MULTIMEDIA MANUAL OF
doi:10.1093/mmcts/mmt017 published online 10 December 2013.
MMCTS
CARDIO-THORACIC SURGERY
Total arterial coronary revascularization James Tatoulisa,b Department of Cardiothoracic Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia University of Melbourne, Melbourne, Victoria, Australia
a
b
Corresponding author. Suite 28, Medical Centre, Royal Melbourne Hospital, Melbourne, Victoria 3050, Australia. Tel: +61-3-93481383; fax: +61-3-93475258; e-mail: [email protected] ( J. Tatoulis). Received 5 September 2013; accepted 21 October 2013
Summary Arterial coronary grafts can be used in the majority of patients and have better patencies than saphenous vein grafts (SVGs), resulting in excellent perioperative and superior long-term outcomes. Barriers to their extensive use include potential for trauma and spasm, extra-operating time, unfamiliarity, concerns over hypoperfusion and deep sternal wound infection in patients in whom bilateral internal thoracic arteries are used—especially diabetics. This presentation addresses these concerns with particular attention to the radial artery, and skeletonized right internal thoracic artery harvest and construction of the proximal anastomoses of these grafts to the ascending thoracic aorta. The facile handling of these grafts and techniques identical to SVG grafting are emphasized. Avoidance of competitive flow and the importance of spasm prophylaxis cannot be overstated. Arterial grafts have patencies >90% at 10 years (SVG 50–60% at 10 years) and once functioning normally, remain free of atheroma. Long-term results are excellent, especially freedom from recurrent cardiac events and reoperations, even in patients with significant preoperative comorbidities such as diabetes and renal dysfunction. Depending on age, long-term survival is between 85 and 90% at 10 years and 75 and 80% at 15 years, and is always better than for one arterial graft plus SVG in all long-term risk-adjusted or propensitymatched studies. Keywords: Coronary surgery • Total arterial revascularization • Multiple arterial coronary grafts
INTRODUCTION
SURGICAL TECHNIQUE
Graft patency underpins coronary artery bypass graft surgery (CABG). Patencies of arterial grafts may be equal to those of saphenous vein grafts (SVGs) in the short term, but are always superior in the long term, in that they offer similar (or better) perioperative results, but markedly enhanced long-term outcomes including less recurrent angina and fewer cardiac events such as myocardial infarction, fewer reoperations and significantly superior long-term survival. There has never been a long-term study published that shows better patency or outcomes for SVG than arterial grafts [1]. The most commonly used arterial grafts are the left internal thoracic artery (LITA; in >90% of cases) and the radial artery (RA; 5–10%). In this article, we describe total arterial CABG, but specifically highlight the RA and the right internal thoracic artery (RITA), which is used in 90%) when the native coronary artery stenosis is at least 80% and preferably 90% or greater [2, 3, 5, 12]. A more objective parameter is the residual diameter at the coronary stenosis. If it is 90%) [13]. Spasm can affect all living vascular grafts (even SVG), but especially arterial grafts. The RA and right gastroepiploic artery are more susceptible as they are muscular arteries. Liberal, topical and/or intraluminal buffered papaverine, or milrinone, are essential (preferably at 37 °C) to avoid spasm from mechanical and cold stimuli. We use intravenous nitroglycerine (GTN) intraoperatively and postoperatively for 24 h (30–200 µg/min) and amlodipine (once daily oral calcium channel blocker) 5 mg daily for 6 months, as we have witnessed arterial graft spasm, particularly in some RAs up to several months postoperatively on graft angiograms. Spasm was confirmed as the conduits dilated immediately after intragraft GTN [3, 5].
