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Middle segment at crossing level of right internal thoracic artery ( RITA ) (as shown in Fig 1). The catheter has been labeled to differentiate it from the RITA graft.
Source publication
The left internal thoracic artery (LITA) graft to the left anterior descending (LAD) artery became the gold standard graft in coronary surgery. Subsequently, the right internal thoracic artery (RITA) graft was increasingly used. However, there is still some debate about the optimal way of using this conduit. The aim of the present study was to asse...
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Citations
... 590 For CABG, recent studies show that RITA-LAD can achieve similar outcomes to LITA-LAD, 591,592 and postoperative graft patency is similar between them. 554,593, 594 The outcome of CABG with RITA grafted to the LCX is also similar to that for LITA-LAD. 593,595-597 However, RITA grafted to the RCA, although limited numbers among the reported cases, has shown a relatively low patency of about 80% with a high postoperative event rate. ...
... The need for coronary angiography was dictated by the occurrence of angina, instability, or electrocardiogram changes in the perioperative or late follow-up period. It is however, worth mentioning that initially when RIMA and RA grafting were adopted in our institution early postoperative angiography to check the quality of the grafts and anastomoses was undertaken [34,35]. ...
Objective:
Additional arterial grafts such as the right internal mammary artery (RIMA) or the radial artery (RA) have been proposed to improve long term outcomes in coronary artery bypass grafting (CABG). RA is largely preferred over RIMA as it is less technically demanding and there is a perception that bilateral IMA usage increases the risk of sternal wound complications. However, there is a paucity of direct comparison of the two conduits to guide surgeons to choose the best second arterial conduit for CABG.
Methods:
A propensity score adjusted analysis of patients undergoing multiple arterial grafting with RIMA (n = 747) and RA (n = 779) during the study period (2001-2013) was conducted to investigate the impact of the two strategies on early and late outcomes.
Results:
RIMA did not increase the incidence of postoperative complications including deep sternal wound infection (P = 0.8). Compared to the RIMA, the RA was associated with an increased risk for late mortality (Hazard Ratio [HR] 1.9; 95% confidence interval (CI) 1.2-3.1; P = 0.008) and repeat revascularization (HR 1.5; 95% CI 1.0-2.2; P = 0.044). A trend towards an extra risk for late mortality from RA over RIMA was observed among diabetic (HR 3.3; 95% CI 1.1-9.7) and obese patients (HR 2.1; 95% CI 0.8-5.46).
Conclusions:
RIMA as a second conduit did not increase the operative risk including sternal wound complications and improved long term outcomes including overall survival when compared to RA. This advantage was stronger among diabetic and obese patients. These findings strongly support RIMA as the first choice second arterial conduit in CABG. Further randomized studies with angiographic control and long-term follow-up are needed to address this issue.
... In the present study, because of lesion complexities or total occlusion of the LSA, LSA stenosis was not amenable to endovascular intervention in half of the patients. For those patients, revascularization using grafts other than the left ITA had to be considered, and revascularization using the in situ right ITA was preferred because of well-established clinical and angiographic superiority of the in situ right ITA graft [12][13][14]. Patency rates of the right ITA (non-PTA group) for revascularization of the LAD were similar to those of the left ITA (PTA group). The present study also demonstrated that there was no difference in patency rates between grafts emanating from the left ITA and other in situ grafts at early, 1-year, and 5-year angiography. ...
We examined the prevalence of significant proximal left subclavian artery (LSA) stenosis in patients referred for isolated coronary artery bypass grafting, and assessed management by percutaneous transluminal angioplasty (PTA) for LSA stenosis and revascularization using the left internal thoracic artery, or revascularization using grafts other than the left internal thoracic artery.
Between 1998 and 2007, significant proximal LSA stenosis was identified in 38 of 1,498 patients who underwent isolated coronary revascularization. Percutaneous transluminal angioplasty was performed before or after surgery in 20 patients (PTA group). Revascularization using grafts other than the left internal thoracic artery was performed in 18 patients with LSA stenosis unamenable to PTA (non-PTA group). Early, 1-year, and 5-year follow-up angiograms were performed to assess patency of both grafts and PTA. Computed tomographic angiography was also performed at 2 years in the PTA group.
Prevalence of significant LSA stenosis was 2.5%. Early, 1-year, and 5-year angiograms showed overall graft patency rates of 97.2% (105 of 108 distal anastomoses), 88% (81 of 92), and 92% (23 of 25), respectively. No differences were observed in graft patency rates between the two groups during the follow-up period. No intervention-related morbidities occurred in the PTA group. Estimated patency rates of PTA at 2 and 5 years were 100% and 85.7%, respectively.
Percutaneous transluminal angioplasty for LSA and revascularization using the left internal thoracic artery may be an effective treatment for patients with significant LSA stenosis. In patients with LSA stenosis unamenable to PTA, revascularization using grafts other than the left internal thoracic artery may be another treatment option.
... Several arrangements of left-sided bilateral internal thoracic artery (ITA) grafting have been proposed, [1][2][3] however, insofar as the superiority of one arrangement over the other remains undetermined. In situ bilateral ITA grafting with ante-aortic crossover RITA is increasing popularity thanks to its simplicity in achieving leftsided revascularization [2][3][4][5] and its benefits in off-pump coronary artery bypass (OPCAB). It has been reasoned that OPCAB techniques may be facilitated by allowing tension-free RITA to left anterior descending (LAD) during displacement of the beating heart. ...
