The 3 R's: The radial artery, the right internal thoracic artery, and the race for the second best

Twenty-Five Years of No-Touch Saphenous Vein Harvesting for Coronary Artery Bypass Grafting: Structural Observations and Impact on Graft Performance

The saphenous vein is the most common conduit used in coronary artery bypass grafting (CABG) yet its failure rate is higher compared to arterial grafts. An improvement in saphenous vein graft performance is therefore a major priority in CABG. No-touch harvesting of the saphenous vein is one of the few interventions that has shown improved patency rates, comparable to that of the left internal thoracic artery. After more than two decades of no-touch research, this technique is now recognized as a Class IIa recommendation in the 2018 European Society of Cardiology and the European Association for Cardio-Thoracic Surgery guidelines on myocardial revascularization. In this review, we describe the structural alterations that occur in conventional versus no-touch saphenous vein grafts and how these changes affect graft patency. In addition, we discuss various strategies aimed at repairing saphenous vein grafts prepared at conventional CABG.

Coronary artery bypass grafting-fifty years of quality initiatives since Favaloro

Coronary artery bypass grafting (CABG) remains one of the most commonly performed major surgical procedures worldwide and the most common procedure performed by cardiac surgeons. Rene Favaloro is widely credited with recognizing the true potential of CABG and subsequently popularizing the technique in a broad manner. Since the era of Favaloro in the late 1960s, the evolution of CABG can be understood through a series of quality initiatives that have defined which patients can benefit from the procedure and via which technique(s) they will derive the greatest benefit. Herein, we will review some of the key developments in CABG over the last 50 years with a focus on ongoing quality initiatives that will continue to refine the optimal applications and outcomes of CABG for the next 50 years.

Composite Y Grafts From the Left Internal Mammary Artery: Current Considerations

The use of composite coronary artery bypass grafts from the left internal mammary artery (LIMA) has increased over the last 20 years. Total arterial revascularisation can be achieved with two arterial conduits and is associated with a reduced risk of stroke. However, the traditional coronary bypass graft configurations of the in situ LIMA and aorto-coronary saphenous vein grafts remain as the mainstay of coronary bypass surgery in most centres. Concerns regarding composite Y grafts relate to (1) the adequacy of a single inflow for all coronary bypass grafts; (2) the risk of compromising the LIMA flow to the left anterior descending coronary artery; (3) the effects of competitive flow on graft patency; and (4) the use of sequential coronary anastomoses. The evidence upon which these concerns are based will be discussed along with the evidence relating to the use of the various second conduit options.

Similar Outcomes in Diabetes Patients After Coronary Artery Bypass Grafting With Single Internal Thoracic Artery Plus Radial Artery Grafting and Bilateral Internal Thoracic Artery Grafting

BACKGROUND

The purpose of this study was to determine in patients with diabetes mellitus whether single internal thoracic artery (SITA) plus radial artery (RA) grafting yields outcomes similar to those of bilateral internal thoracic artery (BITA) grafting.

METHODS

From January 1994 to January 2011, 1,325 diabetic patients underwent primary isolated coronary artery bypass graft surgery with either (1) SITA plus RA with or without saphenous vein (SV) grafts (n = 965) or (2) BITA with or without SV grafts (n = 360); an internal thoracic artery was used in all patients to graft the left anterior descending coronary artery. Endpoints were in-hospital outcomes and time-related mortality. Median follow-up was 7.4 years, with a total follow-up of 9,162 patient-years. Propensity score matching was performed to identify 282 well-matched pairs for adjusted comparisons.

RESULTS

Unadjusted in-hospital mortality was 0.52% for SITA plus RA with or without SV grafts and 0.28% for BITA with or without SV grafts, and prevalence of deep sternal wound infection was 3.2% and 1.7%, respectively. Unadjusted survival at 1, 5, 10, and 14 years was 97%, 88%, 68%, and 51% for SITA plus RA with or without SV grafts, and 97%, 95%, 80%, and 66% for BITA with or without SV grafts, respectively. Among propensity-matched patients, in-hospital mortality (0.35% versus 0.35%) and prevalence of deep sternal wound infection (1.4% versus 1.4%) were similar (p > 0.9) in the two groups, as was 1-, 5-, 10-, and 14-year survival: 97%, 90%, 70%, and 58% for SITA plus RA with or without SV grafting versus 97%, 93%, 79%, and 64% for BITA with or without SV grafting, respectively (early p = 0.8, late p = 0.2).

CONCLUSIONS

For diabetic patients, SITA plus RA with or without SV grafting and BITA with or without SV grafting yield similar in-hospital outcomes and long-term survival after coronary artery bypass graft surgery. Therefore, both SITA plus RA and BITA plus SV grafting should be considered for these patients.