J. Tatoulis / Multimedia Manual of Cardio-Thoracic Surgery
6
RESULTS
DISCUSSION
Perioperative mortality and morbidity
Maximum graft patency is the most important objective of coronary surgery to ensure the best possible long-term outcomes. Arterial grafts offer this, provided they are harvested atraumatically, competitive flow is avoided and spasm prophylaxis is used. Barriers to multiple/total arterial grafting include the extra-operative time required (~30 min to harvest the RITA or the right RA and the left RA is harvested concurrently with the LITA), concerns regarding hypoperfusion with arterial grafts and unfamiliarity with their use. The possibility of deep sternal wound infection and the pressure to achieve excellent perioperative outcomes through familiar time-tried techniques are also significant factors [2]. These barriers can be readily overcome by allocating an additional 30–60 min for the surgery, learning and adopting a skeletonized harvest technique (often quicker for RITA harvest as fewer branches require division) and by being obsessional with spasm prophylaxis. Deep sternal wound infection can be markedly reduced to an incidence similar to single-ITA harvest, by using skeletonized ITA harvesting, meticulous perioperative management of glucose with insulin infusions, appropriate antibiotic prophylaxis and avoiding BITAs in morbidly obese insulin-dependent diabetic patients [2, 3, 11, 14, 15]. Severe chronic obstructive airways disease is another risk factor for sternal dehiscence and infection, and should be borne in mind [2, 3]. The surgical techniques used for grafting should be identical to those used with an SVG to ensure comfort and confidence. In general, we prefer to use the LITA to the LAD and the RITA as an in situ or free graft to the circumflex and the RA to the posterior descending coronary artery. There has never been a publication of long-term results of CABG patency and outcomes, where the majority of grafts are SVG, that are superior to outcomes using arterial grafts. Moreover, multiple arterial grafting, especially when both ITAs are used to the two most important coronary vessels, also results in better long-term outcomes in patients with diabetes [16–18] and preoperative renal dysfunction [19].
In 6084 consecutive patients with total arterial revascularization that we reviewed (mean age 65 years), perioperative mortality was 0.8%, stroke 0.7%, myocardial infarction 0.9%, intra-aortic balloon pump use 2.4% and reoperation for bleeding 1.8%. Deep sternal wound infection (DSWI) was 1.7%. These results are similar to many reports on BITA grafting or total arterial revascularization over the past 5 years that encompass cohorts that had CABG up to 30 years ago [1, 4, 6–10, 14]. In particular, deep sternal wound infection is consistently reported at between 1.0 and 2.5%. Even in diabetic patients, deep sternal wound infection varies from 1.3 to 2.4% when the ITAs are skeletonized [11]. Importantly, these diabetic patients had greater freedom from recurrent cardiac events and better long-term survival.
Long-term survival In our experience, survival for total arterial revascularization patients (taking into account all-cause mortality, National Death Index—Australia) is 89, 65 and 58% at 10, 15 and 20 years, respectively, and is superior to one ITA plus SVG at every interval. This is consistent with reports from others of 10-year survival of 87–90% and 20-year survival of 40–60%. Long-term survival is dependent on many preoperative comorbid factors, but particularly age [1, 2, 6–10].
Graft patencies Left internal thoracic artery patencies In over 2500 LITA graft angiograms (predominantly in symptomatic patients), we found the LITA patency to the LAD to be 98.5% at 5 years, 96.5% at 10 years and 91% at 20 years. LITA patencies were a little less to the circumflex—96.5% at 5 years and 91% at 10 years.
Right internal thoracic artery patencies These are identical to the LITA when placed to the same vessels. In almost 1000 RITA angiograms, we found equal patency for in situ RITA versus free RITA. RITA patency to the LAD was 98% at 5 years and 95% at 10 years and to the circumflex marginal, 96% at 5 years and 90% at 10 years. RITA patencies were significantly poorer to the right coronary artery (80% at 10 years—presumably due to competitive flow, but significantly better to the posterior descending artery, 89%). The above are based on Kaplan–Meier methodology, which may not be appropriate for conduit angiograms, as different conduits are examined at different times. When patencies for specific yearly angiographic cohorts are evaluated, RITA patency in the 352 RITA grafts in place for >10 years, was 92%.
