The right internal thoracic artery: is it underutilized?

The left internal thoracic artery is acknowledged as the best coronary conduit. The right internal thoracic artery (RITA) is identical to the left ITA (LITA), yet, despite excellent published results, the RITA [as part of bilateral ITA (BITA) grafting] is rarely used in coronary artery bypass graft surgery (CABG). With advances in CABG and drug-eluting stents (DESs) for coronary artery disease, it is timely to review the clinical and patency results when RITA is used in BITA, to define its role in the treatment of multivessel coronary artery disease.

RITA use is 4% in the USA, and 10% in the UK and Australia, although higher in some centres. Perioperative mortality of BITA is 1-3%. Morbidity is low, 1-2% for stroke and perioperative myocardial infarction, and 2-3% for postoperative bleeding. Deep sternal wound infection is also low, 1-3%. Excellent results are reported for RITA/BITA in off-pump coronary artery bypass, in patients with renal dysfunction and those with end-stage renal failure and on dialysis. BITA is well tolerated in routine diabetic patients with multivessel coronary disease and may enhance their long-term prognosis. Patencies for RITA are identical to LITA in comparable territories and superior to non-ITA grafts, resulting in enhanced long-term patient outcomes.

As evidence of excellent RITA results increases, strategies are required to encourage its use. Skeletonization, free, and composite grafts, associated with excellent clinical results and patencies, enhance RITA versatility and are important in improving long-term prognosis. The role of BITA/CABG versus DESs also needs further definition.