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Eur J Cardiothorac Surg 2000;18:255-261
© 2000 Elsevier Science NL

The right internal thoracic artery graft – benefits of grafting the left coronary system and native vessels with a high grade stenosis

^a Department of Cardiac Surgery, Austin Campus, HSB-5, Austin & Repatriation Medical Centre, Studley Road, Heidelberg, Victoria 3084, Australia
^b Department of Cardiac Surgery and Cardiology, Epworth Hospital, Melbourne, Victoria, Australia
^c Baker Medical Research Institute, Melbourne, Victoria, Australia

Received 7 September 1999; received in revised form 23 June 2000; accepted 28 June 2000.

Corresponding author. Tel.: +61-3-9496-5044; fax: +61-3-9459-0971
e-mail: bux{at}austin.unimelb.edu.au

	Abstract

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Conclusion 6. Limitations of the... Appendix A Conference discussion References

 
Objective: The left internal thoracic artery (LITA), when grafted to the left anterior descending artery (LAD), is generally accepted as the conduit of choice for coronary artery bypass grafting (CABG). In contrast, the role and efficacy of the right internal thoracic artery (RITA), despite its long-term use as a coronary artery graft, is relatively less understood. Accordingly, in this study, we sought to assess the utility of the RITA as a coronary conduit by examining the long-term patency of both in situ and free RITA grafts and analyzing the association between intraoperative graft and coronary artery variables. Methods: Nine hundred and sixty-two patients (LITA 962, RITA 432) who had CABG between 1985 and 1998 and underwent re-angiography for evidence of myocardial ischemia were included in this observational analysis. The diameter of the internal thoracic artery (ITA), the presence of a proximal anastomosis with the aorta, the location of the anastomosis with the coronary artery, and the coronary artery diameter, were recorded at the initial procedure. The follow-up was 67.0±39.4 months (mean±SD, range 0.1–169.5). The relationship between intraoperative variables and graft patency was assessed using Cox proportional hazard models. Results: Highest RITA failure rates were associated with grafting a native coronary artery with a stenosis of less than 60% compared with 80–100% (RR 3.8 (95% CI, 1.9–7.2) P=0.0001). Grafts to non-LAD arteries had a higher risk of failure, the highest risk ratio being associated with grafting the right coronary artery (RR 4.0 (95% CI, 0.9–17.4) P=0.06)). Free compared with in situ grafts were also associated with a higher risk of failure with this result bordering on statistical significance (RR 1.9 (95% CI, 1.0–6.0) P=0.06)) Conclusion: Preference should be given to grafting arteries with a high grade stenosis or occlusion, to grafting left rather than right coronary arteries, and to using in situ rather than free ITA grafts. Passing the RITA to the left, either anterior to the aorta or through the transverse sinus, did not influence patency.

Key Words: Myocardial revascularization • Coronary surgery • Internal thoracic artery • Long-term results • Arterial conduit

	1. Introduction

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Conclusion 6. Limitations of the... Appendix A Conference discussion References

 
The in situ (pedicled) left internal thoracic artery is generally accepted as the coronary artery bypass conduit of choice with excellent results being reported when the left internal thoracic artery (LITA) is anastomosed to the left anterior descending artery (LAD) [1]. Surgeons are less committed to using the right internal thoracic artery (RITA) because of the lack of data pertaining to late graft patency. These concerns have been reinforced by the paucity of convincing evidence regarding the clinical benefits of RITA grafting.

Recent data, however, suggest that the use of bilateral internal thoracic artery (ITA) grafts is not associated with any increase in early complications and provides long-term benefits over and above those associated with single ITA grafting [2,3]. Despite these positive results, information about the late graft patency of RITA grafts is scarce and there has been little attempt to define differences in late outcomes between free and in situ grafts, grafts targeted to LAD vs. non-LAD vessels, or to investigate the influence of pathological changes in target arteries on late patency.

Accordingly, the main purpose of this observational study is to address a number of unanswered questions regarding the efficacy and optimal usage of the RITA conduit. These questions include: should the graft be used as a free or in situ graft? Does the patency depend on the location of the distal anastomosis? Is patency influenced by the degree of stenosis in the native coronary artery? Is the diameter of the RITA or that of the native coronary artery important? And finally, is it preferable for a graft to the left-sided coronary arteries to lie anterior to the aorta or to pass through the transverse sinus?