Radial artery patency
In over 1100 RA angiograms, for the 318 RAs in place for >5 years, patency was 92.5% and for the 107 RA grafts in place >7 years, patency was also 92.5%. In addition, these long-term clinical and patency results are consistent with those of numerous recent publications of multiple or total arterial grafting [2, 4, 7, 12].
Practical tips on multiple arterial grafts/total arterial revascularization Keep it simple. We prefer one-to-one grafting if possible, e.g. LITA to the LAD, RITA to the circumflex and the RA to the posterior descending artery. Although total arterial revascularization can be achieved with LITA/RITA T or Y grafts, these are more complex and could be used after adequate experience. Do not use the in situ RITA to the right coronary artery prior to the crux. Often new disease develops at the crux. Grafting the PDA is preferable. Skeletonized ITA grafts result in a greater length being available (by 2–4 cm). Their harvest causes less chest wall trauma and is associated with a lower chance of deep sternal infection. The flap of endothoracic fascia ± pleura—left behind which covers the ITA harvest bed—retains vascularity and minimizes bleeding. Excellent myocardial protection is essential so that the distal arterial conduit to coronary anastomoses can be performed in a precise, unhurried manner. Proximal anastomosis to the aorta should be identical to the technique used for the SVG (6/0 or 7/0, larger needle). If the aorta is thick walled, it should be avoided by anaortic off-pump coronary artery bypass or by placing the proximal anastomosis on another graft.
7
J. Tatoulis / Multimedia Manual of Cardio-Thoracic Surgery
Figure 10: Postoperative angiogram showing an excellent sequential left internal thoracic artery graft, side-to-side to the diagonal and end-to-side to the left anterior descending. Free right internal thoracic artery aortocoronary graft to the circumflex marginal.
Using combinations of BITA and RA, or alternatively LITA and one or two radials, we are able to achieve total arterial revascularization in over 80% of patients. We would use an SVG in preference to RA for moderately stenotic lesions, if they are deemed necessary to bypass. Alternatively, moderate lesions, particularly in younger patients, may be left alone, monitored and addressed by stenting or bypass surgery in the future, if necessitated by disease progression and uncontrollable symptoms. Arterial grafts fail for technical reasons (early) from competitive flow (string signs) and localized stenoses (possibly due to trauma). Unlike SVGs, they never develop atheroma (Figure 10). Once an arterial graft is patent, it will continue to be so in the long term. Multiple/total arterial grafting can be achieved in the majority of patients, has the potential to reduce cardiac events, including myocardial infarction and reoperations, and adds several years to the life span of the typical patient undergoing CABG [20]. Opportunities exist to embrace and significantly enhance use of multiple arterial grafts/total arterial revascularization in coronary surgery to the potential benefit of patients and society. Conflict of interest: none declared.
REFERENCES [1] Weiss AJ, Zhao S, Tian DH, Taggart DP, Yan TD. A meta-analysis comparing bilateral internal mammary artery with left internal mammary artery for coronary artery bypass grafting. Ann Cardiothorac Surg 2013;2:390–400. [2] Tatoulis J, Buxton BF, Fuller JA. The right internal thoracic artery: is it under utilized? Curr Opin Cardiol 2011;26:528–35. [3] Tatoulis J, Buxton BF, Fuller JA. The right internal thoracic artery: forgotten conduit, 5,766 patients and 991 angiograms. Ann Thorac Surg 2011;92:9–17.
