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Browne et al. Vessel Plus 2024;8:19 https://dx.doi.org/10.20517/2574-1209.2023.126 Page 9 of 18

Figure 1. Illustration of pedicled and skeletonized internal mammary artery during coronary artery bypass grafting surgery. Adapted
from Gurevitch et al. [72] .

revascularization was higher in skeletonized compared with pedicled IMA harvesting (hazard ratio, 1.25;
95%CI: 1.06-1.47), mainly driven by an increased risk of repeat revascularization (hazard ratio, 1.42; 95%CI:
1.11-1.82). No mortality benefit of skeletonization was observed (hazard ratio, 1.12; 95%CI: 0.92-1.36). In a
subgroup analysis, the authors noted that the difference in major adverse cardiovascular events was larger
for patients operated on by surgeons who enrolled 50 patients or less in the trial, suggesting surgeon
experience may be an important confounder. Likewise, authors of a recent narrative review of the subject
pointed out that early divergence of Kaplan-Meier curves with regard to major adverse cardiovascular
events in the COMPASS CABG study is consistent with a hypothesis that early technical issues relating to
surgery rather than progression of the underlying atherosclerotic disease likely contributed to the poorer
[53]
performance of the skeletonized IMA .

In a recent trial that randomly assigned 109 patients to receive a single skeletonized or pedicled LIMA graft
to the left anterior descending artery, rates of graft failure were similar with either technique at 3 years
(skeletonized 9.6% [5/52] vs. pedicled 4.2% [2/48]; absolute difference 5.4%; 95%CI: -4.2-14.5) and 8 years
after surgery . Subgroup analyses suggested that graft failure rates were higher when anastomosed to target
[54]
arteries with less severe disease (stenosis < 70% vs. ≥ 70%).