	2. Methods

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Conclusion 6. Limitations of the... Appendix A Conference discussion References

 
2.1. Patients
The study population consisted of all coronary bypass ITA graft patients attending the Epworth Cardiac Surgical Unit between 1985 and 1998 who had a re-angiogram due to evidence of myocardial ischemia. At the time of the initial surgery, data were collected regarding graft type (left or right), attachment (in situ or free), and location (right or left heart). For in situ RITA grafts, the approach (transverse or anterior) was recorded. The diameters of the ITA, the presence of a proximal anastomosis with the aorta, the location of the anastomosis with the coronary artery, and the coronary artery diameter were also recorded at the initial procedure (Table 1).

2.2. Surgical technique – initial procedure
Following a conventional sternotomy, the LITA and then the RITA were harvested with a pedicle containing the pleura, the transversus thoracis muscle and fascia, and the internal thoracic veins. On the right side, the internal thoracic vein was mobilized to its termination with the right brachiocephalic vein. The upper branches of the ITA, including the pericardiacophrenic artery, were ligated with small clips adjacent to the ITA. The pedicle was sprayed with 2 mmol of a solution containing 80 mg/100 ml papaverine and Ringer's lactate solution. Following the transsection of either the lower end of the RITA pedicle or its terminal branches, and prior to implantation, the free flow was checked to exclude any proximal obstruction. Two to 3 cc of the papaverine and Ringer's lactate solution was diluted with an equal volume of blood (1 mmol/l, pH 7.4) and was injected into the distal end of the ITA or one of its terminal branches. The distal end was then clipped using hemostatic clips (Weck hemoclip, NC) and allowed to distend under arterial pressure.

Prior to the commencement of cardiopulmonary bypass, the right pedicle was passed through a window in the right pleura and pericardium, immediately anterior to the phrenic nerve, and its length assessed in relation to the left or right coronary artery system. If deemed inadequate, the right internal thoracic vein was used as a free graft.

Cardiopulmonary bypass was performed at 28°C until 1990 and subsequently at 32°C. Prior to 1991, antegrade cardioplegia was used at 15–20 min intervals. Since 1991, combined antegrade and retrograde blood cardioplegia at 25°C has been employed, using a single cross clamp for all distal and proximal anastomoses. While dilatation of the arterial grafts initially relied on topical papaverine, more recently the systemic vasodilator nitroglycerine or the phosphodiesterase III inhibitor (milrinone) has been used in addition to topical agents to produce a cardiac index of 3 l min^-1m^-2.

2.3. Graft strategy
From 1985 to 1988, the RITA was used as an in situ graft where possible. Initially, the RITA was anastomosed distally to the trunk of the right coronary artery, or to its acute marginal or posterior descending branches. From 1988 to 1994, preference was given to using the RITA as a free graft because of its flexibility. From 1995, the RITA was used more frequently as an in situ graft to the left side (to the LAD or diagonal coronary arteries). The graft was passed anterior to the ascending thoracic aorta, through the pericardium and behind the thymus, or through the transverse sinus to the intermediate or circumflex marginal coronary arteries. The LITA was usually grafted to the LAD. When the RITA was anastomosed to the LAD, the LITA was sutured to the diagonal, intermediate or, more commonly, to the circumflex marginal branches by passing either anterior or posterior to the left phrenic nerve [4]. All distal anastomoses were performed using 7/0 polypropylene sutures. Sequential anastomoses were seldom performed. Proximal anastomoses, if required, were performed directly with the ascending thoracic aorta using a continuous 6/0 polypropylene suture. Postoperatively, the mean arterial pressure was maintained at 70 mmHg or above, with a cardiac index of over 2l min^-1 m^-2 and a systemic vascular resistance of >800–1000 dynes s cm^-5.

