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31
External stenting ofvein gras in
coronary artery bypass grasurgery
David P. Taggart
Introduction
e use of external stents to support vein gras placed into the arterial circulation was rst proposed by Parsonnet and colleagues
in 1963 using a carotid artery model. e rationale was to reduce
the diameter mismatch between the vein gra and the artery and to
minimize vein dilatation when subjected to higher ow and pressure
in the arterial system, thereby reducing the risk of intimal damage
and thrombosis. e role of external stents has been reviewed
extensively.
Experimentalstudies
Parsonnet etal. used a monolament knitted gra to cover a segment of jugular vein used to replace the common carotid artery
of dogs and reported that the external stent limited the dilatation
of the vein gra and had an angiographic patency rate of 97% at
2months. Subsequent experimental studies (Karayannacos etal.
in 1978) reported that external stents reduced intimal hyperplasia
and preserved the vasa vasora in the gra wall and similar results
were subsequently reported in several well- designed controlled
studies by Angelini and colleagues and Zilla and colleagues.
e mechanisms of vein gra failure are discussed extensively
in other chapters but as early gra failure is predominantly due
to inadequate surgical harvesting techniques or technical errors
during implantation, the postulated benet of external supports
is likely to be on gra failure over the mid to long term. Animal
models have suggested a large and diverse number of potential
physiological benets of external stents including improved biomechanical properties that mitigate vascular smooth muscle cell
proliferation and migration and promoting neovascularization of
the adventitia.
However, animal studies using carotid or femoral artery interposition techniques may not be representative of the coronary artery circulation and coronary artery bypass graing (CABG). Consequently,
Ben- Gal and colleagues performed a CABG proof- of- principle
randomized controlled study of an external stent on vein gras to
the le anterior descending and circumex coronary arteries in 14
sheep and reported that at 12 weeks there was a signicantly lower
level of gra non- uniformity, intimal hyperplasia, and gra thrombosis in the externally stented vein gras.
Clinicalstudies
Despite an abundance of animal data reporting a potential benet of
external supports for vein gras in improving saphenous vein gra
(SVG) patency, until relatively recently there was little supportive
clinical data. In 1986, Barra and colleagues conducted a small clinical study of four patients and demonstrated patency of the four
gras on angiographic follow- up at 2months. In 2007, a randomized
trial of a macro- porous Dacron® sheath (Fig. 31.1a) in 20 patients reported angiographic thrombosis of all stents and the technique was
abandoned.
Subsequently two far more technologically sophisticated stents
(Fig. 31.1b,c) (eSVS® mesh (Kipsbay Medical Inc., MN, USA) and
the VEST® stent (Vascular Gra Solutions, Tel Aviv, Israel) were trialled in clinical practice. e eSVS® mesh is composed of an elastic
nitinol knit that reduces the gra external diameter by 25%, and
requires xation by glue and incorporation of the stent into the
anastomoses. Several studies have reported low angiographic patency rates in the region of 30% at 1year., However a number
of important lessons were learnt from these studies including the
importance of avoiding over- constriction of the vein gras, incorporating the stent into the proximal or distal anastomoses, and the
use of brin glue.
A few years later, the VEST® external stent was investigated in a
clinical trial. VEST® consists of a cobalt- chrome braid with axial plasticity (allowing elongation) and radial elasticity (making the stent
kink and crush resistant). Following the initial favourable results of
the VEST® device in the sheep model, the rst in- human trial was
performed by Taggart and colleagues. In the venous external support trial (VEST), 30 patients were randomized to receive one SVG
supported by the device and a second vein gra to act as a control.
e primary end point demonstrated a signicant decrease in mean
SECTION 6 Conduits forcoronary artery bypass graft surgery250
of SVG length
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Fig.31.1 Photographs of the external stent devices. (a)The Extent
and featuring a flange to guide placement (image from the Extent study). (b)The eSVS® Mesh, made of highly flexible and kink- resistant knitted nitinol
wires and mounted on colour- coded FEP tubes. (c)The VEST® External Stent, a braided kink- resistant stent made of plastically deformable and elastic
cobalt chrome wires. The combination of wires provides the VEST® stent with radial elasticity and axial plasticity that enables length change and fixation.
intimal– medial area between the stented and unstented groups
(P=0.04) with a small decrease in intimal thickness (P=0.06) at
12months of follow- up.
