title: Concomitant grafting of both postbifurcation internal thoracic artery branches.
abstract: OBJECTIVE
  We aimed to assess the clinical outcome and graft patency after concomitant grafting of both postbifurcation internal thoracic artery (ITA) branches.
  
  
  METHODS
  Between 2007 and 2013, 17 patients (14 men; mean [SD] age, 60 [9.3] years) underwent skeletonized bifurcated ITA grafting. Respective targets were restricted to non-left anterior descending (LAD) area. In all patients, a complementary standard ITA was used to graft the LAD artery. Graft patency was assessed by standard coronary angiography or serial multidetector computed tomography.
  
  
  RESULTS
  Of the bifurcated conduits, 94% were right ITA. Respective right ITA target sets were first and second obtuse marginal arteries (M1-M2) (n = 12), ramus-M1 (n = 2), and distal right coronary artery-posterior descending artery (n = 2). Right ITAs were mobilized retroaortic (via the transverse sinus) in 14 patients (82%) (to circumflex artery targets). Circumflex artery targets comprised 88.2% of all anastomoses (30/34). There were no early mortalities, myocardial infarctions, or hypoperfusion syndromes. During median follow-up of 44 months (range, 3-63), there was no late mortality. Overall reintervention rate was 11.7%, and bifurcated ITA-related reintervention rate was 5.8%. At 5 years, freedom from major adverse cardiac or cerebrovascular event related to bifurcated ITA respective territory was 87% (Kaplan-Meier). Coronary imaging was achieved in 76% of the patients (elective multidetector computed tomography, n = 9; symptoms-directed coronary catheterization, n = 4). Bifurcation branch patency rate was 88.4% (23/26) at a median of 3.5 years.
  
  
  CONCLUSIONS
  Grafting both postbifurcation ITA branches is technically feasible and may be selectively considered. Current observations are valid for skeletonized conduits and limited to non-LAD targets. These preliminary findings should be corroborated by larger data sets.
authors.affiliation: From the *Department of Cardiothoracic Surgery, and †Cardiac Imaging Service, Soroka University Medical Center, Beer-Sheva, Israel.
authors.forename: Gideon
authors.initials: G
authors.lastname: Sahar
authors.forename: Arik
authors.initials: A
authors.lastname: Wolak
authors.forename: Menachem
authors.initials: M
authors.lastname: Matsa
authors.forename: Ilan
authors.initials: I
authors.lastname: Shelef
authors.forename: Lior
authors.initials: L
authors.lastname: Raichel
authors.forename: Yaron
authors.initials: Y
authors.lastname: Ishay
authors.forename: Oren
authors.initials: O
authors.lastname: Lev-Ran
mesh_terms: D000368:Aged; D017023:Coronary Angiography / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007387:Internal Mammary-Coronary Artery Anastomosis / Q000379:methods*; D008297:Male; D008323:Mammary Arteries / Q000000981:diagnostic imaging / Q000601:surgery*; D008875:Middle Aged; D061330:Multidetector Computed Tomography / Q000379:methods; D011184:Postoperative Period; D016896:Treatment Outcome; D014654:Vascular Patency