[4] Achouh P, Isselmou KO, Boutekadjirt R, D’Alessandro C, Pagny JY, Fouquet R et al. Reappraisal of a 20 year experience with the radial arteries of conduit for coronary bypass grafting. Eur J Cardiothorac Surg 2012; 41:87–92. [5] Tatoulis J, Buxton BF, Fuller JA, Meswani M, Theodore S, Powar N et al. Long term patency of 1108 radial arterial/coronary angiograms over 10 years. Ann Thorac Surg 2009;88:23–30. [6] Zacharias A, Schwann TA, Riordan CJ, Durham SJ, Shah AS, Habib RH. Late results of conventional versus all-arterial revascularization based on interval thoracic and radial arterial grafting. Ann Thorac Surg 2009;87:19–26. [7] Tranbaugh RF, Dimitrova KR, Friedmann P, Geller CM, Harris LJ, Stelzer P et al. Coronary artery bypass grafting using the radial artery clinical outcomes, patency, and need for re-intervention. Circulation 2012;126 (Suppl 1):S170–5. [8] Kurlansky PA, Traad EA, Dorman MJ, Galbut DL, Zucker M, Ebra G. Thirty year follow up defined survival benefit for second internal mammary artery in propensity matched groups. Ann Thorac Surg 2010;90:101–8. [9] Lytle BW, Blackstone EH, Sabik JF, Houghtaling P, Loop FD, Cosgrove DM. The effect of bilateral internal thoracic artery grafting on survival during 20 post operative years. Ann Thorac Surg 2004;78:2005–14. [10] Edelman JJB, Sherrah AG, Wilson MK, Bannon PG, Brereton RJ, Ross DE et al. Anaortic, total-arterial, off-pump coronary artery bypass surgery: why bother? Heart Lung Circ 2013;22:161–70. [11] Deo SV, Shah IK, Dunlay SM, Erwin PJ, Locker C, Altarabsheh SE et al. Bilateral internal thoracic artery harvest and deep sternal wound infection in diabetic patients. Ann Thorac Surg 2013;95:862–9. [12] Fukui T, Tabata M, Manabe S, Shimokawa T, Morita S, Takanashi S. Angiographic outcomes of right internal thoracic artery grafts in-situ or as free grafts in coronary artery bypass grafting. J Thorac Cardiovasc Surg 2010;139:868–73. [13] Glineur D, D’Hoore W, De Kerchove L, Noirhomme P, Price J, Hanet C et al. Angiographic predictors of three year patency of bypass grafts implanted on the right coronary artery system: a prospective randomized comparison of gastroepiploic, saphenous vein, and right internal thoracic artery grafts. J Thorac Cardiovasc Surg 2011;142:980–8. [14] Taggart DP, Allman DG, Gray AM, Lees B, Nugara F, Yu LM et al. Randomized trial to compare bilateral versus single mammary coronary artery bypass grafting: 1 year results of the arterial revascularization trial (ART). Eur Heart J 2010;31:2470–81. [15] Kamiyah H, Akhyarip P, Martens A, Karch M, Haverich A, Lichtenberg A. Sternal micro-circulation after skeletonised versus pedicle harvesting of the internal thoracic artery; a randomized study. J Thorac Cardiovasc Surg 2008;135:32–7. [16] Dorman MJ, Kurlansky PA, Traad EA, Galbut DL, Zucker M, Ebra G. Bilateral internal mammary artery grafting enhances survival in diabetic patients. Circulation 2012;126:2935–42. [17] Kinoshita T, Asai T, Nishimura O, Suzuki T, Kambara A, Matsubayashi K. Off-pump bilateral versus single skeletonized internal thoracic artery grafting in patients with diabetes. Ann Thorac Surg 2010;90:1173–9. [18] Puskas JD, Sadiq A, Vassiliades TA, Kilgo PD, Lattouf OM. Bilateral internal thoracic artery grafting is associated with significantly improved long term survival, even among diabetic patients. Ann Thorac Surg 2012; 94:710–6. [19] Kinoshita T, Asai T, Murakami Y, Hiramatsu N, Suzuki T, Kambara A et al. Efficacy of bilateral internal thoracic grafting in patients with chronic renal disease. Ann Thorac Surg 2010;89:1106–11. [20] Tatoulis J. Total arterial coronary revascularisation—patient selection, stenoses, conduits, targets. Ann Cardiothorac Surg 2013;2:499–506.
doi:10.1093/mmcts/mmt017 published online 10 December 2013.
