title: In situ retrocaval skeletonized right internal thoracic artery anastomosed to the circumflex system via transverse sinus: technical aspects and postoperative outcome.
abstract: BACKGROUND
  The aim of this study was to investigate whether, by using the in situ right internal thoracic artery via the transverse sinus (eventually retrocaval), both the proximal and distal major branches of the circumflex system could be grafted and to evaluate the early and late outcome in these patients.
  
  
  METHODS
  Between January 1997 and March 2002, 452 consecutive patients underwent grafting of the circumflex system with the in situ skeletonized right internal thoracic artery routed via the transverse sinus. The mean age was 62.4 +/- 10.3 years. A mean of 2.2 +/- 0.3 arterial grafts per patient were used, and 271 (60%) patients underwent total arterial myocardial revascularization. At 3 months after surgery, 86 patients (right Y or T graft) underwent echo color Doppler imaging before and after an adenosine provocative test. The mean follow-up was 27 +/- 8 months.
  
  
  RESULTS
  The success rate of skeletonized right internal thoracic artery grafting to the circumflex system branch was 100%. There were 15 (3.4%) hospital deaths. In 116 patients who underwent postoperative angiography, the total patency rates of the right and left internal thoracic arteries were 94% and 96.6%, respectively. Strong predictors for nonfunctional internal thoracic artery grafts were a small internal thoracic artery caliber (P <.001), recipient coronary artery diameter less than 1.5 mm (P =.012), stenotic lesions of less than 60% (P =.016), and diffuse stenotic lesions (P =.015) of the recipient coronary artery. In 86 patients who underwent postoperative echo color Doppler imaging, the flow reserves at the main stem of the left and right internal thoracic arteries were 2.24 +/- 0.5 and 2.48 +/- 0.6, respectively. Cumulative actuarial survival at 3 years was 96.3%, and event-free cumulative survival was 93%. The Cox model revealed a left ventricular ejection fraction of less than 35% (P =.016), age greater than 70 years (P =.025), New York Heart Association grade greater than III (P =.0019), nontotal arterial myocardial revascularization (P =.002), and the preoperative presence of more than 1 ischemic area (P <.001) as strong predictors for poor overall cumulative event-free survival.
  
  
  CONCLUSIONS
  The skeletonized right internal thoracic artery, placed via the transverse sinus and eventually retrocaval, can reach most branches of the circumflex system and is associated with an excellent patency rate. The predictors for poor overall event-free survival seem to be similar to those of the general population undergoing conventional coronary artery bypass grafting. Use of bilateral internal thoracic arteries and in situ right internal thoracic artery grafting via the transverse sinus offers the possibility of various configuration constructions, making possible total arterial myocardial revascularization with a minimum number of arterial conduits.
authors.affiliation: Department of Cardiac Surgery, University of Florence, Italy. mbonacchi@unifi.it
authors.forename: Massimo
authors.initials: M
authors.lastname: Bonacchi
authors.forename: Edvin
authors.initials: E
authors.lastname: Prifti
authors.forename: Francesco
authors.initials: F
authors.lastname: Battaglia
authors.forename: Giacomo
authors.initials: G
authors.lastname: Frati
authors.forename: Guido
authors.initials: G
authors.lastname: Sani
authors.forename: Georges
authors.initials: G
authors.lastname: Popoff
mesh_terms: D000328:Adult; D000368:Aged; D015331:Cohort Studies; D017023:Coronary Angiography; D001026:Coronary Artery Bypass / Q000379:methods* / Q000401:mortality; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D015150:Echocardiography, Doppler; D005260:Female; D005500:Follow-Up Studies; D006083:Graft Occlusion, Vascular / Q000000981:diagnostic imaging / Q000453:epidemiology; D006085:Graft Survival; D006334:Heart Function Tests; D006801:Humans; D007387:Internal Mammary-Coronary Artery Anastomosis / Q000379:methods*; D008297:Male; D008323:Mammary Arteries / Q000637:transplantation*; D008875:Middle Aged; D015999:Multivariate Analysis; D011183:Postoperative Complications / Q000000981:diagnostic imaging / Q000453:epidemiology; D011336:Probability; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D018570:Risk Assessment; D018709:Statistics, Nonparametric; D015996:Survival Rate; D020858:Tissue and Organ Harvesting; D016896:Treatment Outcome; D014654:Vascular Patency