How to harvest the left internal mammary artery (LIMA) : Part 1

The left internal mammary artery also called the LIMA or the LITA, is the gold standard conduit for myocardial revascularization because of its widely reported clinical and survival benefits when compared with saphenous vein grafts. The use of LIMA grafts increases survival and reduces the incidence of recurrent angina, late myocardial infarction, and repeat coronary interventions. The LIMA is the gold standard conduit for myocardial revascularization because of its widely reported clinical and survival benefits when compared with saphenous vein grafts. The use of LIMA grafts increases survival and reduces the incidence of recurrent angina, late myocardial infarction, and repeat coronary interventions.

How to harvest:
Techniques
1 Pedicled
Conduit with fascia, muscle and fat
Only conduit with accompanying veins
2 Pedicled but divided distally to start with (Hanging technique)
With fascia, muscle and fat
Without fascia, muscle and fat

Clip Clip Cut : what is it??
Less tissue trauma, less postop drainage or bleeding
Good and undamaged conduit
Less postoperative complication
Preserves collateral connections
Avoid thermal injury to the IMA

Anatomy:
The IMA arises from the subclavian artery, above and behind the sternal end of the clavicle. In 70% of cases the LIMA originates alone, whereas in 30% it arises from a common trunk with other arteries like the thyrocervical trunk, suprascapular artery and the inferior thyroid artery. The artery descends vertically 1 cm to 2.3 cms lateral to the sternal border, behind the first six costal cartilages and is separated from the pleura at the second or third costal cartilage by a strong layer of endothoracic fascia and inferiorly by the transversus thoracis muscle. It is accompanied by two mammary veins, which ascend medially and laterally, respectively. The ITA ends as a bifurcation in 93% of the cases as the superior epigastric and musculophrenic arteries and as a trifurcation in 7% (a third branch, the Xiphoid / diaphragmatic branch adds to the previous ones)

References:
DOI:doi.org/10.1016/S0003-4975(96)00529-2
Full length article
VOLUME 62, ISSUE 3, P908-909, AUGUST 01, 1996
mmcts.org/tutorial/611
Ann Thorac Surg 2015;100:1942–53
Hydrodissection of LIMA: Ann Thorac Surg 2005;80:355– 6

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