Operative Insights on Multigraft Beating Heart Coronary Surgery With Two Internal Thoracic Arteries in a Y-Configuration

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The advantages of multiarterial grafting and aortic bypass are well known; however, their adoption remains low, even in high-volume centers. To date, there is a large amount of data supporting short- and long-term benefits of internal thoracic artery grafting and the no-touch aorta methodology during the operation (1). The beating heart surgical technique without cardiopulmonary bypass may also reduce the rate of significant perioperative complications associated with bypass surgery, such as stroke and blood transfusion (2, 3). Therefore, within the authors’ group, they consider off-pump coronary artery bypass (OPCAB) to be the method of choice for most of their patients, and they routinely use both internal thoracic arteries. This operative video shows a coronary operation with two internal thoracic arteries in a Y-configuration. 

Patient Presentation 

The patient was an otherwise healthy male with diabetes on oral medication and a history of previous myocardial infarction (MI). He was admitted to the hospital with unstable angina, and coronary angiography was immediately performed. The patient was scheduled for coronary artery bypass grafting (CABG) the day after admission. 

Y-Anastomosis Between Right and Left Internal Thoracic Arteries 

Both internal thoracic arteries were taken down in the standard skeletonized fashion, with the right internal thoracic artery cut at its origin to create a free graft. Side branches were ligated with electrocautery, with minimal use of the clips. Next, the bottom surface of the left mammary was exposed, and all tissue and adventitia were removed using a scalpel. A fine incision was made in the arterial wall and extended with scissors to achieve wide anastomosis. In the meantime, the proximal part of the right mammary was prepared to match the incision on the left artery. Finally, both arteries were connected using a running 8-0 polypropylene suture using a parachute technique beginning from the heel of the anastomosis. The running suture started from the inside of the left mammary and went from outside to inside on the right mammary. After three to four stitches were made, the right internal thoracic artery (RITA) landed onto the left internal thoracic artery (LITA). Care was taken to avoid weakening or overtightening of the suture to prevent narrowing of the anastomosis while maintaining the anastomosis hemostatic. Also, the alignment of the arterial edges should be perfect with no tissue left inside the anastomosis, because any flow disturbance inside the Y-construction could affect its overall function. 

Three quarters of the anastomosis, including its heel and toe, were made clockwise using the longer leg of the suture, while the remaining part, as seen in the video, was completed with the short leg. At the last stitch, the arteries were expanded by filling them with blood, and the final suture sealed the anastomosis. Additional hemostatic stitches may be applied, but they are undesirable. 

LITA to Left Anterior Descending Artery (LAD) Anastomosis 

Once the anastomosis was complete, the pericardium was opened, the left pericardium was lifted and fixed to the retractor, and a deep stitch below the left phrenic nerve was applied. The heart was then positioned using a myocardial stabilizer without threatening hemodynamics. The arterial flow was initiated beginning from the LAD. First, the LITA to left anterior descending artery anastomosis was created. The subsequent plan was to graft the diagonal branch using the RITA sequentially and to terminate the construction on the posterior descending artery, which in this case was occluded. Since the patient was diabetic, diffuse back wall lesions on the LAD were observed, severely narrowing its lumen despite the fact that its original diameter was more than 2.0 mm. An intracoronary shunt was installed inside the lumen to prevent excessive bleeding and maintain visibility. All distal arterial anastomoses were performed with 8-0 polypropylene stitches. At the last stitch, the temporary shunt was removed, and air embolism prophylaxis was performed, before finalizing the suture line and launching the arterial flow. 

RITA to Diagonal Branch Side-to-Side Anastomosis 

Once the LIMA-LAD anastomosis was complete, the stabilizer was repositioned to the large diagonal branch, and the sequence was repeated. The potential site of the anastomosis on the RITA was carefully selected. The optimal spot, devoid of the plaque on the diagonal artery, was found and meticulously cleared. No graft misalignment of both ITAs at this stage was accepted. The LITA remained mobile and straight. When all preparationswere complete, the coronary artery was incised, and the intraluminal shunt was positioned promptly. The anticipated spot on the RITA was prepared using a 15-scalpel blade, and the size of the arteriotomy was adjusted to match the coronary arterial opening with scissors. All precautions were taken to avoid overtightening and seagull deformity at the site of the sequential anastomosis. In this particular case, a linear configuration was selected. Otherwise, a diamond-shape technique can be used if best alignment is anticipated. 

RITA to Patent Ductus Arteriosus (PDA) End-to-Side Anastomosis 

At the next stage, the lateral and posterior walls of the heart were revised, and the heart apex was lifted out of the pericardium and elevated. The heart was retracted cranially with tension on the deep stitch, and the stabilizer was repositioned to the PDA. The proper configuration inside the pericardial cavity was provided for the conduit. Good conduit flow was confirmed, and the length of the conduit to its target was measured. The conduit was then fixed firmly, and the target zone was cleared with a scalpel. All subsequent steps were consistent with those described above. The T-form end-to-side parachute anastomosis of the RITA with the PDA was completed using an 8-0 polypropylene stitch with the intracoronary shunt in place. This was removed upon completion of the anastomosis, and the full coronary flow was reestablished. 

Final Revision and Completion of the Operation 

The hemostasis and alignment were checked once again. A fenestration with the left pleural cavity underneath the heart was created, the deep stitch was removed, and the heart was released to its normal position. 

The operation was completed in the routine manner. The total operative time was 150 minutes. The postoperative course was uneventful, and the patient was discharged home on the seventh postoperative day with no signs of angina. 

Discussion 

OPCAB remains a standard of care for the authors’ patients in almost all clinical scenarios, except for those who are truly unstable or require intracardiac repair. Avoiding aortic cannulation and cross-clamping precludes any mechanical causes of embolic complications during coronary surgery. Moreover, the addition of bilateral ITA grafting in any available configuration may allow for better long-term function of the grafts (1). Importantly, with the Y-graft configuration, surgeons may launch the blood flow consequently, improving intracoronary circulation before every forthcoming anastomosis, which may enhance the safety of the operation. Additionally, using the bilateral ITA technique allows for the avoidance of any skin incisions other than sternotomy. This set of arguments may increase adherence to bypass surgery among patients and referring physicians. 

References

1. Vallely MP, Seco M, Ramponi F, Puskas JD. Total-arterial, anaortic, off-pump coronary artery surgery: Why, when, and how. JTCVS Tech. 2021 Oct 4;10:140-148. doi: 10.1016/j.xjtc.2021.09.050. PMID: 34977717; PMCID: PMC8691864;
2. Peksa M, Nawotka M, Moskal L, Awad AK, Stankowski T, Pieszko K, Zemleduch T, Onutska Y, Adamiak G, Zielska J, Miklejewska M, Torregrossa G, Gaudino M, Cichon R, Aboul-Hassan SS. Long-Term Clinical and Angiographic Outcomes of Off-Pump Versus On-Pump Coronary Artery Bypass Grafting. J Surg Res. 2025 Mar 27;309:8-18. doi: 10.1016/j.jss.2025.02.041. Epub ahead of print. PMID: 40153915;
3. Taggart DP. Off-pump coronary artery bypass grafting (OPCABG)—a ‘personal’ European perspective. J Thorac Dis 2016;8(Suppl 10):S829-S831. doi: 10.21037/ jtd.2016.10.104.

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