e overall patency at 1year was 70% for the stented gras and
72% for the control gras and with patent stented gras having a
much higher Fitzgibbon perfect patency (80% vs 50%) (Fig. 31.2).
ere was a signicantly lower gra failure with stenting in gras
to the circumex territory (18% in the stented group vs 28% in the
unstented group; P=0.01), but an increase in failure of stented gras
to the right coronary territory (46% vs 13%; P=0.01). As transit
time ow measurements had been satisfactory in all gras prior to
sternal closure, it was hypothesized that gra failure may have been
due to xation of the device to the proximal and/ or distal anastomoses whose geometry then altered with chest closure, particularly
those on the right side because of the acute margin of the heart.
Furthermore, a lower occlusion rate was observed when sutures
rather than metallic clips had been used to occlude vein gra side
branches implying that metallic clips may have caused vessel distortion within the stent especially on the right side. Intravascular
ultrasonography also showed that sutures compared to metal clips
reduced overall plaque thickness (P=0.04), and area (P=0.05).
In this same cohort, computational uid dynamic analysis reported increased laminar and less turbulent blood ow (Fig. 31.3)
and a signicant reduction in mean oscillatory shear index in the
®
device, a macroporous Dacron® sheath reinforced with polytetrafluoroethylene ribs
stented group that correlated with a reduction in intimal hyperplasia
(P=0.01, n=43).
Finally, a further analysis of optical coherence tomography
showed that the mean lumen cross- sectional area was lower in the
stented gras than in the control gras (P=0.005), accompanied by
greater uniformity and similar to the preclinical ndings, an absence
of any sign of thrombus (Fig. 31.4).
e results of the VEST trial led to the establishment of the VEST
II study, in which clip ligation of side branches and xation of the
stent to the proximal or distal anastomoses of gras to the right coronary artery were avoided. At 3– 6months, postoperative angiography showed the patency rate of stented SVGs to the right coronary
artery improved to 86%, comparable to published historical data for
unstented SVGs to the same territory.
In VEST IV, 21 stented and 29 control SVGs from VEST
Iunderwent angiography and ultrasound at approximately 5years.
Overall, vein gra failure rates were comparable between stented
and control gras (30% and 23% respectively; P=0.42). with all
failures having been present at 1year except for one additional
control failure. In patent vein gras, Fitzgibbon perfect patency
remained signicantly higher in the stented versus control gras
as shown in 81% and 48% respectively (P=0.002), while intimal
hyperplasia area and thickness were signicantly reduced (Fig.
31.5). Intimal hyperplasia proliferation correlated with lumen
Perfect patency
Fig.31.2 Angiographic appearance of patent vein grafts according to Fitzgibbon classification.
Fitzgibbon I
Fitzgibbon II
Lumen irregularities < 50%
Fitzgibbon III
Lumen irregularities > 50%
of SVG length
31 External stenting ofvein grafts in coronary artery bypass graftsurgery 251
SMOOTHED
MAX
SHEA
STRESS
RST CALC
TIME 1.500
MAXIMUM
Δ
NODE 3531
MINIMU
∗
NODE 4493 (0.833)
Unsupported Supported
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R
42.00
39.00
36.00
33.00
30.00
27.00
24.00
21.00
18.00
15.00
12.00
9.00
6.00
3.00
0.00
58.68
M
0.5431
Fig.31.3 Computational flow haemodynamics show more laminar and less turbulent blood flow in the stented grafts.
uniformity and with the distance between the stent and the lumen
(P=0.04 and P <0.001 respectively).
Ongoingstudies
e results of previous studies involving the VEST® device have led
to the establishment of two further trials that have now completed
enrolment:VEST III (ClinicalTrials.gov identier:NCT02511834)
is a 184- patient European multicentre study and VEST PIVOTAL
(ClinicalTrials.gov identier:NCT03209609) is a 224- patient study
in the United States approved by the Food and Drug Administration.
e nal results are expected in 2020.
Further potential benefits ofexternalstenting
External stents may allow the use of conduits that would have previously been deemed unsuitable for surgery. Zurbrügg and colleagues
reported the use of an external ultrane constrictive metal mesh to
generate ‘biocompound’ gras with varicose vein tissue., ey
demonstrated that such gras had favourable patency rates aer
Fig.31.4 (a) Histological cross- section of unsupported saphenous vein bypass graft to the obtuse marginal artery 3months post implantation in
sheep model shows organized thrombus within the vessel wall (black arrow). (b)Optical coherence tomography analysis of unsupported saphenous
vein graft from the VEST Itrial shows organized thrombus within the vessel wall (white arrow).
