Left-sided Retroaortic Right Internal Thoracic Artery Grafting via the Transverse Sinus

Background: Contemporary data regarding retroaortic right internal thoracic artery (rRITA) technique (rRITA routed to circumflex artery (Cx) targets through the transverse sinus) are scarce. Concerns regarding rRITA accessibility and risk of retroaortic bleeding appear to deter surgeons from using this technique.

Methods: The data of 601 patients undergoing bilateral ITA (BITA) grafting with rRITA between 2006 and 2015 were analyzed. BITA were invariably skeletonized. rRITA targets were categorized as proximal (ramus intermedius or first obtuse marginal) or distal (second or third obtuse marginal).

Results: Mean age was 60 years (range 35-86) and female gender comprised 11%. BITA only grafting was performed in 20% (n=120) and BITA with radial artery in 71% of patients (n=426). Complete arterial revascularization was subsequently performed in 91% (complementary saphenous veins used in 13.4%). Mean number of grafts/patient was 3.8 (range, 2-6). The mean number of arterial graft/patient and ITA grafts/patient was 3.7 (range, 2-6) and 2.7 (range, 2-5), respectively. Proximal and distal Cx targets were grafted in 85% and 15%, respectively. 30-day mortality was 0.8% and perioperative neurological events were documented in 1% of patients. Re-exploration for bleeding was required in 1.3% (n=8) of whom rRITA bleeding was documented in two patients (0.3%).

Conclusion: In-situ skeletonized BITA with rRITA is highly reproducible for proximal circumflex artery targets. Distal Cx target are accessible but may warrant post-bifurcation rRITA harvesting. The risk of retroaortic bleeding is low despite rRITA skeletonization.