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Ann Thorac Surg 2001;72:798-803
© 2001 The Society of Thoracic Surgeons

Original article: cardiovascular

Arterial myocardial revascularization with in situ crossover right internal thoracic artery to left anterior descending artery

Oren Lev-Ran, MDa, Dimitri Pevni, MDa, Menachem Matsa, MDa, Yosef Paz, MDa, Amir Kramer, MDa, Rephael Mohr, MDa

a Department of Cardiac and Thoracic Surgery, The Tel Aviv Sourasky Medical Center, Tel Aviv, Israel

Accepted for publication May 25, 2001.

Address reprint requests to Dr Mohr, Department of Cardiac and Thoracic Surgery, The Tel Aviv Sourasky Medical Center, Tel Aviv 64239, Israel
e-mail: rephmohr{at}tasmc.health.gov.il


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 References
 
Background. The extra length obtained by skeletonizing the internal thoracic arteries (ITAs) enables versatile use of in situ bilateral ITAs for coronary artery bypass grafting, as the longer skeletonized right ITA more easily reaches the anastomotic site on the left anterior descending coronary artery.

Methods. Between April 1996 and November 1999, 365 consecutive patients underwent revascularization with bilateral in situ ITAs (29% of 1,250 grafting procedures performed with both ITAs in our department during this period). The right ITA was routed anterior to the aorta to graft the left anterior descending coronary artery, and the in situ left ITA was used to graft circumflex branches. Right coronary artery branches were grafted with right gastroepiploic artery or saphenous vein graft. The right ITA crossed the midline above the aorta at the most cranial point to avoid damage in case of a repeat sternotomy in the future.

Results. The operative mortality rate was 2.2% (8 patients). Postoperative morbidity included seven strokes (1.9%), eight sternal wound infections (2.2%), and four perioperative myocardial infarctions (1.1%). Follow-up (6 to 49 months) of 97% of hospital survivors showed a return of angina in 3%. Postoperative coronary angiography (22 patients) revealed a 95% patency rate of both ITAs. One-year and 4-year survival rates (Kaplan-Meier) were 95% and 92.4%, respectively. Important predictors of an early unfavorable event were chronic obstructive pulmonary disease, old age (>= 70 years), emergency operation, and diabetes. Chronic obstructive pulmonary disease was the only independent predictor of sternal wound infection (odds ratio, 15; 95% confidence interval, 2.8 to 80). It also predicted decreased late survival (hazard ratio, 8.3; 95% confidence interval, 3 to 21.5).

Conclusions. With skeletonized dissection of ITAs, the right ITA easily reaches the left anterior descending coronary artery for left-sided arterial revascularization with in situ bilateral ITAs. This procedure is safe, but we recommend avoiding its use in patients with chronic obstructive pulmonary disease.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 References
 
The internal thoracic artery (ITA) has been established as the preferred conduit for coronary artery bypass grafting. Accumulating information has demonstrated the merits of bilateral ITA grafting over single ITA grafting in regard to survival, event-free survival, freedom from repeat angioplasty, and freedom from reoperations [1–3]. The survival benefit seen with bilateral ITA grafting has been related particularly to grafting the myocardium supplied by the left anterior descending (LAD) and circumflex (Cx) coronary arteries, ie, the left coronary artery system [3, 4].

Several arrangements of grafting have been used to achieve left-sided myocardial revascularization with bilateral ITAs. These include in situ right ITA (RITA) to the LAD and the left ITA (LITA) to Cx marginal branches [5], directing the RITA through the transverse sinus in a retroaortic course [6, 7], and free RITA grafts connected proximally either to the LITA [8] or to the ascending aorta [9].

No data exist to support the superiority of any one of the proposed methods. However, despite potential advantages of left-sided bilateral in situ ITA grafting over the T-graft technique, the use of this configuration has been discouraged because of insufficient length for routine grafting of the LAD and concerns regarding the proximity of the crossover RITA to the sternum, which could compromise a subsequent repeat sternotomy.

