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Contributorsxx

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Shuichiro Takanashi , MD D e p a r t m e n t o f

Cardiovascular Surgery, Sakakibara Heart Institute, Tokyo, Japan

Koji Takeda , MD, PhD Cardiac Surgery

Department, Columbia University, NewYork, NY, USA

Derrick Y. Tam , MD Division of Cardiac Surgery,

Department of Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, ON, Canada

James Tatoulis , MBBS, MS, MD, FRACS

Department of Surgery, University of Melbourne; Department of Cardiothoracic Surgery, Royal Melbourne Hospital, Melbourne, Australia

Giuseppe Tavilla , MD, PhD D e p a r t m e n t o f

Surgery, Division of Cardiac and  oracic Surgery, Scott & White Medical Center, Baylor Scott & White Health, Temple, TX, USA

Hadi Toeg , MD, MSc, MPH Division of Cardiac

Surgery, University of Ottawa Heart Institute, Ottawa, ON, Canada

Matthew I. Tomey , MD Icahn School of Medicine

at Mount Sinai, NewYork, NY, USA

Sho Torii , MD CVPath Institute, Gaithersburg,

MD, USA

Gianluca Torregrossa , MD Division of Robotic

and Minimally Invasive Cardiac Surgery, Section of Cardiac and  oracic Surgery, Department of Surgery,  e University of Chicago Medicine and Biological Sciences, Chicago, IL, USA

Nick Townsend , PhD, FHEA D e p a r t m e n t f o r

Health, University of Bath, Bath, UK

Robert F. Tranbaugh , MD D e p a r t m e n t o f

Cardiothoracic Surgery, Weill Cornell Medicine, NewYork, NY, USA

Naresh Trehan , MD Medanta  e Medicity,

Gurgaon, Haryana, India

Prashant Vaishnava , MD Mount Sinai Hospital

and Icahn School of Medicine at Mount Sinai, NewYork, NY, USA

Renu Virmani , MD CVPath Institute,

Gaithersburg, MD, USA

Alice Wang , MD Department of Surgery, Division

of Cardiovascular and  oracic Surgery, Duke University Medical Center, Durham, NC, USA

Menachem M. Weiner , MD D e p a r t m e n t o f

Anesthesiology, Perioperative, and Pain Medicine,

Icahn School of Medicine at Mount Sinai, NewYork, NY, USA

William S. Weintraub , MD, FACC C h r i s t i a n a C a r e

Health System, Newark, DE, USA

Sandra A. Weiss , MD Christiana Care Health

System, Newark, DE, USA

Mary Ann C. Wertan , RN Lankenau Medical

Center, Wynnewood, PA, USA

R. Jay Widmer , MD, PhD Division of Cardiology,

Scott & White Heart Memorial Hospital, Baylor Scott & White Health, Temple, TX, USA

Tristan D. Yan , MD, PhD, FRACS  e Collaborative

Research (CORE) Group, Macquarie University, Sydney, Australia

Bobby Yanagawa , MD, PhD, FRCSC Division of

Cardiac Surgery, St. Michael’s Hospital, University of Toronto, Toronto, O N, C ana da

Babatunde A. Yerokun , MD Department of

Surgery, Division of Cardiovascular and  oracic Surgery, Duke University Medical Center, Durham, NC, USA

Vipin Zamvar , MD Royal In rmary of Edinburgh,

Department of Cardiothoracic Surgery, Edinburgh, UK

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Abbreviations

3VD three- vessel disease AAOCA anomalous aortic origin of a coronary artery AAOLCA anomalous aortic origin of the le main

coronary artery

AAORCA anomalous aortic origin of the right

coronary artery

ACAPA anomalous origin of the coronary artery from the

pulmonary artery ACC American College of Cardiology ACCF American College of Cardiology Foundation ACI Acoustic Coupling Index AHA American Heart Association AHTECAB arrested heart totally endoscopic coronary

artery bypass AI aortic insuciency ALCA anomalous le coronary artery arising from the

right sinus of Valsalva ALCAPA anomalous origin of the le coronary artery from

the pulmonary artery ARCAPA anomalous origin of the right coronary artery

from the pulmonary artery ARCAPA anomalous right coronary artery arising from the

le sinus of Valsalva ART Arterial Revascularisation Trial ARTS Arterial Revascularization erapies Study AS aortic stenosis ASA acetylsalicylic acid ASCVD atherosclerotic cardiovascular disease ASMR age- standardized mortality rate AVR aortic valve replacement AWB autologous whole blood BARI Bypass Angioplasty Revascularization