SECTION 6 Conduits forcoronary artery bypass graft surgery252
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Fig.31.5 Within- patient comparison of supported (a– c) graft to obtuse marginal 2 and unsupported (d– f) graft to obtuse marginal 1 5years
after CABG. Angiographic and intravascular ultrasonographic follow- up show improved lumen uniformity and reduced intimal hyperplasia in the
supported grafts.
hospital discharge (41/ 43) and had similar patency rates to nonstented SVGs aer 3years, thus potentially increasing the number of
conduits the surgeon may utilize in CABG.
4. Angelini GD, Izzat MB, Bryan AJ, Newby AC. External stenting
reduces early medial and neointimal thickening in a pig model
of arteriovenous bypass graing. J orac Cardiovasc Surg.
1996;112(1):79– 84.
5. Zilla P, Human P, Wolf M, Lichtenberg W, Raee N, Bezuidenhout
Conflict ofinterest
D, etal. Constrictive external nitinol meshes inhibit vein gra
intimal hyperplasia in nonhuman primates. J orac Cardiovasc
Surg. 2008;136(3):717– 25.
David Taggart states that he has received research funding, speaking
and travelling honoraria from Vascular Gra Solutions (VGS) and
also has share options in VGS.
6. Ben- Gal Y, Taggart DP, Williams MR, Orion E, Uretzky G, Shoi
R, etal. Expandable external support device to improve saphenous
vein gra patency aer CABG. J Cardiothorac Surg. 2013;8:122.
7. Barra JA, Volant A, Leroy JP, Braesco J, Airiau J, Boschat J, etal.
Constrictive perivenous mesh prosthesis for preservation of vein
REFERENCES
1. Parsonnet V. New stent for support of veins in arterial gras. Arch
Surg. 1963;87:696.
2. Mawhinney JA, Mounsey CA, Taggart DP. e potential role of
external venous supports in coronary artery bypass gra surgery.
Eur J Cardiothorac Surg. 2018;53(6):1127– 34.
3. Karayannacos PE, Hostetler JR, Bond MG, Kakos GS, Williams
RA, Kilman JW, etal. Late failure in vein gras:mediating
factors in subendothelial bromuscular hyperplasia. Ann Surg.
1978;187(2):183– 8.
integrity. Experimental results and application for coronary bypass
graing. J orac Cardiovasc Surg. 1986;92(3):330– 6.
8. Murphy GJ, Newby AC, Jeremy JY, Baumbach A, Angelini GD. A
randomized trial of an external Dacron sheath for the prevention
of vein gra disease:the Extent study. J orac Cardiovasc Surg.
2007;134(2):504– 5.
9. Schoettler J, Jussli- Melchers J, Grothusen C, Stracke L,
Schoeneich F, Stohn S, etal. Highly exible nitinol mesh to encase
aortocoronary saphenous vein gras:rst clinical experiences
and angiographic results nine months postoperatively. Interact
Cardiovasc orac Surg. 2011;13(4):396– 400.
31 External stenting ofvein grafts in coronary artery bypass graftsurgery 253
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10. Rescigno G, Aratari C, Matteucci SM, Parisi R, Gironi G, Schicchi
N, etal. Saphenous vein gra wrapping by nitinol mesh:a word of
caution. orac Cardiovasc Surg. 2015;63(4):292– 7.
11. Taggart DP, Gal Y Ben, Lees B, Patel N, Webb C, Rehman SM, etal.
A randomized trial of external stenting for saphenous vein gras in
coronary artery bypass graing. Ann orac Surg. 2015;99(6):2039– 45.
12. Meirson T, Orion E, Di Mario C, Webb C, Patel N, Channon KM,
etal. Flow patterns in externally stented saphenous vein gras
and development of intimal hyperplasia J orac Cardiovasc
Surg. 2015;150(4):871– 9.
13. Webb CM, Orion E, Taggart DP, Channon KM, Di Mario C.
OCT imaging of aorto- coronary vein gra pathology modied
by external stenting:1- year post- surgery. Eur Heart J Cardiovasc
Imaging. 2016;11(11):1290– 95.