Refinements in ITA harvesting technique and ITA mobilization as a skeletonized vessel provide increased graft length [10, 11] and improved distal free flow [12] and may reduce postoperative sternal wound complications [5, 11]. The extra length obtained by skeletonizing dissection increases the versatility of the procedure; thus the RITA can reach the LAD more often and allow its use as an in situ graft.

In this report, we evaluate our experience with grafting the left coronary artery system using bilateral in situ skeletonized ITAs. Midterm results and technical aspects are discussed.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 References
 
Between April 1996 and November 1999, 365 consecutive patients underwent left-sided myocardial revascularization with bilateral in situ skeletonized ITAs. In all patients, we used the same configuration, ie, in situ RITA to LAD and LITA to Cx marginal branches (Fig 1). Branches of the right coronary artery system were grafted either with right gastroepiploic artery or with saphenous vein. This ITA arrangement comprised 29% of the 1,250 coronary artery bypass grafting procedures with bilateral ITAs performed in our department during this period. Arterial revascularization with bilateral ITAs constituted 71% of all coronary artery bypass grafting procedures.



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  		Fig 1. Crossover configuration: in situ right internal thoracic artery (RITA) to left anterior descending coronary artery (LAD) and in situ left internal thoracic artery (LITA) to marginal branches of circumflex artery. (D = diagonal branch; PDA = posterior descending artery; R + GEA = right gastroepiploic artery.)

 
The decision regarding which grafting configuration to use was made after both ITAs had been harvested and after inspection of the target coronary arteries had been completed. We did not use the in situ RITA to LAD arrangement when the distal ITA bifurcation could not loosely reach the LAD. In this category were patients with a short RITA, a very long ascending aorta, an enlarged right ventricle, or an LAD anastomotic site that was too distal or unpredictable. Another important reason to avoid the bilateral in situ configuration was the need to graft a diagonal artery. Side-to-side sequential LITA grafting of the lateral left ventricular wall was usually acceptable when applied to the Cx marginal branches and an intermediate ramus branch. Including a diagonal artery with that type of grafting can create a dangerous LITA curve or kink. In instances where bilateral in situ ITA grafting was considered "unreliable," revascularization was achieved by constructing a T graft with a free RITA on an in situ LITA. Preoperative conditions that constituted a contraindication for using bilateral ITAs were emergency operation [5] and chronic obstructive pulmonary disease (COPD), a category including patients with a preoperative diagnosis of chronic bronchitis, emphysema, or bronchial asthma and abnormal pulmonary function test results.

The preoperative and operative data are presented in Table 1. The ITAs were dissected as skeletonized arteries [10, 11] before heparin sodium administration to decrease the risk of damage and hematoma formation in the region of the side branches during dissection. Injury to the ITAs was extremely rare (occurring mainly in the learning-curve period) for the following reasons:

  1. The technique of skeletonizing ITA dissection is performed routinely and daily in our operating rooms.
  2. The work is delicate and refined and takes longer to perform.
  3. Cautery, which might cause direct or indirect injury, is not used.


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  		Table 1. Patient Characteristics and Overall Mortalitya,b

 
Surgical technique
Operations were performed with cardiopulmonary bypass. The myocardial preservation technique involved intermittent warm cardioplegia (30°C to 32°C) [13]. Our strategies for complete arterial revascularization are detailed in a recently published study [14].

The RITA was directed anterior to the aorta to graft the LAD. Preventive measures were taken with respect to repeat sternotomy. The ITA was tunneled through a right pericardial incision at the level of the aorta and pulmonary trunk and directed leftward, crossing the midline at the most cranial point before angling toward the LAD. This maneuver allows free space on the aorta for future instrumentation and provides a safety distance between the ITA and the sternum (Fig 2).



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  		Fig 2. Lateral chest radiograph demonstrating distance between sternum and metal clip (arrow) marking midline point of crossover right internal thoracic artery.

