sternal wound complications: insights from the Arterial Revascularization Trial. J Thorac Cardiovasc Surg 2016;152:270–276.10.1016/j.jtcvs.2016.03.056CrossRefGoogle ScholarPubMed
Ji, Q, Zhao, Y, Liu, H, et al. Impacts of skeletonized bilateral internal mammary artery bypass grafting on the risk of deep sternal wound infection. Int Heart J 2020;61:201–208.10.1536/ihj.19-311CrossRefGoogle ScholarPubMed
Risnes, I, Abdelnoor, M, Almdahl, SM, Svennevig, JL. Mediastinitis after coronary artery bypass grafting risk factors and long-term survival. Ann Thorac Surg 2010;89:1502–1509.10.1016/j.athoracsur.2010.02.038CrossRefGoogle ScholarPubMed
Meszaros, K, Fuehrer, U, Grogg, S, et al. Risk factors for sternal wound infection after open heart operations vary according to type of operation. Ann Thorac Surg 2016;101:1418–1425.10.1016/j.athoracsur.2015.09.010CrossRefGoogle ScholarPubMed
Biancari, F, Gatti, G, Rosato, S, et al. Preoperative risk stratification of deep sternal wound infection after coronary surgery. Infect Control Hosp Epidemiol 2020;41:444–451.10.1017/ice.2019.375CrossRefGoogle ScholarPubMed
Figure 0

Table 1.Potential Risk Factors for Deep Incisional and Organ-Space Post-CABG SSI