title: Repeat median sternotomy after prior ante-aortic crossover right internal thoracic artery grafting.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Cardiothoracic Surgery, The Tel Aviv Sourasky Medical Center and The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. orenlevran@hotmail.com
authors.forename: Oren
authors.initials: O
authors.lastname: Lev-Ran
authors.forename: Rephael
authors.initials: R
authors.lastname: Mohr
authors.forename: Galit
authors.initials: G
authors.lastname: Aviram
authors.forename: Menachem
authors.initials: M
authors.lastname: Matsa
authors.forename: Nahum
authors.initials: N
authors.lastname: Nesher
authors.forename: Dmitry
authors.initials: D
authors.lastname: Pevni
authors.forename: Gideon
authors.initials: G
authors.lastname: Uretzky
mesh_terms: D000368:Aged; D000714:Anastomosis, Surgical; D001013:Aorta, Thoracic / Q000637:transplantation; D001026:Coronary Artery Bypass; D005260:Female; D006801:Humans; D008297:Male; D008323:Mammary Arteries / Q000637:transplantation; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology / Q000503:physiopathology / Q000601:surgery; D017534:Radial Artery / Q000637:transplantation; D012086:Reoperation; D012501:Saphenous Vein / Q000637:transplantation; D013249:Sternum / Q000098:blood supply* / Q000601:surgery*; D016896:Treatment Outcome; D014654:Vascular Patency / Q000502:physiology