 
An in situ LITA was used to graft the Cx branches (see Fig 1). Up to three sequential anastomoses were allowed on a single conduit (Fig 3). Diamond-shaped anastomoses were generally used for side-to-side grafting. A length of ITA segment longer than the actual intercoronary distance was adjusted to prevent ITA tension after left ventricular filling. A relative contraindication for this type of anastomosis was an intramyocardial marginal artery or an artery buried inside a deep layer of epicardial fat. In these settings, we preferred the parallel side-to-side anastomosis. End anastomoses were usually constructed in a conventional fashion. However, when a length-sparing manuever was required, a T-shaped anastomosis was performed [14]. This was particularly rewarding in patients with multiple sequential grafts.



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  		Fig 3. Postoperative coronary angiography of left internal thoracic artery (LITA) with two sequential diamond-shaped anastomoses (to diagonal [D1] and marginal [M1] branches) and an end-to-side T-shaped anastomosis to another marginal branch (M2). (Lt-PDA = left posterior descending artery.)

 
Grafting of the right coronary artery branches was performed, preferentially, with an in situ right gastroepiploic artery. However, in patients with coronary stenosis that was not critical (< 70%), saphenous vein grafting was preferred [15, 16].

A giant metal clip was used to mark the RITA midline location with respect to the sternum for a possible future median sternotomy (see Fig 2). Mediastinal fat was used to cover the artery and fixate it in the selected route to prevent tenting after removal of the retractor and closure of the sternum.

Postoperative protocol included high doses of intravenously administered isosorbide dinitrate (4 to 20 mg/h) for 2 days [5]. Cardiac enzyme analysis and electrocardiography were done in all patients 8 hours after the operation and at daily intervals for 3 days. All patients underwent a routine radionuclear scan within 3 months after the operation and have been examined by an independent cardiologist twice annually. Postoperative coronary angiography was offered to every patient for assessment of graft patency and detection of technical graft dysfunction. Eventually, coronary angiography was performed mainly in patients with recurrent angina, undetermined chest pain, or positive radionuclear scan.

Statistical analysis
Data are expressed as the mean ± the standard deviation or as proportions. The Fisher exact test and two-sample t tests were used to compare discrete and continuous variables, respectively. Early mortality and major morbidity events (stroke, perioperative myocardial infarction, and sternal wound infection) were defined as early unfavorable events for the purpose of statistical analysis. Multivariate logistic regression analysis was used to determine important predictors of operative mortality and early unfavorable events. The Cox proportional hazard model was used to evaluate the influence of preoperative variables on overall mortality (early and late). Postoperative survival was expressed by the Kaplan-Meier method. All analyses were performed by SPSS 9 software (SPSS, Inc, Chicago, IL).


   Results
Top
 Abstract
 Introduction
 Material and methods
 Results
Comment
 References
 
The 365 study patients received from two to five grafts (mean number of grafts, 3.2), and the ITA graft to patient ratio was 2.7. Two hundred thirty-one (24%) of the 983 arterial anastomoses were sequential diamond-shaped anastomoses. The average cardiopulmonary bypass time was 81 ± 31 minutes, and the average aortic cross-clamping time was 68 ± 23 minutes. The operative mortality rate (during hospitalization and within 30 days postoperatively) was 2.2% (8 patients). Postoperative morbidity included perioperative myocardial infarction in 4 patients (1.1%) and stroke in 7 patients (1.9%) (4 with permanent neurological deficiency and 3 with complete recovery). Eight patients (2.2%) sustained a sternal wound infection, 1 of whom died in the perioperative period. The rate of sternal wound infection in patients with COPD was 11.5% (3 of 26), and COPD was found to be the only significant risk factor for sternal wound infection (odds ratio, 15; 95% confidence interval, 2.8 to 80). Postoperative bleeding requiring reexploration occurred in 4 patients (1.1%).