Investigation BEST Randomized Comparison of Coronary Artery

Bypass Surgery and Everolimus- Eluting Stent

Implantation in the Treatment of Patients With

Multivessel Coronary Artery Disease BF backward ow BHTECAB beating heart totally endoscopic coronary

artery bypass BITA bilateral internal thoracic artery BMI body mass index BMS bare- metal stent BP blood pressure CA contrast agent CABG coronary artery bypass gra(ing)

CAC coronary artery calcium CAD coronary artery disease cAMP cyclic adenosine monophosphate CARDia Coronary Artery Revascularization in Diabetes CBF coronary blood ow cCAB conventional coronary artery bypass graing CCS Canadian Cardiovascular Society CCTA coronary computed tomography angiogram cGMP cyclic guanosine monophosphate CI condence interval CKD chronic kidney disease CMD coronary microvascular dysfunction CMR cardiovascular magnetic resonance CO cardiac output COR class of recommendations CORONARY CABG O- or On- Pump Revascularization Study CPB cardiopulmonary bypass CSA cross- sectional area CT computed tomography CTO chronic total occlusion CTSN Cardiothoracic Surgical Clinical Trials Network CX circumex artery DAPT dual antiplatelet therapy DES drug- eluting stent DSWI deep sternal wound infection EACA epsilon- aminocaproic acid EACTS European Association for Cardio- oracic

Surgery EAS epiaortic ultrasound scanning EAUS epiaortic ultrasound ECG electrocardiogram ECMO extracorporeal membrane oxygenation ECUS epicardial ultrasound EEM external elastic membrane EF ejection fraction ERAH endoscopic radial artery harvesting ESA erythropoiesis- stimulating agent ESC European Society of Cardiology EuroSCORE European System for Cardiac Operative Risk

Evaluation EVH endoscopic vein harvesting EXCEL Evaluation of XIENCE versus Coronary Artery

Bypass Surgery for Eectiveness of Le Main

Revascularization FDA Food and Drug Administration FDG uorodeoxyglucose

Abbreviationsxxii

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FFP fresh frozen plasma FFR fractional ow reserve FREEDOM Future Revascularization Evaluation in Patients

with Diabetes Mellitus:Optimal Management of

Multivessel Disease GFR glomerular ltration rate GOPCABE German O Pump Coronary Artery Bypass in

Elderly HAA hospital- acquired anaemia HCR hybrid coronary revascularization HDL high- density lipoprotein HR hazard ratio or heart rate HTK histidine– tryptophan– ketoglutarate IABP intra- aortic balloon pump ICS intercostal space ICU intensive care unit IHD ischaemic heart disease IMR ischaemic mitral regurgitation INOCA ischaemia with non- obstructive coronary artery

disease ISMICS International Society of Minimally Invasive

Cardiac Surgery ISR in- stent restenosis ITA internal thoracic artery ITT intention- to- treat IV intravenous IVUS intravascular ultrasound LAA le atrial appendage LAD le anterior descending artery LDL low- density lipoprotein LGE late gadolinium enhancement LITA le internal thoracic artery LMCA le main coronary artery LOE level of evidence LV le ventricle/ ventricular LVD le ventricular dysfunction LVEF le ventricular ejection fraction MACE major adverse cardiac events MACCE major adverse cardiac and cerebrovascular events MAG multiple arterial gra MBF myocardial blood ow MCS mechanical circulatory support MI myocardial infarction MIDCAB minimally invasive direct coronary artery graing MiECC minimal invasive extracorporeal circulation MR mitral regurgitation MRSA methicillin- resistant Staphylococcus aureus MSCT multislice computed tomography NAT no- aortic- touch NICE- SUGAR Normoglycaemia in Intensive Care Evaluation

and Survival Using Glucose Algorithm Regulation NO nitric oxide NOBLE Nordic– Baltic– British le Main Revascularization

