Bilateral internal thoracic artery harvesting; anatomical variations to be considered

Abstract

Introduction: Predictable intrathoracic course, anatomical proximity to heart and long-term patency has made Internal thoracic artery (ITA) a conduit of choice in coronary artery bypass grafting (CABG). Its frequent bilateral use has necessitated the need to have a comparative knowledge of surgical anatomy of ITA on both sides.Methods: A random study was conducted on 100 adult human cadavers. Sternocostal wall was removed and fixed in 10% formalin and dissected for detailed anatomy of ITA. All observations were expressed as mean ± 2SD and appropriate statistical analysis conducted.Observations: ITA originated in common trunk with other branches of subclavian artery in 12% on right side and 4% on left . Mean length of right ITA was 20.15 ± 1.22 cm, left 19.83 ± 1.66 cm in 28% of cases where bilateral ITA terminated in 6th Intercostal space (ICS). On pattern of origin of sternal branches from ITA 3 groups were observed. Group-I-some sternal branches arising from common trunk of ITA on both sides (24%), Group-II-some sternal branches arising from common branch of ITA on one side only (54%), Group-III-all sternal branches arising directly from ITA on both sides (22%). Phrenic nerve crossed anterior to ITA on both sides in 52%, posteriorly in 14% and in remaining it crossed anteriorly on one side and posteriorly on other.Conclusion: Variations as described in our study in relations to phrenic nerve, level of bifurcation and sternal blood supply must be kept in mind while harvesting bilateral ITA to reduce risk of sternal dehiscence by preserving the sternal blood supply from common trunk and to prevent post operative phrenic nerve palsy. (Ind J Thorac Cardiovasc Surg, 2007; 23: 192-196)

Arterial conduits in coronary bypass surgery: Iraqi experience

“…Other subtypes due to different ITA branching patterns the collateral supply is at high risk for disruption. 13 In spite of small statistical sample in this review, we suggest that the key point in harvesting methods is to preserve the collaterals, trying to apply clips close to the artery and do not use excessive cauterization but rapid interrupted spark to cut the branches. Still, Skeletonization of one of ITA may be beneficial.…”

“…Sternal circulation can be diminished with the harvesting leading to sternal dehiscence 13 especially after using both ITA. Diabetes mellitus, BMI more than 35, severe COPD, exposure to radiotherapy and immunosuppressant 14 consider as risk factors that contribute to the raising incidence of this complication.…”

“…The complications were reported to be higher in BITA grafting than using single ITA (SITA). 13 BITA and 0.89 with skeletonized SITA. We lack comparison groups to determine a better way of harvesting BITA.…”

Higher Division of Right Internal Thoracic Artery – a case report

“…Now a day's unilateral / bilateral pedicle, sequential or free graft of ITA will be used in CABG surgery because of long term patency and event free survival. Now studies have shown that skeletonised bilateral internal thoracic artery grafting can provide better event free survival than single internal thoracic artery grafting in selected group of patients [3]. In autologous breast reconstruction internal thoracic vessels are widely used as recipient vessels.…”

Abnormal origin of internal thoracic artery from the thyrocervical trunk: surgical considerations

“…It is widely utilized for coronary artery bypass grafting (CABG) surgery. The ITA’s anatomic characteristics, such as distinct intrathoracic course and anatomical vicinity with the heart [ 1 ], its long-term patency [ 1 - 4 ], the long-term survival rate [ 2 , 4 ] and post-operative quality of life [ 5 ] render it as an excellent arterial graft for myocardial revascularization.…”