Sequential, free and Y internal thoracic artery grafts

The internal thoracic artery (ITA) has excellent durability and its ability to survive for 10 years or more far exceeds the saphenous vein graft (SVG). In an attempt to improve long-term survival from coronary artery bypass grafting (CABG), three or more (up to six) ITA coronary anastomoses have been placed in 718 patients since 1982. Initial flow in the ITA immediately after grafting is critical to the success of the operation. Careful dissection and preparation of the ITA pedicle to prevent injury and spasm, constructing parallel and perpendicular anastomoses so the most proximal portion of the ITA is used for anastomosis and the use of the free right ITA to increase length of graft available are measures employed to increase critical flow. Actuarial survival at 6 years is 92.5% in this group of patients, which includes elderly patients, patients with left ventricular dysfunction and patients undergoing emergency operations.