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In-situ left-sided bilateral internal thoracic artery: elevated hemidiaphragm
Oren Lev-Ran1, Dan Abrahamov1, Nina Baram2
11 Department of Cardiothoracic Surgery, 26746 Soroka University Medical Center , Beer-Sheva, Israel.
Asian Cardiovascular & Thoracic Annals
|January 25, 2018
Summary
Procuring the internal thoracic artery can injure the phrenic nerve, causing diaphragm elevation. This study found permanent diaphragm elevation is rare, even with specific right internal thoracic artery configurations, suggesting skeletonization reduces risk.
Area of Science:
- Cardiothoracic Surgery
- Vascular Surgery
- Anatomy
Background:
- Internal thoracic artery (ITA) procurement for coronary artery bypass grafting carries a risk of ipsilateral phrenic nerve injury, leading to hemidiaphragm elevation.
- Anatomical variations, particularly on the right side, can increase this risk, with left-sided in-situ right ITA configurations posing the greatest concern.
Purpose of the Study:
- To evaluate the incidence and characteristics of hemidiaphragm elevation following left-sided in-situ bilateral internal thoracic artery (BITA) grafting.
- To compare the risk of phrenic nerve injury between different right internal thoracic artery configurations (retroaortic vs. ante-aortic).
Main Methods:
- A cohort of 432 patients undergoing left-sided in-situ BITA grafting from 2014 to 2016 were analyzed.
- Patients were grouped based on right ITA configuration: retroaortic (77%) or ante-aortic (23%), targeting circumflex and LAD territories, respectively.
- Hemidiaphragm elevation was assessed via serial chest radiographs, noting side, completeness (≥2 intercostal spaces), and duration (transient vs. permanent).
Main Results:
- Overall right hemidiaphragm elevation occurred in 4.2% of patients; complete radiological elevation was 2.8%, with 8 cases (66.7%) being transient.
- Permanent right hemidiaphragm elevation was rare (0.9%) and occurred only in the retroaortic group.
- Permanent left hemidiaphragm elevation occurred in 0.9%, significantly higher in the ante-aortic group (3/99 vs. 1/333, p=0.039).
Conclusions:
- Permanent hemidiaphragm elevation following skeletonized ITA procurement for BITA grafting is infrequent, even with susceptible right phrenic nerve anatomy.
- The incidence of permanent right hemidiaphragm elevation is comparable to the left side in BITA subsets.
- A retroaortic right ITA configuration may be associated with a higher risk of right phrenic nerve injury, although statistical significance was not reached.
Keywords:
Coronary artery bypassDiaphragmPhrenic nervePostoperative complicationsRespiratory paralysisThoracic arteriesMore Related Videos
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