Study NS normal saline NSTEMI non- ST- segment myocardial infraction

NT no- touch OCT optical coherence tomography OMT optimal medical therapy ONCAB on- pump coronary artery bypass graing OPCAB o- pump coronary artery bypass graing PA pulmonary artery PAC pulmonary artery catheter PBM patient blood management PCC prothrombin complex concentrate PCI percutaneous coronary intervention PCR polymerase chain reaction PDE phosphodiesterase PET positron emission tomography PI pulsatility index PREVENT Project of Ex- Vivo Vein Gra Engineering via

Transfection RA radial artery RASV right aortic sinus of Valsalva RCA right coronary artery RCT randomized controlled trial RF radiofrequency RGEA right gastroepiploic artery RIME Randomized Ischemic Mitral Evaluation RITA right internal thoracic artery ROOBY Randomized On/ O Bypass RPE rating of perceived exertion RR relative risk SCD sudden cardiac death SFA saturated fatty acid SITA single internal thoracic artery SPECT single- photon emission computed tomography SSWI supercial sternal wound infection STEMI ST- segment myocardial infraction STS Society of oracic Surgeons STS- ND Society of oracic Surgeons National Database SV saphenous vein SVG saphenous vein gra SYNTAX Synergy between Percutaneous Coronary

Intervention with Taxus and Cardiac Surgery TAR total arterial revascularization TECAB totally endoscopic coronary artery bypass TIA transient ischaemic attack TMR transmyocardial laser revascularization TOE transoesophageal echocardiography TTFM transit- time ow meter TVR target vessel revascularization TXA tranexamic acid ULMCA unprotected le main coronary artery VA CARDS Veterans Aairs Coronary Artery

Revascularization in Diabetes Study VAD ventricular assist device VAS visual analogue scale VGF vein gra failure WMSI Wall Motion Score Index

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SECTION 1

Pathophysiology and investigation ofcoronary artery disease

Section editors:Thomas F.Lüscher, Valentin Fuster, and Prashant Vaishnava

1. A brief history of the surgical treatment of

coronary artery disease 3

Mario Gaudino, Stuart J.Head, and David P.Taggart

2. Epidemiology of ischaemic heart disease 9

Nick Townsend

3. Pathophysiology of coronary artery

disease 11

3.1 Regulation of coronary ﬂow 11

Nico Bruining, Eric Boersma, and Dirk J.Duncker

3.2 Coronary endothelial function 13

R. Jay Widmer and Amir Lerman

3.3 Coronary artery spasm 16

Hiroaki Shimokawa and Jun Takahashi

3.4 The coronary microcirculation and coronary

microvascular dysfunction 18

Romana Herscovici and C.Noel Bairey Merz

3.5 Plaque rupture and erosion 21

Hiroyoshi Mori, Sho Torii, and Renu Virmani

3.6 Biology of bypass vessels and their relation

to patency and disease 23

Thomas F.Lüscher

4. Anomalous coronary arteries 31

Chin Siang Ong, Ronald K.Binder, Marshall L.Jacobs, and Duke E.Cameron

5. Non- invasive investigation of coronary

artery disease 39

5.1 Echocardiography and stress echocardiography

for coronary artery disease 39

Jae K.Oh

5.2 Nuclear cardiology 41

Aju P.Pazhenkottil and Ronny R.Buechel

5.3 Magnetic resonance imaging 45

Alexander Gotschy and Robert Manka

5.4 Cardiac computed tomography 48

Steve L.Liao

6. Ischaemia, hibernation, and viability 53

Roberto Ferrari

7. Invasive investigation of coronary artery

disease 57

7.1 Angiography 57

Matthew I.Tomey

7.2 Intravascular ultrasound 60

Lorenz Räber

7.3 Fractional ﬂow reserve 63

Giovanni Ciccarelli, Emanuele Barbato, and Bernard De Bruyne

7.4 Optical coherence tomography 67

Keyvan Karimi Galougahi, Tomasz Roleder, Akiko Maehara, and Ziad A.Ali

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Abrief history ofthe surgical treatment ofcoronary arterydisease

Mario Gaudino, Stuart J. Head, and David P. Taggart

Introduction

e history of the treatment of coronary artery disease (CAD) and of coronary artery bypass gra (CABG) surgery is a story of innovators, persistence in the face of ferocious criticism, disappointing failures, and serendipitous discovery (Fig. 1.1). It is a story of giants and visionaries.