MMCTS
CARDIO-THORACIC SURGERY
Total arterial coronary revascularization James Tatoulisa,b Department of Cardiothoracic Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia University of Melbourne, Melbourne, Victoria, Australia
a
b
Corresponding author. Suite 28, Medical Centre, Royal Melbourne Hospital, Melbourne, Victoria 3050, Australia. Tel: +61-3-93481383; fax: +61-3-93475258; e-mail: [email protected] ( J. Tatoulis). Received 5 September 2013; accepted 21 October 2013
Summary Arterial coronary grafts can be used in the majority of patients and have better patencies than saphenous vein grafts (SVGs), resulting in excellent perioperative and superior long-term outcomes. Barriers to their extensive use include potential for trauma and spasm, extra-operating time, unfamiliarity, concerns over hypoperfusion and deep sternal wound infection in patients in whom bilateral internal thoracic arteries are used—especially diabetics. This presentation addresses these concerns with particular attention to the radial artery, and skeletonized right internal thoracic artery harvest and construction of the proximal anastomoses of these grafts to the ascending thoracic aorta. The facile handling of these grafts and techniques identical to SVG grafting are emphasized. Avoidance of competitive flow and the importance of spasm prophylaxis cannot be overstated. Arterial grafts have patencies >90% at 10 years (SVG 50–60% at 10 years) and once functioning normally, remain free of atheroma. Long-term results are excellent, especially freedom from recurrent cardiac events and reoperations, even in patients with significant preoperative comorbidities such as diabetes and renal dysfunction. Depending on age, long-term survival is between 85 and 90% at 10 years and 75 and 80% at 15 years, and is always better than for one arterial graft plus SVG in all long-term risk-adjusted or propensitymatched studies. Keywords: Coronary surgery • Total arterial revascularization • Multiple arterial coronary grafts
INTRODUCTION
SURGICAL TECHNIQUE
Graft patency underpins coronary artery bypass graft surgery (CABG). Patencies of arterial grafts may be equal to those of saphenous vein grafts (SVGs) in the short term, but are always superior in the long term, in that they offer similar (or better) perioperative results, but markedly enhanced long-term outcomes including less recurrent angina and fewer cardiac events such as myocardial infarction, fewer reoperations and significantly superior long-term survival. There has never been a long-term study published that shows better patency or outcomes for SVG than arterial grafts [1]. The most commonly used arterial grafts are the left internal thoracic artery (LITA; in >90% of cases) and the radial artery (RA; 5–10%). In this article, we describe total arterial CABG, but specifically highlight the RA and the right internal thoracic artery (RITA), which is used in 90%) when the native coronary artery stenosis is at least 80% and preferably 90% or greater [2, 3, 5, 12]. A more objective parameter is the residual diameter at the coronary stenosis. If it is 90%) [13]. Spasm can affect all living vascular grafts (even SVG), but especially arterial grafts. The RA and right gastroepiploic artery are more susceptible as they are muscular arteries. Liberal, topical and/or intraluminal buffered papaverine, or milrinone, are essential (preferably at 37 °C) to avoid spasm from mechanical and cold stimuli. We use intravenous nitroglycerine (GTN) intraoperatively and postoperatively for 24 h (30–200 µg/min) and amlodipine (once daily oral calcium channel blocker) 5 mg daily for 6 months, as we have witnessed arterial graft spasm, particularly in some RAs up to several months postoperatively on graft angiograms. Spasm was confirmed as the conduits dilated immediately after intragraft GTN [3, 5].