14. Taggart DP, Amin S, Djordjevic J, Oikonomou EK, omas S,
Kampoli AM, etal. A prospective study of external stenting of
saphenous vein gras to the right coronary artery:the VEST II
study. Eur J Cardiothorac Surg. 2017;51(5):952– 8.
15. Lopes RD, Mehta RH, Haey GE, Williams JB, Mack MJ,
Peterson ED. Relationship between vein gra failure and
subsequent clinical outcomes aer coronary artery bypass
surgery. Circulation. 2012;125(6):749– 56.
16. Taggart DP, Webb CM, Desouza A, Yadav R, Channon KM, De
Robertis F, etal. Long- term performance of an external stent for
saphenous vein gras:the VEST IV trial. J Cardiothorac Surg.
2018;13(1):117.
17. Zurbrügg HR, Wied M, Angelini GD, Hetzer R. Reduction of
intimal and medial thickening in sheathed vein gras. Ann
orac Surg. 1999;68(1):79– 83.
18. Zurbrügg HR, Hetzer R. e use of biocompound- gras together
with varicose veins. First clinical experience. J Cardiovasc Surg
(Torino). 1996;37(6 Suppl 1):143– 6.
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32
Revascularization using the
saphenous vein asa compositegra
Ki- Bong Kim
Introduction
e saphenous vein (SV) conduit has been used as an aortocoronary
bypass gra in almost all previous studies, and its use as a composite
gra was reserved for patients with diusely atherosclerotic or calcied ascending aorta to minimize ascending aorta manipulation
and to reduce the risk of neurological injury., Previous studies
describing the use of the SV composite gra based on the in situ
le internal thoracic artery (ITA) demonstrated conicting results
although revascularization strategies using the arterial composite
gras have been demonstrated to be a safe and ecient method for
revascularization. One study, which included 25 patients who received an SV composite gra based on the le ITA, recommended
against the use of a SV composite gra because it could steal ow
from the le ITA conduit and lead to suboptimal short- term ITA
patency results (patency rates of SV and ITA conduits, 96% and 76%
at a mean 2.5years, respectively). Other studies demonstrated comparable haemodynamic and early patency results between SV versus
right ITA composite gras based on the in situ le ITA., Of various
eorts to overcome the limitations of SV that result from inherent
anatomical/ structural and functional dierences between SV and
arterial conduits, recent improvement in harvesting techniques including no- touch technique and a surgical strategy of using the SV
as a composite gra rather than an aortocoronary bypass gra may
improve long- term patency of SV conduits in coronary artery bypass graing (CABG).
The no- touch technique forsaphenous
veinharvesting
e no- touch technique of SV harvesting with or without surrounding pedicle tissue, in which the manipulation and tension of
the SV are minimized and manual intraluminal dilatation is avoided
during harvest, has been suggested to overcome the limitations of
SV conduits.– e no- touch technique with surrounding fat pedicle tissue, introduced in 1996, protects the vein from direct handling
that causes injury and spasm. Preservation of the surrounding
cushion of fat may reduce medial ischaemia by maintaining the vasa
vasorum,, provide various vasodilators and adipokines including
nitric oxide, and act as an external biological stent. Although the
no- touch technique with surrounding fat pedicle demonstrated improved patency, it may have a high risk of SV wound complications.
In the no- touch technique without surrounding pedicle tissue, the
so- called minimal manipulation technique, the SV was gently separ-
–
ated from the bed using scissors, leaving perivascular scanty adipose
tissue in place; the manipulation and tension of the SV also were
minimized and manual intraluminal dilatation was avoided during
harvest. e no- touch technique without surrounding pedicle
tissue was shown immunohistochemically to be benecial in preserving endothelial structure and function, and showed a low risk
of SV wound complication.