2.4. Follow-up
Clinical follow-up data were obtained from office visits to the surgeon, cardiologist or general practitioner; by telephone interview; and by routine mail-out every 2 years. Postoperative coronary angiography was undertaken to assess any symptoms or cardiac events suggesting ischemia. Angiographic results were obtained from the cardiologist or directly from the angiographic laboratory. In addition to the surgeon's evaluation, graft patency was assessed independently by a cardiologist and a radiologist. Graft failure was defined as occlusion or stenosis 80%.

2.5. Statistical analysis
Data were collected by one of the investigators (J.F.), verified and entered into a dBase IV database program. All analyses were conducted using SAS Ver. 6.12 statistical software. Patient characteristics were determined using group descriptive statistics.

Survival analysis methods were used based on time to re-angiogram and graft failure as the outcome event. In addition, a multivariate analysis was conducted to identify intraoperative predictors of RITA graft failure. Comparisons were adjusted for the changes in operative technique occurring during the course of the data collection period. Adjusting for time of operation did not influence the statistical significance of reported comparisons, hence unadjusted data are presented. Estimated risk ratios (RR) and 95% confidence intervals (CI) are reported and statistical significance is based on the Wald Chi-square statistic. Unless specified, continuous data are expressed as mean±SD.

	3. Results

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Conclusion 6. Limitations of the... Appendix A Conference discussion References

 
Between 1985 and 1998, 962 patients who had previously had coronary artery bypass grafting underwent re-angiography because of myocardial ischemia. The mean age of these patients at the time of the initial graft procedure was 59.6±8.5 years. The mean re-angiography interval was 67.0±39.4 months postoperatively (range 0.1–169.5 months).

Five hundred and thirty patients had LITA grafts only and 432 patients had both RITA and LITA grafts. Of these 432 RITA grafts, 241 were in situ and 191 were free grafts. Of the in situ RITA grafts, 123 were to the right heart and 118 to the left heart. Of the in situ RITA grafts to the left heart, 62 were placed via the transverse sinus and 56 via the anterior route. The demographic, intraoperative, and postoperative characteristics of patients in each of these observational groups are summarized in Table 2. At the time of re-angiogram, 72 graft failures were identified, 15 in the LITA graft group and 57 in the RITA group.

View larger version (13K): [in this window] [in a new window]   Fig. 1. Cumulative graft patency (survival) of RITA vs. LITA grafts to the left anterior descending artery (RR 1.0 (95% CI, 0.2–4.7) P=0.98).

For RITA grafts to the left coronary system, those that passed anterior to the aorta were associated with a higher risk of failure compared with those that passed through the transverse sinus. This difference was not statistically significant (RR 2.1 (95% CI, 0.4–10.3) P=0.37).

3.3. Intraoperative predictors of RITA graft failure
Of the 432 RITA grafts, 57 failed (13%). Predictor variables for graft failure are shown in Table 3. Fig. 2a shows the cumulative patency curves for each of the RITA anastomotic sites. There was an increase in the risk of graft failure associated with using any alternative site to the LAD with the relative risk associated with using the right coronary artery graft almost reaching statistical significance (RR 4.0 (95% CI, 0.9–17.4) P=0.06; Table 3).

View larger version (19K): [in this window] [in a new window]   Fig. 2. (a) Cumulative patency for RITA anastomotic sites. There was an increase in the risk of graft failure associated with using any alternative site to the LAD with the relative risk associated with using the right coronary artery graft almost reaching statistical significance (RR 4.0 (95% CI, 0.9–17.4) P=0.06). (b) Cumulative patency associated with the degree of stenosis of the coronary artery at the time of surgery. In comparison with a stenosis of 80% or more, a stenosis of less than 60% incurred an almost 4-fold increase in risk (RR 3.8 (95% CI, 1.9–7.2) P=0.0001), while a stenosis of 60–79% incurred a 37% increase in risk (RR 1.4 (95% CI, 0.7–2.7) P=0.36). (c) Cumulative patency for free versus in situ RITA grafts. Free compared with in situ grafts were also associated with a higher risk of failure with this result bordering on statistical significance (RR 1.9 (95% CI, 1.0–6.0) P=0.06).