J. Tatoulis / Multimedia Manual of Cardio-Thoracic Surgery
6
RESULTS
DISCUSSION
Perioperative mortality and morbidity
Maximum graft patency is the most important objective of coronary surgery to ensure the best possible long-term outcomes. Arterial grafts offer this, provided they are harvested atraumatically, competitive flow is avoided and spasm prophylaxis is used. Barriers to multiple/total arterial grafting include the extra-operative time required (~30 min to harvest the RITA or the right RA and the left RA is harvested concurrently with the LITA), concerns regarding hypoperfusion with arterial grafts and unfamiliarity with their use. The possibility of deep sternal wound infection and the pressure to achieve excellent perioperative outcomes through familiar time-tried techniques are also significant factors [2]. These barriers can be readily overcome by allocating an additional 30–60 min for the surgery, learning and adopting a skeletonized harvest technique (often quicker for RITA harvest as fewer branches require division) and by being obsessional with spasm prophylaxis. Deep sternal wound infection can be markedly reduced to an incidence similar to single-ITA harvest, by using skeletonized ITA harvesting, meticulous perioperative management of glucose with insulin infusions, appropriate antibiotic prophylaxis and avoiding BITAs in morbidly obese insulin-dependent diabetic patients [2, 3, 11, 14, 15]. Severe chronic obstructive airways disease is another risk factor for sternal dehiscence and infection, and should be borne in mind [2, 3]. The surgical techniques used for grafting should be identical to those used with an SVG to ensure comfort and confidence. In general, we prefer to use the LITA to the LAD and the RITA as an in situ or free graft to the circumflex and the RA to the posterior descending coronary artery. There has never been a publication of long-term results of CABG patency and outcomes, where the majority of grafts are SVG, that are superior to outcomes using arterial grafts. Moreover, multiple arterial grafting, especially when both ITAs are used to the two most important coronary vessels, also results in better long-term outcomes in patients with diabetes [16–18] and preoperative renal dysfunction [19].
In 6084 consecutive patients with total arterial revascularization that we reviewed (mean age 65 years), perioperative mortality was 0.8%, stroke 0.7%, myocardial infarction 0.9%, intra-aortic balloon pump use 2.4% and reoperation for bleeding 1.8%. Deep sternal wound infection (DSWI) was 1.7%. These results are similar to many reports on BITA grafting or total arterial revascularization over the past 5 years that encompass cohorts that had CABG up to 30 years ago [1, 4, 6–10, 14]. In particular, deep sternal wound infection is consistently reported at between 1.0 and 2.5%. Even in diabetic patients, deep sternal wound infection varies from 1.3 to 2.4% when the ITAs are skeletonized [11]. Importantly, these diabetic patients had greater freedom from recurrent cardiac events and better long-term survival.
Long-term survival In our experience, survival for total arterial revascularization patients (taking into account all-cause mortality, National Death Index—Australia) is 89, 65 and 58% at 10, 15 and 20 years, respectively, and is superior to one ITA plus SVG at every interval. This is consistent with reports from others of 10-year survival of 87–90% and 20-year survival of 40–60%. Long-term survival is dependent on many preoperative comorbid factors, but particularly age [1, 2, 6–10].
Graft patencies Left internal thoracic artery patencies In over 2500 LITA graft angiograms (predominantly in symptomatic patients), we found the LITA patency to the LAD to be 98.5% at 5 years, 96.5% at 10 years and 91% at 20 years. LITA patencies were a little less to the circumflex—96.5% at 5 years and 91% at 10 years.
Right internal thoracic artery patencies These are identical to the LITA when placed to the same vessels. In almost 1000 RITA angiograms, we found equal patency for in situ RITA versus free RITA. RITA patency to the LAD was 98% at 5 years and 95% at 10 years and to the circumflex marginal, 96% at 5 years and 90% at 10 years. RITA patencies were significantly poorer to the right coronary artery (80% at 10 years—presumably due to competitive flow, but significantly better to the posterior descending artery, 89%). The above are based on Kaplan–Meier methodology, which may not be appropriate for conduit angiograms, as different conduits are examined at different times. When patencies for specific yearly angiographic cohorts are evaluated, RITA patency in the 352 RITA grafts in place for >10 years, was 92%.