The saphenous vein asa composite graft
based onthe internal thoracicartery
One intraoperative haemodynamic study measured gra ow
using transit time owmetry at baseline and during dobutamineinduced stress in patients who received SV composite gras based
on the in situ le ITA, and demonstrated that both the le ITA and
SV showed physiological adaptability according to myocardial demand. Another study, which performed serial quantitative coronary angiograms early and 1year aer CABG and also performed
an intravascular ultrasonographic study of the proximal le ITA and
SV conduits during the 1- year angiography, revealed that the SV
lumen diameter decreased signicantly without accompanying abnormal intima– media thickening during the rst year aer CABG
(Fig. 32.1). In a randomized trial, the SV composite gras were
non- inferior to the right ITA composite gras in terms of 1- year
angiographic patency rates (SV vs right ITA, 97.1% (238/ 245) vs
97.1% (198/ 204); P=0.958) and overall survival and major adverse
cardiac and cerebrovascular events- free rates up to 4years aer surgery. eoretical advantages of SV composite gra based on the
SECTION 6 Conduits forcoronary artery bypass graft surgery256
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Fig.32.1 Images of intravascular ultrasound performed at 1year
postoperatively. The lumen of the proximal left internal thoracic artery (pLITA) and saphenous vein (SV) showed a thin intima– media without any
abnormal plaque.
Reproduced from Hwang HY, Koo BK, Oh SJ, Kim KB. (2015) Morphologic changes of
the saphenous vein Y- composite graft based on the left internal thoracic artery:1- year
intravascular ultrasound study. The Journal of Thoracic and Cardiovascular Surgery.
149(2). pp.487– 493 with permission.
in situ le ITA over an aortocoronary bypass gra include (1)the
SV conduit anastomosed to the le ITA is exposed to less haemodynamic pulse pressure stress (dP/ dT) than a conduit anastomosed
to the ascending aorta; (2)the SV composite gra is continuously exposed to endothelium- protective substances such as nitric oxide released from the le ITA; (3)the length of the SV needed to reach the
target vessel is shorter than that of an aortocoronary SV gra, especially when using a sequential anastomosis technique; and (4)complications such as embolic stroke and aortic dissection are known to
be reduced by avoiding aortic clamping for proximal anastomosis.
Additional benets of SV composite gras compared with bilateral ITA composite gras are (1)the right ITA, oen considered the
second conduit of choice aer the le ITA, is reserved for possible
later redo CABG; and (2)the risk of perioperative morbidity, such
as sternal infection, which can occur aer bilateral ITA use, is decreased. ere are still concerns about long- term patency of the SV
composite gra because of the pathological changes in SV conduits,
such as neointimal hyperplasia and atherosclerosis, which evolve
very slowly several years postoperatively. e follow- up study of
a randomized trial demonstrated that the clinical results of CABG
using SV composite gras showed no statistically signicant differences compared with those of CABG using right ITA composite
gras up to 8years aer surgery in terms of overall survival and
major adverse cardiac and cerebrovascular events- free survival.
e 5- year occlusion rate of the SV composite gras was 4.3% and
was non- inferior to that of the right ITA composite gras (2.4%) (P
<0.001 for non- inferiority) (Fig. 32.2). However, long- term angiographic and clinical follow- up may be needed to demonstrate that
the advantages of SV composite graing are sucient to overcome
the previously published advantages of the right ITA over the SV as
an additional conduit.
Fig.32.2 Patent saphenous vein (SV) Y- composite grafts based on the in situ left internal thoracic artery (ITA) at (a)early postoperative, (b)1- year, and
(c)5- year angiographies in a 54- year- old male patient. The in situ left ITA was anastomosed to the second diagonal (black arrowheads) and left anterior
descending coronary arteries (white arrowheads), and the SV was anastomosed to the first diagonal (black arrows) and distal obtuse marginal (white
arrows) and right posterolateral coronary arteries (black thin arrows) using a sequential anastomotic technique.
Reproduced from Kim M- S, Hwang HY, Kim JS, Oh SJ, Jang M- J, Kim K- B (2018). Saphenous vein versus right internal thoracic artery as a Y- composite graft:Five- year angiographic
and clinical results of a randomized trial. The Journal of Thoracic and Cardiovascular Surgery, 156(4), pp.1424– 1433 with permission Elsevier.
32 Revascularization using the saphenous vein asa compositegraft 257
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1. Brodman R, Robinson G. Internal mammary artery- saphenous
vein composite conduit:an alternative for the proximal coronary
anastomosis. Ann orac Surg. 1981;31(4):370– 2.
2. Murphy DA, Hatcher CR. Coronary revascularization in the
presence of ascending aortic calcication:use of an internal
mammary artery- saphenous vein composite gra. J orac
Cardiovasc Surg. 1984;87(5):789– 91.