Follow-up
Follow-up ranged from 6 to 49 months and was complete for 97% of the hospital survivors. During this period, 16 patients (4.4%) died, and 11 (69%) of these deaths were cardiac related. One-year and 4-year survival rates (Kaplan-Meier) were 95% ± 1.1% and 92.4% ± 1.5%; respectively (Fig 4). The documented rates of nonfatal myocardial infarction and return of angina were 0.5% (2 patients) and 3% (11 patients), respectively, 7 to 23 months after operation.



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  		Fig 4. Kaplan-Meier survival curve.

 
Postoperative coronary angiography was performed 19 months after operation on average (range, 2 to 41 months) in 22 patients (6.0%) who either were clinically symptomatic or demonstrated a positive radionuclear scan. All sequential anastomoses were patent, and the patency rate of both ITAs was 95%. Postoperative angioplasty was performed in 6 patients (1.6%). In 3 of them, ungrafted coronary arteries were involved. In 2 patients, the procedure was necessary because of ITA graft failure (one RITA and one LITA). Repeat coronary artery bypass grafting was performed in 1 patient 23 months after the initial operation.

In general, the metal clip marking the midline point of the crossover RITA maintained its original position, as shown on lateral chest radiographs. Follow-up was performed as late as 20 months postoperatively. Migration toward the sternum was not evident (see Fig 2).

Analysis of morbidity and mortality
Analysis of operative data and preoperative risk factors revealed emergency operation (odds ratio 4.9; 95% confidence interval [CI], 1 to 24) and COPD (odds ratio, 16.8; 95% CI, 3 to 94.3) to be the only predictors of operative mortality. The overall rate of early unfavorable events (hospital mortality, perioperative myocardial infarction, cardiovascular accident, and deep sternal wound infection) was 6.6%. Important predictors of such events were COPD (odds ratio [OR] 4.8; 95% CI, 1.5 to 15.1), age of 70 years or more (OR, 2.64; 95% CI, 1.1 to 6.66), emergency operation (OR, 4.3; 95% CI, 1.56 to 12), and diabetes (OR, 3.15; 95% CI, 1.27 to 7.8).

Univariate analysis of overall (early and late) mortality events revealed several risk factors to be associated with decreased survival (see Table 1). However, Cox regression analysis revealed only COPD and old age (>= 70 years) to be significant independent risk factors for overall mortality. Chronic obstructive pulmonary disease had an HR of 8.3 (95% CI, 3 to 21.5), and old age, an HR of 0.94 (95% CI, 0.9 to 0.99).


   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
References
 
Left-sided bilateral ITA grafting has been recognized as a major determinant of survival [2, 3], and consequently, several patterns for such grafting have been proposed. However, the best ITA configuration has not yet been established. Reduced patency rates for free RITA grafts have been demonstrated when these grafts are connected proximally to the aorta [9, 17]. Attachment of the free RITA to the in situ LITA (T or Y graft) may improve patency [18, 19], but this arrangement may not be suitable in all instances.

Grafting an in situ RITA to the left coronary system can either be performed through the transverse sinus in a retroaortic course or by a route anterior to the aorta [7]. Disadvantages of the retroaortic course, such as the inability to control bleeding from retroaortic ITA branches, compression of the RITA graft by the aorta [20], and compromised graft patency because of undetected kinks, have limited its widespread use. The satisfactory results obtained with this technique [7] must be weighed against contradicting reports of inadequate flow in RITA grafts placed through the transverse sinus [20]. A retroaortic in situ RITA is generally used to graft the Cx marginal or diagonal branches [7].

The in situ RITA is considered as good a graft as the LITA, with identical patency rates when grafted to the LAD [3, 17, 21]. Moreover, its best patency rate is achieved when it is grafted to the LAD [21]. For the pattern of grafting described here, skeletonized ITA harvesting seems to provide several benefits over pediculate mobilization. The additional length obtained by harvesting the ITA as a skeletonized vessel enables better selection of the LAD anastomotic site and precludes the use of the more distal vasospastic RITA segments [22, 23]. Another important advantage of skeletonized harvesting is the reduction in postoperative sternal wound infections [5], which contributes to the wider use of this technique, with less rigorous patient selection [24, 25].

