The right internal thoracic artery graft - benefits of grafting the left coronary system and native vessels with a high grade stenosis - Appendix A. Conference discussion

Objective: The left internal thoracic artery (LITA), when grafted to the left anterior descending artery (LAD), is generally accepted as the conduit of choice for coronary artery bypass grafting (CABG). In contrast, the role and efficacy of the right internal thoracic artery (RITA), despite its long-term use as a coronary artery graft, is relatively less understood. Accordingly, in this study, we sought to assess the utility of the RITA as a coronary conduit by examining the long-term patency of both in situ and free RITA grafts and analyzing the association between intraoperative graft and coronary artery variables. Methods: Nine hundred and sixty-two patients (LITA 962, RITA 432) who had CABG between 1985 and 1998 and underwent re-angiography for evidence of myocardial ischemia were included in this observational analysis. The diameter of the internal thoracic artery (ITA), the presence of a proximal anastomosis with the aorta, the location of the anastomosis with the coronary artery, and the coronary artery diameter, were recorded at the initial procedure. The follow-up was 67.0±39.4 months (mean±SD, range 0.1-169.5). The relationship between intraoperative variables and graft patency was assessed using Cox proportional hazard models. Results: Highest RITA failure rates were associated with grafting a native coronary artery with a stenosis of less than 60% compared with 80-100% (RR 3.8 (95% CI, 1.9-7.2) P=0.0001). Grafts to non-LAD arteries had a higher risk of failure, the highest risk ratio being associated with grafting the right coronary artery (RR 4.0 (95% CI, 0.9-17.4) P=0.06)). Free compared with in situ grafts were also associated with a higher risk of failure with this result bordering on statistical significance (RR 1.9 (95% CI, 1.0-6.0) P=0.06)) Conclusion: Preference should be given to grafting arteries with a high grade stenosis or occlusion, to grafting left rather than right coronary arteries, and to using in situ rather than free ITA grafts. Passing the RITA to the left, either anterior to the aorta or through the transverse sinus, did not influence patency. Copyright (C) 2000 Elsevier Science B.V.