Radial artery patency
In over 1100 RA angiograms, for the 318 RAs in place for >5 years, patency was 92.5% and for the 107 RA grafts in place >7 years, patency was also 92.5%. In addition, these long-term clinical and patency results are consistent with those of numerous recent publications of multiple or total arterial grafting [2, 4, 7, 12].
Practical tips on multiple arterial grafts/total arterial revascularization Keep it simple. We prefer one-to-one grafting if possible, e.g. LITA to the LAD, RITA to the circumflex and the RA to the posterior descending artery. Although total arterial revascularization can be achieved with LITA/RITA T or Y grafts, these are more complex and could be used after adequate experience. Do not use the in situ RITA to the right coronary artery prior to the crux. Often new disease develops at the crux. Grafting the PDA is preferable. Skeletonized ITA grafts result in a greater length being available (by 2–4 cm). Their harvest causes less chest wall trauma and is associated with a lower chance of deep sternal infection. The flap of endothoracic fascia ± pleura—left behind which covers the ITA harvest bed—retains vascularity and minimizes bleeding. Excellent myocardial protection is essential so that the distal arterial conduit to coronary anastomoses can be performed in a precise, unhurried manner. Proximal anastomosis to the aorta should be identical to the technique used for the SVG (6/0 or 7/0, larger needle). If the aorta is thick walled, it should be avoided by anaortic off-pump coronary artery bypass or by placing the proximal anastomosis on another graft.
7
J. Tatoulis / Multimedia Manual of Cardio-Thoracic Surgery
Figure 10: Postoperative angiogram showing an excellent sequential left internal thoracic artery graft, side-to-side to the diagonal and end-to-side to the left anterior descending. Free right internal thoracic artery aortocoronary graft to the circumflex marginal.
Using combinations of BITA and RA, or alternatively LITA and one or two radials, we are able to achieve total arterial revascularization in over 80% of patients. We would use an SVG in preference to RA for moderately stenotic lesions, if they are deemed necessary to bypass. Alternatively, moderate lesions, particularly in younger patients, may be left alone, monitored and addressed by stenting or bypass surgery in the future, if necessitated by disease progression and uncontrollable symptoms. Arterial grafts fail for technical reasons (early) from competitive flow (string signs) and localized stenoses (possibly due to trauma). Unlike SVGs, they never develop atheroma (Figure 10). Once an arterial graft is patent, it will continue to be so in the long term. Multiple/total arterial grafting can be achieved in the majority of patients, has the potential to reduce cardiac events, including myocardial infarction and reoperations, and adds several years to the life span of the typical patient undergoing CABG [20]. Opportunities exist to embrace and significantly enhance use of multiple arterial grafts/total arterial revascularization in coronary surgery to the potential benefit of patients and society. Conflict of interest: none declared.
REFERENCES [1] Weiss AJ, Zhao S, Tian DH, Taggart DP, Yan TD. A meta-analysis comparing bilateral internal mammary artery with left internal mammary artery for coronary artery bypass grafting. Ann Cardiothorac Surg 2013;2:390–400. [2] Tatoulis J, Buxton BF, Fuller JA. The right internal thoracic artery: is it under utilized? Curr Opin Cardiol 2011;26:528–35. [3] Tatoulis J, Buxton BF, Fuller JA. The right internal thoracic artery: forgotten conduit, 5,766 patients and 991 angiograms. Ann Thorac Surg 2011;92:9–17.
