Right internal thoracic artery versus radial artery as the second-best arterial conduit in multi-arterial coronary artery bypass grafting

Abstract

Background

Multi-arterial coronary artery bypass grafting (maCABG) improves long-term outcomes compared to single internal thoracic artery grafting. Choosing the second arterial conduit—the right internal thoracic artery (RITA) or the radial artery (RA)—is critical. RITA offers superior biological integrity but raises deep sternal wound infection (DSWI) concerns; RA provides ease of harvest but is susceptible to vasospasm and patency issues.

Methods

This narrative review synthesizes recent high-quality clinical investigations, including propensity-matched cohort studies and meta-analyses, comparing RITA and RA as the second conduit in left internal thoracic artery-based CABG. We analyzed comparative long-term survival, graft patency, and complication rates.

Findings

Multiple propensity score-matched studies demonstrate the superiority of RITA/bilateral internal thoracic artery (BITA) use, reporting significantly improved long-term survival and major adverse cardiac event-free survival compared to RA. BITA use was associated with a 35% reduction in the long-term hazard of death. Conversely, recent large-scale registries and randomized trials increasingly support the use of RA. The risk of DSWI with BITA use can be mitigated through skeletonized harvesting; however, this technique requires significant expertise to ensure graft patency.

Conclusion

The second arterial graft selection must be individualized, balancing patient-specific risks—such as diabetes and obesity—against the surgeon's proficiency in multi-arterial revascularization.