Background: Contemporary techniques used for single left internal thoracic artery (LITA) revascularization of the left anterior descending artery (LAD) area (sequential diagonal-LAD grafting or auto-Y LITA composite-graft) warrant prior LITA anastomosis that may risk LAD revascularization due to technical errors or flow competition. This study evaluates a novel LAD-first technique using skeletonized LITA in inverted-J configuration.

Methods: 150 LAD-D anastomoses symptom-directed angiograms were studied in 75 patients. Data were derived from patients undergoing primary multivessel coronary artery bypass surgery during 2006-2013. Concomitant LITA grafting of the LAD and diagonal artery (D) was performed in 250 patients by standard sequential grafting (D-first) or inverted J-configuration (LAD-first) (130 patients, 52%). The LAD-first concept was achieved by longitudinal side-to-side LITA-LAD anastomosis and reversed end-to-side LITA-D anastomosis forming inverted-J LITA configuration (Figure 1).

Results: Overall, 92% LITA-LAD and 93.3% % LITA-D grafts were patent at median 62 months postoperatively (range, 1-107 months). Graft-failures were significantly more frequent in peripheral segments/distal anastomoses (81.8% vs 18.2%, p=0.001).

The inverted-J technique was angiographically demonstrated in 40 patients (53%; 80 anastomoses) and standard D-LAD grafting in 35 patients. Mean time to re-angiogram was comparable (p=0.539). LITA-LAD graft-failure (1/40 vs 5/35) was significantly lower in the inverted-J group (2.5% vs 14.2%, p=0.039); resulting in significantly better LAD patency-rate in patients undergoing inverted-J technique at 5.2 years postoperatively (97.5% vs 85.7%, p=0.039). Patency-rate of the diagonal artery was comparable between both techniques (97.1% vs 90% at 5.2 years, p=0.221).

Conclusion: The inverted-J technique achieves superior LAD patency-rate, thus, recommended whenever technically feasible.

Figure 1. Sequential LAD (side-to-side) and diagonal artery (reversed end-to-side) grafting using inverted-J LITA configuration (LAD-first). Coronary angiography, anterior (1a) and lateral (1b) views.

LAD, Left anterior descending artery; LITA, Left internal thoracic artery

figure 1a

figure 1b