In situ bilateral internal thoracic artery (ITA), with ante-aortic crossover right ITA (RITA) is gaining popularity. However, the retrosternal position of the crossover RITA has raised concerns with regard to its compromise during subsequent resternotomy.
Ten patients underwent repeat median sternotomy after prior ante-aortic crossover RITA grafting. Specific RITA routing and fixation had been performed in the initial operation. Preoperative imaging, including computed tomography (CT) angiography, was performed to confirm RITA position in relation to the sternum and assess feasibility.
Resternotomy was performed 4-48 months after the initial operation (median, 22 months). Nine crossover RITA grafts were functioning at the time of resternotomy. CT angiography was performed in four patients in whom the premarked RITA could not be localized on the plain chest radiograph. The feasibility of conducting a nonmodified resternotomy was determined based on preoperative imaging. All RITA grafts resumed their original position and none was injured during reentry. There was no early mortality, perioperative stroke, or reexploration for bleeding. One patient sustained myocardial infarction, however, not in a RITA-related distribution. CT angiography was predictive in confirming a free retrosternal space.
Resternotomy after prior ante-aortic crossover RITA grafting can be performed at acceptable risk. Confirmation of a free retrosternal space by preoperative imaging may contribute to the safety of the procedure. Maneuvers performed during the first operation are useful in preventing RITA adherence to the sternum.
Coronary artery disease remains a formidable challenge to clinicians. Percutaneous interventions and surgical techniques for myocardial revascularization continue to improve. Concurrently, in light of emerging data, multiple practice guidelines have been published guiding clinicians in their therapeutic decisions. The multidisciplinary Heart Team concept needs to be embraced by all cardiovascular providers to optimize patient outcomes.
Objective: We evaluated early outcomes of right internal thoracic artery graft for left coronary system in off-pump coronary artery bypass grafting. Methods: We reviewed the records of 174 patients who underwent off-pump coronary artery bypass grafting using right internal thoracic artery (RITA), between January 2009 and December 2011. The RITA was used as an in situ graft in 72 patients (72 anastomosis) and as a free graft in 102 patients (129 anastomosis). When we anastomosed the free RITA to the ascending aorta, we routinely used intraoperative epiaortic echocardiography to detect a diseased free area of the aorta. When the ascending aorta was diseased and in-situ graft was short, we anastomosed the free RITA proximally to another graft (left internal thoracic artery and saphenous vein graft) with create a Y-shaped composite graft. We compared operative and postoperative variables and early patency rates of the right internal thoracic artery between the groups. Results: The operative morality was 0.6%. The operative mortality and incidence of postoperative complications were not significantly different between groups. The overall early patency rates of the RITA were 95.8 96. There were no significant differences in patency rate between in situ and free RITA grafts (96.2 % vs. 95.8 % p=0.679). In free graft group, there were no significant differences in patency rate between proximal anastomotic site, ascending aorta was 100% and Y-composite was 94.4% (p= 0.559). Conclusions'. Early patency rates of in situ and free RITA grafts were good. When the ascending aorta was diseased and in-situ graft was short, the proximal RITA should be anastomosed to another graft with Y-shaped composite graft.
Superior patency-rate of ITA, especially BITA-grafting to saphenous vein grafts, is conclusive. This study evaluates angiographic findings postoperatively in 663 symptomatic patients receiving one or both ITAs and vein grafts.
663 patients (553 male, mean age 62) with CABG operated between 1/94 and 6/02 underwent reangiography due to reappearance of angina or unclear cardiac symptoms. Angiographic data were compared for patency rate of single ITA (n = 379), bilateral ITA (n = 220) or vein grafts. Recatherization was performed after an average of 1000 days (+/- 766 days). Severe bypass stenosis or occlusion was related to target vessels for all grafts.
2099 Bypasses were performed in 663 patients. Severe stenosis or occlusion was detected in 255 ACB (19.9 %) of 1280 and 93 ITAs of 819 (11.4 %, p < 0.001). Patency was 88.8 % (532) for LITA, 88.2 % (194) for RITA. Target vessels were as follows: LITA: 60 % (358) LAD, 23.5 % (141) CX, RITA: 82 % (180) LAD. Occlusion rate for LITA was as follows: to LAD 7 %, to DIA 8.7 %, to CX 8.5 %. Occlusion rate for RITA as follows: to LAD 6.7 %, to DIA 16.7 %, to CX 0, to RCA 14.3 %. Occlusion rate for ACB was as follows: to LAD 18.7 %, to DIA 12.6 %, to CX 14.1 %, to RCA 16.1 %. Despite symptoms, bypass patency was observed in 412 (62.1 %) of 663 patients.
Superior patency of ITA, especially BITA grafting could be documented angiographically in a negative selected symptomatic population. Graft occlusion was nearly two fold higher in vein grafts. Our surgical strategy, revascularizising RITA with LAD, LITA with circumflex artery results in satisfactory mid-term graft patency.
