Reimplantation of the right internal thoracic artery as a free graft into the left in situ internal thoracic artery (Y Procedure): One-year angiographic results

Abstract

Reimplantation of the right internal thoracic artery, as a free graft, into the left in situ internal thoracic artery (Y procedure) has enabled us to bypass more distant marginal vessels, which was not possible by the bilateral technique alone. This prospective study was aimed at evaluating the clinical state of the patients and the degree of patency of grafts within 16 months of follow-up. All 80 patients who underwent the Y procedure between January 1988 and January 1992 were included. This group represented 10% of the 840 patients having coronary bypass during the same period. A total of 202 coronary anastomoses were performed in this series. Early postoperative (30 days) complications included three deaths (3.75%), eight myocardial infarctions (10%), one case of phrenic nerve paralysis (1.25%), two cases of respiratory failure (2.5%), and six wound infections (7.5%). At 3 months' follow-up, 96% of patients were free of symptoms. During the follow-up period, four patients died of noncardiac causes (lung, pancreatic, and brain cancer and rupture of an abdominal aortic aneurysm). At 1 year, 71 patients were free of symptoms (97%). Sixty-one patients underwent coronary angiography between 12 and 24 months. Six patients with peripheral arterial disease were not suitable for coronary angiography, and six refused to be tested. These 12 patients had normal thallium test results in the bypassed area (stress or dipyridamole test). The patency rate of the left internal thoracic artery was 98.3% ( n = 60), occlusion rate 1.6% ( n = 1), and incidence of threadlike arteries 4.9% ( n = 3). Thus the rate of perfect patency was 93.4%. The patency rate of the right internal thoracic artery as a free graft was 93.4% ( n = 57), occlusion rate 6.5% ( n = 4), and the incidence of threadlike arteries 8% ( n = 5). Thus the rate of perfect patency was 85.2%. A total of 169 anastomoses were studied. The rate of patency of the anastomoses to the left anterior descending coronary artery was 96% ( n = 58) and the occlusion rate, 4% ( n = 2). The patency rate of sequential anastomoses (side to side) to diagonal arteries was 100% ( n = 16). Patency rate of anastomoses to obtuse marginal arteries was 95% ( n = 58) and the rate of occlusion, 4.9% ( n = 3). The patency rate of anastomoses to the posterior descending artery or distal branches of the right coronary artery was 80% ( n = 4/5). We conclude that the Y procedure is a safe technique with an acceptable morbidity and a good patency rate. This procedure can be used when the in situ technique is not possible because of far-reaching distal marginal coronary arteries. (J T HORAC C ARDIOVASC S URG 1995;109:1042-8)