In-situ left-sided bilateral internal thoracic artery: elevated hemidiaphragm

Oren Lev-Ran, Dan Abrahamov, Nina Baram, Menachem Matsa, Yaron Ishai, Ohad Gabai, Yael Refaely, Mahmud Abu Salah, Gideon Sahar

Research output: Contribution to journalArticlepeer-review

1 Scopus citations


Background: Procurement of the internal thoracic artery risks ipsilateral phrenic nerve injury and elevated hemidiaphragm. Anatomical variations increase the risk on the right side. Patients receiving left-sided in-situ right internal thoracic artery configurations appear to be at greatest risk. Methods: From 2014 to 2016, 432 patients undergoing left-sided in-situ bilateral internal thoracic artery grafting were grouped according to right internal thoracic artery configuration: retroaortic via transverse sinus (77%) or ante-aortic (23%); targets were the circumflex and left anterior descending artery territories, respectively. Elevated hemidiaphragm was assessed by serial chest radiographs and categorized by side, complete (≥2 intercostal spaces) versus partial, and permanent versus transient. Results: Right elevated hemidiaphragm occurred in 4.2% of patients. The incidence of radiological complete right elevated hemidiaphragm was 2.8% (12/432); 8 cases were transient with recovery in 3.5 ± 0.3 weeks. Permanent right elevated hemidiaphragm occurred in 0.9% (retroaortic group only). Permanent left elevated hemidiaphragm occurred in 0.9% and was significantly higher in the ante-aortic group (3/99 vs. 1/333, p = 0.039). No bilateral hemidiaphragm elevation was documented. Partial right elevated hemidiaphragm occurred in 1.4% and was not associated with adverse early or late respiratory outcomes. Conclusions: Despite susceptible right phrenic nerve-internal thoracic artery anatomy, the incidence of permanent right elevated hemidiaphragm is low and no higher than left-sided in prone bilateral internal thoracic artery subsets. This reflects skeletonized internal thoracic artery procurement. Although statistical significance was not achieved, a retroaortic right internal thoracic artery configuration may constitute a higher risk of right phrenic nerve injury.

Original languageEnglish
Pages (from-to)94-100
Number of pages7
JournalAsian Cardiovascular and Thoracic Annals
Issue number2
StatePublished - 1 Feb 2018
Externally publishedYes


  • Coronary artery bypass
  • Diaphragm
  • Phrenic nerve
  • Postoperative complications
  • Respiratory paralysis
  • Thoracic arteries


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