Proximal attachment to the aorta resulted in a 2-fold increase in the risk of graft failure compared with an in situ graft (RR 1.9 (95% CI, 1.0–6.0) P=0.06; Fig. 2c, Table 3).

	4. Discussion

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Conclusion 6. Limitations of the... Appendix A Conference discussion References

 
While the RITA has been used as a coronary artery bypass graft for nearly 30 years, there is a still some debate in the literature over the best approach to using this conduit. The RITA was employed initially as an in situ graft. In some situations, however, the length of the RITA is insufficient to reach the desired position on the target artery. Insufficient length may be overcome by detaching the RITA and using it as a free graft or by adding an additional conduit through a procedure known as graft extension [5]. In 1996, Verhelst and colleagues [6] found that the graft patency was lower if the RITA was used as a free graft and recommended that it be used as a pedicle (in situ) where possible. Our results support these findings. Free grafts, anastomosed to the aorta, have an increased graft failure rate at both early and late stages postoperatively suggesting that there may be early technical factors and ongoing problems with graft flow compromising the patency of the free graft. Attachment of the free RITA to the in situ LITA may overcome these problems; however, this procedure needs to be further evaluated. Although the late patency rates of free grafts are not as satisfactory as those of in situ grafts, they still appear to be superior to the results reported for saphenous vein grafts [7,8].

The target artery has also been recognized as an important determinant of ITA graft patency. The excellent patency of both right and left ITAs when grafted to the LAD has been demonstrated by a number of studies [9,10], a finding we have replicated in this investigation. The results of grafting non-LAD systems, however, have been less consistent and more controversial. Bezon and colleagues in 1998 [11] and Chow and colleagues in 1994 [12], found that anastomozing the RITA to the circumflex system was less satisfactory than grafting it to the LAD. Rankin and colleagues in 1986 [9] and Dietl and associates in 1995 [13] reported high failure rates when the posterior descending coronary artery was grafted with an in situ RITA and suggested that the right gastroepiploic artery was a preferable target vessel. Our choice is to graft the left-sided coronary arteries with an in situ RITA where possible.

The in situ RITA may be routed to the left side anterior to the aorta or through the transverse sinus. The anterior route allows us to use the in situ RITA to graft the LAD. Studies have shown that the utility of the in situ RITA grafted to the left coronary system can be further extended by passing it posteriorly through the transverse sinus, a procedure that provides a satisfactory long term outcome [12,14–18]. The results of our study also supported this finding. A theoretical objection to the anterior route is that it may compromise a subsequent re-operation for coronary artery disease or aortic valve replacement. In our experience this has not proved to be a problem. The RITA when passed anterior to the aorta lies within the pericardium posterior to the thymus and is applied to the aorta, which it crosses near the site for aortic cannulation. The excellent patency of in situ RITA grafts applied to the LAD anterior to the aorta outweighs any theoretical objection.

Competitive flow is perceived to be a problem using the bypass technique. Although there are numerous anecdotal reports [19–21], there are few data that relate patency to the degree of the original coronary artery stenosis [22–23]. Our analysis confirms the increased hazard when lesions with a low-grade stenosis are grafted.

This detailed analysis of the late patency of the RITA and its complex relationship with the coronary artery variables provides key information by which grafting strategies can be optimized. In particular, this study confirms the durability of the in situ RITA and therefore its potential for preventing the late complications following coronary artery surgery. In planning a coronary reconstruction, the RITA should assume the same important role as that of the LITA. For instance, an in situ RITA that reaches the desired location on the LAD may be used in preference to the LITA, which may then be deployed elsewhere, for example, to a large marginal branch. Alternatively, the situ RITA may be anastomosed to another left sided coronary artery, or used as a free graft.

In summary: (1) when the in situ RITA is anastomosed to the LAD the results are similar to those of LITA grafting. (2) Grafting the RITA to an artery with a low-grade stenosis markedly increases the risk of graft failure. (3) Overall, an increased risk of graft failure is associated with grafting non-LAD arteries, in particular, the right coronary artery. (4) This study suggests it may be beneficial to use in situ rather than free RITA grafts. (5) Neither the diameter of the ITA nor that of the coronary artery predicted graft patency.

