title: The right internal thoracic artery and right gastroepiploic artery: alternative sites for proximal anastomosis in patients with atherosclerotic calcified aorta.
abstract: BACKGROUND
  Atherosclerotic or calcified ascending aorta is an important predictor of adverse cerebrovascular events. Using off-pump coronary artery bypass (OPCAB) with composite and in situ arterial grafting to avoid aortic manipulation and clamping may reduce the risk of stroke related to aortic atheroembolism. When the aorta is calcified and cannot serve as a safe site for proximal anastomosis, this anastomosis can be performed on the proximal segment of the right internal thoracic artery (ITA) and right gastroepiploic artery (RGEA). Four such cases are described.
  
  
  METHODS
  In 2 patients, the proximal right ITA was used as the site for proximal saphenous vein graft (SVG) anastomosis. Chronic obstructive lung disease in one patient and insulin-dependent diabetes in the other precluded performance of OPCAB with bilateral ITA. In addition, positive Allen test precluded performance of composite T-graft with radial artery (RA) on ITA. Both SVGs were anastomosed distally to the posterior descending artery. In 2 other patients, RA was connected end-to-side to the proximal segment of the RGEA. Both of these patients had repeat operations. The distal end of the RGEA was too small, and concerns regarding the future flow to a very large coronary bed precluded its use as an in situ graft.
  
  
  RESULTS
  All patients underwent the operative procedures without any neurological or cardiovascular adverse effects, and all are midterm, symptom-free survivors. Postoperative graft patency was confirmed intraoperatively with flow measurements and postoperatively with control angiography or coronary imaging computed tomography.
  
  
  CONCLUSIONS
  The RITA and proximal RGEA can serve safely as sites for proximal anastomosis in patients with atherosclerotic calcified aorta undergoing OPCAB.
authors.affiliation: Department of Cardiology, The Tel Aviv Sourasky Medical Center and The Sackler Faculty of Medicine, Tel Aviv University, Israel. isach@tasmc.health.gov.il
authors.forename: Itzhak
authors.initials: I
authors.lastname: Herz
authors.forename: Rephael
authors.initials: R
authors.lastname: Mohr
authors.forename: Galit
authors.initials: G
authors.lastname: Aviram
authors.forename: Dan
authors.initials: D
authors.lastname: Loberman
authors.forename: Chaim
authors.initials: C
authors.lastname: Locker
authors.forename: Yanai
authors.initials: Y
authors.lastname: Ben-Gal
authors.forename: Gideon
authors.initials: G
authors.lastname: Uretzky
mesh_terms: D000714:Anastomosis, Surgical / Q000379:methods*; D001018:Aortic Diseases / Q000601:surgery*; D050197:Atherosclerosis / Q000601:surgery*; D002114:Calcinosis / Q000601:surgery*; D024405:Gastroepiploic Artery / Q000601:surgery*; D006801:Humans; D008297:Male; D008323:Mammary Arteries / Q000601:surgery*; D016896:Treatment Outcome