Natural Y-grafting using internal thoracic artery branches for off-pump coronary artery bypass

The excellent long-term patency rates achieved utilizing the internal thoracic arteries (ITAs) have stimulated a variety of approaches to expand the use of these conduits in coronary revascularization. The ITA divides at the level of the fifth or sixth intercostal space into the superior epigastric and musculophrenic branches. If these terminal branches of the ITA are large and long enough for grafting, they can be used to construct a "Y" anastomosis to the coronary arteries. We experienced 2 patients who underwent multivessel off-pump coronary artery bypass (OPCAB) using these ITA branches. In both patients the bilateral ITAs and the right gastroepiploic artery were taken down using the skeletonization technique as in situ grafts. One patient had 5 grafts including the right ITA terminal branches which were used for the left anterior descending branch (LAD) and diagonal branch. Another patient had 6 grafts including the left ITA terminal branches which were used for the posterolateral branch (PL)1 and PL2. Postoperative angiography revealed widely patent grafts in both patients. We believe that one of the advantages of applying the off-pump technique when the ITA branches are used is that it might be easier to arrange the angle of constructing a natural "Y" configuration compared with conventional coronary artery bypass grafting (CABG). In conclusion, the terminal branches of the ITA, if of suitable size, should be considered for "Y" grafts to diseased coronary arteries when performing complete arterial revascularization with only in situ grafts.