[4] Achouh P, Isselmou KO, Boutekadjirt R, D’Alessandro C, Pagny JY, Fouquet R et al. Reappraisal of a 20 year experience with the radial arteries of conduit for coronary bypass grafting. Eur J Cardiothorac Surg 2012; 41:87–92. [5] Tatoulis J, Buxton BF, Fuller JA, Meswani M, Theodore S, Powar N et al. Long term patency of 1108 radial arterial/coronary angiograms over 10 years. Ann Thorac Surg 2009;88:23–30. [6] Zacharias A, Schwann TA, Riordan CJ, Durham SJ, Shah AS, Habib RH. Late results of conventional versus all-arterial revascularization based on interval thoracic and radial arterial grafting. Ann Thorac Surg 2009;87:19–26. [7] Tranbaugh RF, Dimitrova KR, Friedmann P, Geller CM, Harris LJ, Stelzer P et al. Coronary artery bypass grafting using the radial artery clinical outcomes, patency, and need for re-intervention. Circulation 2012;126 (Suppl 1):S170–5. [8] Kurlansky PA, Traad EA, Dorman MJ, Galbut DL, Zucker M, Ebra G. Thirty year follow up defined survival benefit for second internal mammary artery in propensity matched groups. Ann Thorac Surg 2010;90:101–8. [9] Lytle BW, Blackstone EH, Sabik JF, Houghtaling P, Loop FD, Cosgrove DM. The effect of bilateral internal thoracic artery grafting on survival during 20 post operative years. Ann Thorac Surg 2004;78:2005–14. [10] Edelman JJB, Sherrah AG, Wilson MK, Bannon PG, Brereton RJ, Ross DE et al. Anaortic, total-arterial, off-pump coronary artery bypass surgery: why bother? Heart Lung Circ 2013;22:161–70. [11] Deo SV, Shah IK, Dunlay SM, Erwin PJ, Locker C, Altarabsheh SE et al. Bilateral internal thoracic artery harvest and deep sternal wound infection in diabetic patients. Ann Thorac Surg 2013;95:862–9. [12] Fukui T, Tabata M, Manabe S, Shimokawa T, Morita S, Takanashi S. Angiographic outcomes of right internal thoracic artery grafts in-situ or as free grafts in coronary artery bypass grafting. J Thorac Cardiovasc Surg 2010;139:868–73. [13] Glineur D, D’Hoore W, De Kerchove L, Noirhomme P, Price J, Hanet C et al. Angiographic predictors of three year patency of bypass grafts implanted on the right coronary artery system: a prospective randomized comparison of gastroepiploic, saphenous vein, and right internal thoracic artery grafts. J Thorac Cardiovasc Surg 2011;142:980–8. [14] Taggart DP, Allman DG, Gray AM, Lees B, Nugara F, Yu LM et al. Randomized trial to compare bilateral versus single mammary coronary artery bypass grafting: 1 year results of the arterial revascularization trial (ART). Eur Heart J 2010;31:2470–81. [15] Kamiyah H, Akhyarip P, Martens A, Karch M, Haverich A, Lichtenberg A. Sternal micro-circulation after skeletonised versus pedicle harvesting of the internal thoracic artery; a randomized study. J Thorac Cardiovasc Surg 2008;135:32–7. [16] Dorman MJ, Kurlansky PA, Traad EA, Galbut DL, Zucker M, Ebra G. Bilateral internal mammary artery grafting enhances survival in diabetic patients. Circulation 2012;126:2935–42. [17] Kinoshita T, Asai T, Nishimura O, Suzuki T, Kambara A, Matsubayashi K. Off-pump bilateral versus single skeletonized internal thoracic artery grafting in patients with diabetes. Ann Thorac Surg 2010;90:1173–9. [18] Puskas JD, Sadiq A, Vassiliades TA, Kilgo PD, Lattouf OM. Bilateral internal thoracic artery grafting is associated with significantly improved long term survival, even among diabetic patients. Ann Thorac Surg 2012; 94:710–6. [19] Kinoshita T, Asai T, Murakami Y, Hiramatsu N, Suzuki T, Kambara A et al. Efficacy of bilateral internal thoracic grafting in patients with chronic renal disease. Ann Thorac Surg 2010;89:1106–11. [20] Tatoulis J. Total arterial coronary revascularisation—patient selection, stenoses, conduits, targets. Ann Cardiothorac Surg 2013;2:499–506.
