Bilateral Internal Thoracic Artery Grafting: Technical Aspects

The use of both internal thoracic arteries (ITAs) has been shown to provide a decreased risk of death, need for reoperation, or need for percutaneous coronary intervention when compared with one ITA in combination with vein grafts.

Inadequate length of the free right ITA (RITA) has often limited the ability to bypass the posterior marginal branches of the circumflex and the distal right coronary artery (RCA) with this conduit. Tector and coworkers describe a technique in which the RITA is anastomosed to the side of the attached left ITA (LITA), forming a T-graft configuration. This can place the RITA closer to the distal circumflex artery and the RCA by 10 cm or more, allowing it to reach these vessels.

The surgical technique used in the bilateral ITA (BITA) group consists of using both ITAs as exclusive conduits for coronary revascularization. The RITA was divided at its origin and connected end-to-side to the in situ LITA, which was grafted to the LAD, as a sequential T graft to the circumflex artery and the distal RCA. This video shows the authors’ routine technique for off-pump coronary artery bypass grafting. The quality of the anastomosis was assessed by transit-time flow measurement and Doppler probes. Postoperative coronary angiography was used as control in a series of patients and was reported in a previous study.

Skeletonized dissection of left and right internal thoracic arteries, preserving distal bifurcation and the internal thoracic vein, is performed. The subclavian vein served as the proximal limit of the dissection. The RITA is clipped and sectioned at both distal and proximal extremes and submerged in warm water. Both ITAs were instilled with topic papaverine. After opening the pericardium along the midline, the right pericardium was opened towards the inferior vena cava, permitting the right ventricle to enter the right pleural cavity. The left pericardium was opened towards the cardiophrenic reflection. A pericardium notch was performed at the level of the pulmonary trunk, from its free border to the left phrenic nerve, to permit LITA entrance to the pericardial cavity.

After measuring the LITA over the left anterior descending artery (LAD), the authors use a plastic bulldog to mark the site of the LITA-RITA anastomosis. The end-to-side LITA-RITA anastomosis is performed as described by Tector and colleagues with continuous 7-0 polypropylene suture. A 4-0 polypropylene tourniquet suture is placed in the proximal LAD. The LITA-LAD anastomosis is performed using a malleable footpad heart stabilizer. For the anastomosis to the circumflex artery, the heart is lifted up with a suction swivel arm stabilizer placed at the apex, and the right ventricle is placed in the right pleural cavity. A 4-0 polypropylene tourniquet suture is placed in the proximal circumflex artery. A side-to-side RITA-circumflex artery anastomosis is performed with continuous 7-0 polypropylene suture. The heart is placed in position for the RITA anastomosis to the posterior descending artery (PDA), and a tourniquet suture is placed in the proximal circumflex artery. The RITA-PDA anastomosis is completed as shown in the video.

Reference

1. Tector AJ, Amundsen S, Schmahl TM, Kress DC, Peter M. Total revascularization with T grafts. Ann Thorac Surg. 1994;57(1):33-39.