Coronary Artery Bypass Grafting with Atypical Configurations of Bilateral Internal Thoracic Artery Composite Graft: Why, How, and What is the Outcome?

Kay-hyun Park, Hak Joo Kim, Dong Jung Kim, Jun Sung Kim, Cheong Lim

Seoul National University Bundang Hospital, Seongnam, Korea (South)

Date, time and location: 2018.05.25 13:30, Congress Hall, 2F–A

Abstract

Background: CABG with bilateral internal thoracic artery (ITA) composite graft is a good option for multiarterial revascularization. While left ITA-based Y composite graft has been the mostly widely adopted configuration, technical problems or anatomic difficulty may necessitate modifications into atypical configuration. We aimed to investigate the clinical outcome of various atypical configurations of bilateral ITA composite grafting.

Methods: While our standard technique has been LITA-based Y-composite graft with the LITA anastomosed to the left anterior descending coronary artery (LAD) and the RITA sequentially anastomosed to non-LAD targets, various modifications were needed in 160 patients among 1161 patients who underwent CABG with bilateral ITA between 2006 and June 2017. Their medical records and postoperative imaging data were reviewed to investigate the technical details, clinical outcome, and graft patency.

Results: Modifications of typical Y-graft (group I, n=90) including end-to-end extension of RITA with another graft (n=65), LITA-based I-graft (group II, n=39) and RITA-based composite grafts (group III, n=31) were used for the following reasons; insufficient length of RITA (47%), problems of LITA (28%) and target vessel anatomy (25%). The 30-day mortality rate was 1.8%. In 116 patients (72.5%) who underwent CT or conventional angiography at the mean interval of 29.9±33.1 months after surgery, graft patency rate was 98.2%, 90.1%, and 86% for LAD, LCx, and RCA territory, respectively. Patency rate for inflow, secondary, and tertiary graft was 98.2%, 90.5%, and 80.4%, respectively. The 5-year freedom from target vessel revascularization was 98.5%, 100% and 84.7% for group I, II, and III, respectively.

Conclusion: Even in atypical configurations, ITA-composite graft showed satisfactory clinical outcome and patency. Use of bilateral ITA should not be discouraged for the fear of unexpected difficulties, which can be managed effectively with various technical modifications.