Over almost 140years, it can be divided into four dierent eras

as follows:

Development ofscientiﬁc background and extracardiac procedures (1880– 1934)

Hammer was the rst to postulate that angina may be related to interruption of blood supply to the heart in 1876. In 1880, Langer described the existence of anastomotic networks between the coronary circulation and surrounding structures such as the diaphragm, the lung, and the pericardium. Among the rst proposals of a surgical approach to CAD is an article from 1898 where Pratt suggested that blood ow in the coronary sinus could be reversed by the insertion of an artery. Alternatively, in 1903, orel proposed that ischaemia could be relieved through the formation of myopericardial adhesions. Alexis Carrel, then reported a series of animal experiments in 1910 where segments of arteries or veins were anastomosed to the aorta and the coronary arteries. In clinical practice at that time, however, the surgical treatments for CAD did not involve a direct approach to the heart.

Meanwhile, extracardiac procedures also continued to develop. In 1899, Franck recommended removal of the sympathetic thoracic ganglia to treat angina pectoris, and in 1902, the great Swiss physician, Kocher, observed how angina disappeared aer thyroidectomy in a patient with CAD. Jonnesco performed the rst cardiac sympathectomy in 1920, and in 1925, Mandl reported paravertebral injection of alcohol for the same purpose. Of note, the use of cardiac denervation procedures persisted for almost 40years. Boas, in 1926, performed a subtotal thyroidectomy building on the previous observations from Kocher. Finally, towards the end of this

era, Sussman described cardiac irradiation to denervate the heart and produce coronary vasodilatation in 1930.

Indirect revascularization procedures (1935– 1953)

e year 1935 marked the start of an era where cardiac surgeons directly approached the heart, but not the coronary circulation. e aim was to induce neovascularization and improve collateral circulation to the myocardium. Beck,, who was one of the pioneers of this approach, described the ‘cardiopericardiopexy’ where the epicardium and visceral pericardium were mechanically abraded in the hope of inducing scar formation and neovascularization. Neovascularization was further enhanced by irritating agents such as talcum powder as well as the suturing of a pectoralis muscle ap to the heart. Alternatives tried in later years included the omentum by O’Shaugnessy in 1936, the lung by Lezius in 1937, and the jejunum by Key in 1954.

Another approach was described by Robertson and Gross who in the late 1930s partially ligated the great cardiac vein and the coronary sinus, respectively, with the hope that the increased venous pressure would redirect thebesian vessel blood ow into the myocardium. In 1939, Fieschi described ligation of the internal thoracic artery (ITA) with the aim of increasing collateral ow through the pericardiophrenic arteries back to the heart. More than 20years later, Kline and Kownacki tried to increase collateral pulmonary ow to the heart by ligating dierent parts of the pulmonary circulation.

Beck described the Beck’s Ioperation which included coronary sinus ligation, pericardial poudrage, and mediastinal fat graing.

Lillehei proposed connecting the pulmonary artery and the left atrium to increase left heart and coronary flow, and Roberts worked on an experimental model of arterialization of the coronary sinus using arterial grafts that was applied in humans by Beck in 1948. This was the Beck’s II operation which was a staged procedure of arterialization of the coronary sinus using saphenous vein or brachial artery implants followed by partial ligation of the coronary sinus.

1964:

2011:

disease

2018:

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First

CABG

procedure

1971:

Carpentier

describes

radial artery

graft

1977:

Gruntzig:

first

balloon

angioplasty

1978:

FitzGibbon:

poor

saphenous

vein

graft

patency

follow-

1982:

CASS

trial

comparing

CABG

with medical therapy

1986:

Loop

and

Lytle:

superiority

LITA—

LAD to

saphenous

vein

1987:

Suma

and

Pym:

first use

of the

right

gastroepiploic

artery

for CABG

1994:

Minimally

invasive

CABG

introduced

1999:

Eduardo

Sousa:

first DES (sirolimus) implanted

2009:

SYNTAX

trial:

CABG

superior

to PCI

for

severe

coronary

artery

disease

HEART

and STICH

trials:

RCTs comparing CABG with

medical

therapy in

patients with left

ventricular

dysfunction

2013:

CORONARY:

largest

trial

comparing

on-pump

vs offpump CABG

RADIAL:

first

RCT-

based

demonstration

clinical benefits with the

radial artery

1967:

Favaloro's

first

CABG

procedure

Early

1970s:

Introduction

cardioplegia

1977:

Trial

comparing

CABG

with medical therapy

1979:

European

CABG

trial:

comparing

CABG

with

medical

therapy

1985:

Benetti

and

Buffolo

popularize

offpump CABG

1986:

Sigwart

and

Puel:

first

implantation

of a bare

metal

stent in

human

coronary

artery

1988:

Puig-

first use

of the

inferior

epigastric

artery

as graft

1996:

Octopus stabilizer

introduced

2003:

RAPCO

trial:

first

RCT on

the radial artery

2010:

ART

trial:

first

RCT

comparing

BITA to

SITA—

operative

results

2012:

FREEDOM

trial: CABG vs PCI

patients

with

diabetes

2016:

EXCEL

and

NOBLE

comparing

CABG

everolimus

eluting

stenting

in left

main

2018:

ART trial

at 10

years: no

difference

between

BITA and

SITA

Fig.1.1 Atimeline of the history of CABG. BITA, bilateral internal thoracic artery; CABG, coronary artery bypass graft; DES, drug- eluting stent; LAD, left anterior descending coronary artery; LITA, left

internal thoracic artery; PCI, percutaneous coronary intervention; RCT, randomized controlled trial; SITA, single internal thoracic artery.

51 Abrief history ofthe surgical treatment ofcoronary arterydisease

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While myocardial acupuncture or use of needles to create channels between the ventricular cavity and the myocardium was described by Sen in 1965, the most renowned of the indirect revascularization procedures was described as tunnelling and implantation of the ITA in the myocardium in 1946 by Arthur Vineberg. Still other surgeons experimented with the use of the gastroepiploic and the intercostal arteries. In the early 1970s, aer the development of coronary angiography, the formation of a network of collaterals between the ITA and the coronary circulation was proven in some patients with severe coronary artery stenosis who underwent the Vineberg procedure. Several thousand Vineberg procedures were performed worldwide.

The modern era ofCABG (1968– present)

e rst published CABG series was reported by Johnson and Urschel between 1968 and 1970, while Spencer and Green championed the use of the ITA and of the operating microscope in NewYork City which set the stage for modern- day practice. Green performed the rst clinical le ITA– le anterior descending coronary artery anastomosis in the United States in February 1968.,

In 1967, Renee Favaloro reported his rst case of CABG using saphenous vein as a conduit in a patient where the planned coronary thromboendoarterectomy was found to be technically impossible. Although not the rst to describe the procedure, Favaloro’s contribution to CABG is unmatched, and he is usually considered the ‘fa-

Non- CABG direct revascularization procedures and ﬁrst attempts atCABG (1954– 1967)

ther’ of coronary surgery (Fig. 1.2). Favaloro was the rst to perform CABG in the setting of acute myocardial infarction and among the rst to perform multivessel CABG. His lifelong collaboration with Mason Sone, who pioneered coronary angiography, underpinned the basis of modern coronary surgery.

Aer Demikhov described his experiments in canines where he graed the le ITA to the le anterior descending artery in 1952, the time had come to further explore direct revascularization. Smith

Johnson, Flemma, and Lepley were among the rst to use sequential vein gras for CABG, while Barner introduced the use of the ITA as a free gra. In 1975, Trapp and Bisarya and Ankeney

was the rst to harvest saphenous vein for use as a gra from the aorta to the myocardium. In 1956, Bailey performed the rst closed coronary thromboendoarterectomy, and in 1958, Longmire reported the rst open procedure. Dubost performed an ostial coronary reconstruction in a patient with syphilitic aortitis in 1959. is was also the year that Mason Sone performed the rst coronary angiography at the Cleveland Clinic allowing a better way to evaluate coronary anatomy and pathology.

A large amount of experimental work was concurrently underway for the preparation of direct coronary artery anastomosis, and in 1954, Murray reported the rst successful anastomosis of a systemic artery to a coronary artery in dogs. Smith described the myocardial implantation of arterial or venous gras anastomosed to the descending aorta, and Julian performed direct CABG in dogs using cardiopulmonary bypass. In 1955, Melrose introduced the concept of cardioplegia through his experiment on stopping the heart from beating and restarting it using hyperkalaemic solutions in dogs. Finally, Goetz used an anastomotic connector for ITA– coronary anastomoses in animals. Notably, as an appendix to the article describing the dog model, he reported having performed the procedure on a patient in NewYork in May 1960 by anastomosing the right ITA to the right coronary artery. is is usually regarded as the rst clinical CABG procedure in history.