3. Gaudino M, Alessandrini F, Pragliola C, Luciani N, Trani C,
Burzotta F, etal. Composite Y internal thoracic artery– saphenous
vein gras:short- term angiographic results and vasoreactive
prole. J orac Cardiovasc Surg. 2004;127(4):1139– 44.
4. Glineur D, Boodhwani M, Poncelet A, De Kerchove L, Etienne
PY, Noirhomme P, etal. Comparison of fractional ow reserve of
composite Y- gras with saphenous vein or right internal thoracic
arteries. J orac Cardiovasc Surg. 2010;140(3):639– 45.
5. Kim K-B, Hwang HY, Hahn S, Kim JS, Oh SJ. A randomized
comparison of the Saphenous Vein Versus Right Internal oracic
Artery as a Y- Composite Gra (SAVE RITA) trial:one- year
angiographic results and mid- term clinical outcomes. J orac
Cardiovasc Surg. 2014;148(3):901– 7.
6. Souza D. A new no- touch preparation technique. Technical notes.
Scand J orac Cardiovasc Surg. 1996;30(1):41– 4.
7. Samano N, Geijer H, Lidén M, Fremes S, Bodin L, Souza D. e notouch saphenous vein for coronary artery bypass graing maintains a
patency, aer 16years, comparable to the le internal thoracic artery:a
randomized trial. J orac Cardiovasc Surg. 2015;150(4):880– 8.
8. Kim YH, Oh HC, Choi JW, Hwang HY, Kim K-B. No- touch
saphenous vein harvesting may improve further the patency
of saphenous vein composite gras:early outcomes and 1- year
angiographic results. Ann orac Surg. 2017;103(5):1489– 97.
9. Dreifaldt M, Souza DS, Loesch A, Muddle JR, Karlsson MG, Filbey
D, etal. e ‘no- touch’ harvesting technique for vein gras in
coronary artery bypass surgery preserves an intact vasa vasorum. J
orac Cardiovasc Surg. 2011;141(1):145– 50.
10. Dashwood MR, Tsui JC. ‘No- touch’ saphenous vein harvesting
improves gra performance in patients undergoing coronary
artery bypass surgery:a journey from bedside to bench. Vascul
Pharmacol. 2013;58(3):240– 50.
11. Fernández- Alfonso MS, Gil- Ortega M, Aranguez I, Souza
D, Dreifaldt M, Somoza B, etal. Role of PVAT in coronary
atherosclerosis and vein gra patency:friend or foe? Br J
Pharmacol. 2017;174(20):3561– 72.
12. Dashwood MR, Savage K, Tsui JC, Dooley A, Shaw SG, Fernández
Alfonso MS, etal. Retaining perivascular tissue of human
saphenous vein gras protects against surgical and distensioninduced damage and preserves endothelial nitric oxide synthase
and nitric oxide synthase activity. J orac Cardiovasc Surg.
2009;138(2):334– 40.
13. Hwang HY, Kim MA, Seo JW, Kim K-B. Endothelial preservation
of the minimally manipulated saphenous vein composite
gra:histologic and immunohistochemical study. J orac
Cardiovasc Surg. 2012;144(3):690– 6.
14. Lobo HG, Lobo JG, Pimentel MD, Silva BG, de Souza CS,
Montenegro ML, etal. Intraoperative analysis of ow dynamics
in arteriovenous composite Y gras. Braz J Cardiovasc Surg.
2016;31(5):351– 7.
15. Hwang HY, Koo BK, Oh SJ, Kim K-B. Morphologic changes of
the saphenous vein Y- composite gra based on the le internal
thoracic artery:1- year intravascular ultrasound study. J orac
Cardiovasc Surg. 2015;149(2):487– 93.
16. Fitzgibbon GM, Kaa HP, Leach AJ, Keon WJ, Hooper
GD, Burton JR. Coronary bypass gra fate and patient
outcome:angiographic follow- up of 5,065 gras related to survival
and reoperation in 1,388 patients during 25years. J Am Coll
Cardiol. 1996;28(3):616– 26.
17. Kim M-S, Hwang HY, Kim JS, Oh SJ, Jang MJ, Kim K-B.
Saphenous vein versus right internal thoracic artery as
a Y- composite gra:ve- year angiographic and clinical
results of a randomized trial. J orac Cardiovasc Surg.
2018;156(4):1424– 33.
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