	5. Conclusion

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Conclusion 6. Limitations of the... Appendix A Conference discussion References

 
The RITA is an excellent coronary artery bypass graft. To obtain the best long-term patency, the RITA should be grafted to a coronary artery with a high-grade stenosis or occlusion. It may be preferable to use the RITA as an in situ graft, however, this observation requires further substantiation. Passing the in situ RITA either anterior or posterior to the aorta gives a satisfactory result.

	6. Limitations of the study

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Conclusion 6. Limitations of the... Appendix A Conference discussion References

 
Although Cox proportional hazard models may provide a valuable assessment of the relationship between the various predictors and patency subgroups, it is important to recognize that these techniques are based on a number of assumptions that may have biased the results. Selection for re-angiography by using markers of ischemia may have resulted in the inclusion of a relatively high proportion of patients with advanced disease. The analyses were confined to the important intraoperative surgical variables and, like any retrospective study, other important predictors, for example, patient variables that were not included may have influenced the outcome. Furthermore, when using the Cox model, the time to graft failure and the time to angiography are assumed to be the same, when, in reality, graft failure may have occurred previously. Also, while some patients have had multiple angiograms, in this study only the time to the first graft failure was recorded so that subsequent angiographic data that may have contained important information were not included.

	Acknowledgments

 
The authors gratefully acknowledge the cardiac surgeons Peter Skillington, John Goldblatt, George Matalanis, Serge Lubicz and Don Esmore at the Austin & Repatriation Medical Centre and the Epworth Hospital for their cooperation and help; Dr Tania Lewis for her editorial excellence; and Janifer van Vliet for coordinating the hand-out and retrieval of patient clinical re-angiograms to date.

	Footnotes

 
Presented at the 13th Annual Meeting of the European Association for Cardio-thoracic Surgery, Glasgow, Scotland, UK, September 5–8, 1999.

	Appendix A Conference discussion

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Conclusion 6. Limitations of the... Appendix A Conference discussion References

 
Mr J. Pepper (London, UK): What was the indication for angiography in these patients?

Prof Buxton: The patients chosen for re-angiography were not routinely selected. They had re-angiography if they displayed symptoms or signs suggestive of ischemia although clearly some of them might not have had ischemia.

Mr Pepper: So this is a very select group then?

Prof Buxton: It is a select group, and that may have included people who were at high risk or a high number who had advanced coronary artery disease.

Mr A. Ritchie (Cambridge, UK): Professor Buxton, thank you very much for coming from your group with probably the largest experience of arterial bypass grafting anywhere in the world. Could I just ask you, only 7% of the total number of coronary artery bypass operations in your total time frame that have been studied in this study have been re-angiographied. So how do you think that impairs the power of your statistical analysis? And the second question is what to by pass the right coronary artery or the PD with. In my experience I can always get onto the PD with the RIMA. Bearing in mind your statistical doubts about the validity of the data, do you really think it's worth taking the time and trouble of taking the RIMA down and sticking it on the PD or the right coronary artery as opposed to a piece of vein? Do you have any information on that?

Prof Buxton: The first question relates to the small number of re-angiograms in our patient population. I could only find 8% of patients in that larger group who had re-angiography, and that may say something in itself. Obviously the power of the calculations would have been greater if there had been more cases. We have a mechanism for locating these patients and analyzing the data. The second question concerning the vessel of choice for grafting a posterior descending coronary artery was not part of the brief of this talk. The graft occlusion rate using free and, to a lesser extent, pedicled internal thoracic grafts on the right side is high, compared with a low failure rate of 0.5–1% per annum for the left internal thoracic artery grafted to the LAD. However, right internal thoracic arteries still only have a graft failure of 2% per year, that is, over 10 years there is still a patency rate of 80%, or a failure of 20%. A direct comparison with vein grafts was not made therefore I can't answer the question. Thought some of the configuration with which we are faced are not ideal, we have to play the hand that is dealt, and sometimes this means grafting a posterior descending lesion using a free internal thoracic artery graft. In this situation, even though the rate ratio or failure rate is higher, it is probably still better than using a vein graft.

	References

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Conclusion 6. Limitations of the... Appendix A Conference discussion References

 

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