In April 1962, Sabiston performed the rst saphenous vein to coronary artery bypass procedure in a patient who had previously undergone unsuccessful thromboendoarterectomy. e patient died from a stroke on postoperative day three, and Sabiston was so discouraged that he abandoned the procedure for many years and did not report this landmark event until 1974.

Kolesov is credited for the rst successful hand- sewn ITA– coronary anastomosis which he performed in 1964 in Saint Petersburg (then known as Leningrad) and performed on the beating heart. Ultimately, the rst successful saphenous vein to coronary bypass procedure was performed in Houston later that year by Garrett, Dennis, and DeBakey, and in 1966, Favoloro successfully performed bilateral ITA implantation using the Vineberg technique at the Cleveland Clinic.

Fig.1.2 Front cover of Rene Favaloro’s Surgical Treatment of Coronary

Arteriosclerosis (1970).

SECTION 1 Pathophysiology and investigation ofcoronary artery disease6

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rst demonstrated the feasibility of CABG could be performed without cardiopulmonary bypass and cardioplegia.

In 1978, FitzGibbon etal. highlighted an early failure rate of vein

procedure, the optimal techniques for performing this life- saving surgery are not yet widely agreed, underlining the need for more

carefully controlled trials. gras. In 1986, Loop and the Cleveland Clinic group established the key prognostic importance of an ITA gra to the le anterior descending coronary artery. Afew years later, Lytle and the same group were among the rst to systematically study the use of bilateral ITAs.

e use of the radial artery as a conduit was introduced by Carpentier in 1971, as was the gastroepiploic artery by Pym and Suma in 1987, and the inferior epigastric artery by Puig in 1990. However, early failure of the radial artery as a conduit led to its abandonment until its revival by Cristophe Acar in 1992 with demonstration of improved patency secondary to more rened harvesting techniques. e use of arterial conduits was further popularized with new graing methods including the T- gra introduced by Tect or in 1994.

In the 1990s, Benetti and Buolo popularized the concept of o- pump CABG. Puskas, published the rst randomized controlled trial of o- pump CABG among unselected patients with angiographic follow- up, demonstrating similar revascularization and patency between groups. In 1997, Rivetti and Gandra presented a series of patients describing the successful use of intracoronary shunts. Calaore etal. introduced minimally invasive CABG, and Duhaylongsod etal. reported a multicentre series of successful thoracoscopic harvest of the internal mammary artery in 1998. Angelini etal. were eventually the rst to describe hybrid myocardial revascularization. In 1999, the EUROSCORE was introduced to predict early mortality in cardiac surgical patients on the basis of objective risk factors. All of this led to the conception of minimally invasive robotic surgery which was initially reported on by Falk etal. in 2000.

Since 2000, several landmark trials have been published. In 2003, the rst randomized controlled trial to assess the suitability of the radial artery as a conduit, RAPCO, was initiated. In 2004, the Arterial Revascularization Trial (described extensively in Chapter34) was initiated to compare bilateral and single ITA gras, and eventually became the largest coronary artery intervention trial, whether by stents or surgery, in terms of patient numbers and length of followup (10years). Other published studies comparing radial artery patency versus saphenous vein patency were the RAPS trial in 2004 and the RSVP trial in 2008. In 2009, the SYNTAX trial demonstrated CABG to be superior to percutaneous coronary intervention in terms of major adverse cardiac or cerebrovascular events in patients with severe coronary disease. e HEART and STICH trials, which compared CABG with medical therapy in patients with le ventricular dysfunction, and the FREEDOM trial, which compared CABG with percutaneous coronary intervention in diabetic patients, followed. In 2013, the largest trial comparing o- pump and on- pump CABG, CORONARY, demonstrated similar outcomes for o- pump and on- pump CABG, and in 2016, the results of the EXCEL trial were published.

Fiy years aer Favaloro’s rst systematic description of CABG, two landmark randomized trials (discussed in detail in subsequent chapters) explored the current role of multiple arterial gras. RADIAL was the rst demonstration of improved clinical outcomes using multiple arterial gras and the ART trial published the 10- year outcomes of the use of single and bilateral ITA

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