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Harik et al. Vessel Plus 2023;7:30 https://dx.doi.org/10.20517/2574-1209.2023.124 Page 7 of 16

Figure 1. Diagram of sequential grafting. Adapted from Nakajima et al. [74] .

CONSIDERATIONS FOR USE OF THE LITA
Harvesting technique
Skeletonized ITA harvesting [Figure 2] has been accepted as the standard ITA harvesting technique
compared with pedicled ITA harvesting [1,10] . Skeletonization of the ITA may help preserve sternal
perfusion and, in observational studies, has been associated with a lower risk of deep sternal wound
[1]
infection, especially in CABG patients receiving bilateral ITA grafts . Yet recent data suggest that
[1]
skeletonization may result in lower patency rates and poorer clinical outcomes compared with pedicled
harvesting, possibly due to greater intraoperative graft trauma incurred by manipulation during
skeletonization [52,53] . A post-hoc analysis of the Cardiovascular Outcomes for People using Anticoagulation
Strategies (COMPASS) trial including 282 skeletonized ITA grafts (out of 1,002 CABG patients with ITA
[52]
grafts) at mean 1.9-year follow-up reported a higher incidence of occlusion of skeletonized ITAs than of
pedicled ITAs (9.6% vs. 3.9%, OR 2.41, 95%CI: 1.39-4.0). ITA skeletonization was also associated with higher
rates of major adverse cardiac events (cardiovascular mortality, myocardial infarction, stroke, or
revascularization) compared with pedicled ITA harvesting: 7.1% vs. 2.1%; adjusted HR 3.19,
95%CI: 1.53-6.67; P = 0.002, which was driven by repeat revascularization (5.0% vs. 1.4%; adjusted HR 2.75,
95%CI: 1.10-6.88; P = 0.03) . A post-hoc 10-year analysis of ART including 995 patients with skeletonized
[52]
ITAs (out of 2,161 CABG patients) found that ITA skeletonization was associated with a higher risk of
major adverse cardiac events (all-cause mortality, myocardial infarction, and repeat revascularization) than
pedicled ITA harvesting (34.2% vs. 28.6%, HR 1.25, 95%CI: 1.06-1.47), which was again attributed mainly to
repeat revascularization (13.5% vs. 9.9%; P = 0.01). Unfortunately, this study did not report angiographic
data .
[53]
Anastomotic technique
Individual or sequential anastomosis may be used to graft the LITA . Observational data has shown that
[10]
there is no difference in patency between the individually anastomosed LITA and the sequentially
anastomosed LITA [10,54-57] . A propensity-score matched study of 120 CABG patients reported no difference
in LITA patency between patients receiving sequential LITA grafting to the diagonal artery and then the
LAD and those receiving individual LITA grafting to the LAD (anastomotic patency: 99% for the diagonal
site, 98% for the LAD site, and 98% for the individual LAD site; P > 0.05). At 2.25-year follow-up, there was
no difference between groups in the incidence of all-cause death (OR 0.79, 95%CI: 0.22-27, P = 0.72) and
repeat revascularization (OR 0.66, 95%CI: 0.13-4.12) .
[57]