Right Internal Thoracic Artery with an Anteroaortic Course

Abstract

Coronary artery bypass graft surgery remains the procedure of choice to revascularize patients with complex multivessel coronary artery disease. The left internal thoracic artery and saphenous vein are the most commonly utilized conduits in coronary artery bypass graft surgery. The left internal thoracic artery is widely accepted as the conduit of choice for coronary artery bypass grafting. Accumulated evidence in recent years has demonstrated the superiority of bilateral internal thoracic artery grafting over single internal thoracic artery grafting in terms of event-free survival, freedom from reintervention and survival. The survival benefit seen with bilateral internal thoracic artery grafting has been associated particularly with grafting the myocardium supplied by the left coronary artery system. Many surgical strategies have been tested in order to achieve left-sided myocardial revascularization with bilateral internal thoracic artery grafting. These include directing the right internal thoracic artery through the transverse sinus in a retroaortic course, free graft connected proximally either to the left internal thoracic artery (composite grafting) or to the ascending aorta. Another technical option is in situ right internal thoracic artery to the left anterior descending and left internal thoracic artery to circumflex marginal branches; in this chapter we will comment on this technique.