A major objection to the anterior retrosternal RITA crossover route is the potential risk of damage to the artery during repeat sternotomy. This study confirmed that the crossing graft maintains its original position in relation to the sternum (see Fig 2), thus securing the safety distance. In the only reoperation in this group of patients, the failed graft was identified, and aortic cannulation and clamping zones were safely maintained. In a previous experience with 11 patients undergoing reoperation with a patent retrosternal RITA crossing the midline, one graft (9%) was damaged and eventually repaired successfully [26]. Thus, we concur that the danger of reoperation in patients with patent crossover RITA grafts may be overstated [3] and that the benefits outweigh any theoretical objection [2]. Incorporating the retrosternal RITA into a polytetrafluoroethylene graft has been proposed as an additional safeguard for reoperations [27]. However, this technique has the disadvantages of inability to control bleeding ITA branches and risk of graft tenting at the edges of the rigid material.

Despite the fact that during the study period, most of the patients seen in our service underwent bilateral ITA grafting, analysis of our results and comparison with previous reports show that the perioperative mortality is comparable, and the morbidity in our patients (overall unfavorable events) seems to be relatively low. This may be related to several factors: use of bilateral ITA grafts, intact ITA graft to the LAD, avoidance of proximal anastomoses on the aorta, use of single cross-clamp technique, and skeletonized mobilization of the ITA.

The foremost predictor of early and overall mortality and sternal wound infection in this study was COPD. This is apparently related to the use of bilateral ITAs in general and is not particularly a result of the described ITA configuration. Two mechanisms account for the unfavorable outcome of patients with COPD: the effect of increased postoperative respiratory effort on sternal dehiscence and medial pressure exerted on the grafts by the hyperinflated lungs. These results validate our previous observations [5], and therefore we recommend that bilateral ITA grafting, regardless of the configuration used, be avoided in patients with COPD.

Angiographic evaluation was performed during the study period only for symptomatic patients or patients with positive scans. Overall, 22 in situ RITA grafts to the LAD were demonstrated at an average period of 19 months postoperatively (range, 2 to 41 months after operation), and 21 (96%) were patent. Although we cannot confidently draw conclusions from this small number of patients, they represented a higher risk for angiographic abnormalities. Hence, it may be reasonable to expect equally good results in patients who are clinically asymptomatic and who have unremarkable postoperative scans. Importantly, attrition of ITA anastomoses is confined to the first months after operation (17); thus, long-term satisfactory results can be anticipated. In the 22 patients who had control postoperative angiography, all sequential anastomoses were patent.

Sequential ITA grafting allows more complete arterial revascularization with good patency rates and is essential in any arrangement of arterial grafting [8]. However, current experience shows that a very proximal diagonal branch or the intermediate ramus are the topmost positions for in situ LITA grafting without compromising sequential anastomoses. Thus, in most instances, when it was necessary to graft a diagonal artery, the crossover technique was inadequate, and an alternative ITA arrangement was preferred.

This group of 365 patients represents one of the largest reported series of in situ RITA grafts to the LAD with the RITA routed anterior to the aorta. No data exist to support the superiority of any of the proposed arrangements of left-sided ITA grafting. However, compared with other forms (T-graft revascularization or retroaortic in situ RITA), this technique provides several benefits. It is technically somewhat less demanding, the LAD is grafted by an intact in situ ITA, complete left-sided ITA grafting is readily achieved, and the principle of multiple-origin blood supply is maintained. In conclusion, we think that bilateral skeletonized ITA grafting with an in situ RITA to the LAD is safe and reproducible, and its benefits offset its disadvantages.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 References
 

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S. Al-Ruzzeh, S. George, M. Bustami, K. Nakamura, C. Ilsley, and M. Amrani
Early clinical and angiographic outcome of the pedicled right internal thoracic artery graft to the left anterior descending artery
Ann. Thorac. Surg., May 1, 2002; 73(5): 1431 - 1435.
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