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

yBackground. The extra length obtained by skeletonizing the internal thorac ic arteries (ITAs) enables versatile use of in situ bilateral ITAs for coro nary artery bypass grafting, as the longer skeletonized right ITA more easi ly reaches the anastomotic site on the left anterior descending coronary ar tery. Methods. Between April 1996 and November 1999, 365 consecutive patients und erwent 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 circ umflex branches. Right coronary artery branches were grafted with right gas troepiploic artery or saphenous vein graft. The right ITA crossed the midli ne above the aorta at the most cranial point to avoid damage in case of a r epeat 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%. Po stoperative coronary angiography (22 patients) revealed a 95% patency rate of both ITAs. One-year and 4-year survival rates (Kaplan-Meier) were 95% an d 92.4%, respectively. Important predictors of an early unfavorable event w ere chronic obstructive pulmonary disease, old age (greater than or equal t o 70 years), emergency operation, and diabetes. Chronic obstructive pulmona ry disease was the only independent predictor of sternal wound infection (o dds ratio, 15; 95% confidence interval, 2.8 to 80). It also predicted decre ased late survival (hazard ratio, 8.3; 95% confidence interval, 3 to 21.5). Conclusions. With skeletonized dissection of ITAs, the right ITA easily rea ches the left anterior descending coronary artery for left-sided arterial r evascularization with in situ bilateral ITAs. This procedure is safe, but w e recommend avoiding its use in patients with chronic obstructive pulmonary disease. (C) 2001 by The Society of Thoracic Surgeons.