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

BackgroundMulti-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.MethodsThis 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.FindingsMultiple 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.ConclusionThe 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.