title: Right Internal Mammary Artery Use in 140 Robotic Totally Endoscopic Coronary Bypass Cases: Toward Multiarterial Grafting.
abstract: OBJECTIVE
  Benefits of adding a second arterial graft in coronary bypass are well documented. In patients requiring mulitvessel grafting robotic totally endoscopic coronary bypass (TECAB) has allowed for routine harvesting and use of the right internal mammary artery (RIMA). We retrospectively reviewed the technical considerations and target choice in 140 cases of beating heart TECAB where a RIMA graft was used.
  
  
  METHODS
  In 2008, we introduced beating heart TECAB with anastomotic connectors into our practice, first with single IMA and then with bilateral internal mammary artery. A robotic stabilizer was used not only to facilitate exposure of the coronary targets but also to aid the RIMA harvest using a skeletonized approach. Flow measurements were obtained routinely. We reviewed the technical aspects, target choice, and intraoperative flows in our TECAB patients who underwent grafting with RIMA grafts.
  
  
  RESULTS
  From February 2008 to January 2015, a total of 404 patients underwent beating heart TECAB with anastomotic connectors, of which 194 (48%) were mulitvessel procedures. One hundred forty patients (35%) had a RIMA graft and constitute the patient population for this review. One hundred thirty-one RIMA grafts were harvested via left-sided ports and grafted to left coronary targets, and nine RIMA grafts were harvested via right-sided ports and grafted to the right coronary artery. Flow was greater than 25 mL/min (pulsatility index < 2) in 95% of grafts. Perioperative mortality was 0.7% and mean ± standard deviation length of hospital stay was 3.1 (1.5) days. The RIMA was used as an in situ graft in 124 cases (84%) and as a free T-graft in 24 cases (16%) cases. Right internal mammary artery graft use in all TECABS increased from 23% in the first 5 years to 53% in the last 2 years.
  
  
  CONCLUSIONS
  Robotic TECAB allows the routine harvesting and use of the RIMA graft in a safe and reproducible manner. Skeletonization and sternal sparing allow the RIMA to reach various coronary targets. Further studies are needed for this approach to impact the adaption of multiarterial grafting.
authors.affiliation: From the Departments of *Cardiothoracic Surgery and †Cardiology, University of Chicago Medicine, Chicago, IL USA.
authors.forename: Husam H
authors.initials: HH
authors.lastname: Balkhy
authors.forename: Sandeep
authors.initials: S
authors.lastname: Nathan
authors.forename: Susan E
authors.initials: SE
authors.lastname: Arnsdorf
authors.forename: Dorothy J
authors.initials: DJ
authors.lastname: Krienbring
mesh_terms: D000368:Aged; D003324:Coronary Artery Disease / Q000601:surgery*; D005260:Female; D006801:Humans; D007387:Internal Mammary-Coronary Artery Anastomosis / Q000295:instrumentation* / Q000379:methods / Q000639:trends; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D065287:Robotic Surgical Procedures / Q000295:instrumentation / Q000379:methods*; D016019:Survival Analysis; D016896:Treatment Outcome