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this meta- analysis indicating important variability among the eight
studies. us, on one hand, Tranbaugh etal. showed that the RA
had a trend towards better survival (P=0.06) and similar patency to
the RITA while older and emphysematous patients had better survival with RA graing. Conversely, Ruttmann and colleagues reported 2.6 times the in- hospital mortality and ten times the number
of strokes and myocardial infarctions in the RA group with no mortality in the RITA group to 8years. us, their reported long- term
mortality benet (hazard ratio 0.23) of RITA graing needs further
conrmation.
In 2016, the 10- year results of the RAPCO randomized controlled
trial were presented at the American Association for oracic
Surgery Annual Meeting. is well- designed randomized controlled trial evaluated outcomes of 394 patients less than 70years
of age randomized to receive either a RA or free RITA to the second
most important coronary target aer the LAD. Most gras went to
the circumex system. Actuarial survival was better for RA than
RITA (P=0.032) and there was a trend towards better event- free
RA survival (P=0.085). Patency was statistically similar although
numerically better for RA (91.8%) versus RITA (88.5%; P=0.057).
us, it appears that the weight of the evidence suggests that either
the RA or the RITA may be used as the second arterial gra during
CABG. Of note, current European guidelines recommend the RA as
a classIB second arterial gra in case of severe target vessel stenosis.
Conclusion
e RA is an easily harvested and versatile conduit with a growing
body of literature supporting the safety and ecacy of RA graing
during CABG. Current guidelines clearly support RA graing use
during CABG as an adjunct to a LITA– LAD gra. It increasingly
appears that either the RA or RITA may be used as the preferred
second arterial conduit supporting the LITA to LAD gra. Multiple
arterial bypass graing using the RA should be routine in those patients with appropriate coronary anatomy, reasonable life expectancy, and no contraindications to RA use.
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etal. Radial artery as a coronary artery bypass conduit:20- year
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6. Shi WY, Tatoulis J, Newcomb AE, Rosalion A, Fuller JA, Buxton
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7. Tranbaugh RF, Dimitrova KR, Lucido DJ, Homan DM,
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J orac Cardiovasc Surg. 2014;147(1):133– 42.
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Benedetto U, etal. 2018 ESC/ EACTS Guidelines on myocardial
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9. Gaudino M, Prati F, Caradonna E, Trani C, Burzotta F,
Schiavoni G, etal. Implantation in coronary circulation induces
morphofunctional transformation of radial gras from muscular
to elastomuscular. Circulation. 2005;112(9 Suppl):I208– 11.
10. Gaudino M, Glieca F, Luciani N, Alessandrini F, Possati G.
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blocker therapy continued beyond rst postoperative year
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1):I64– 7.
11. Dimitrova KR, Homan DM, Geller CM, DeCastro H, Dienstag
B, Tranbaugh RF. Endoscopic radial artery harvest produces
equivalent and excellent midterm patency compared with open
harvest. Innovations. 2010;5(4):265– 9.
12. Aldea GS, Bakaeen FG, Pal J, Fremes S, Head SJ, Sabik J, etal.
e Society of oracic Surgeons clinical practice guidelines on
arterial conduits for coronary artery bypass graing. Ann orac
Surg. 2016;101(2):801– 9.
13. Goldman S, Sethi GK, Holman W, ai H, McFalls E, Ward
HB, etal. Radial artery gras vs saphenous vein gras in
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14. Hayward PA, Buxton BF. Mid- term results of the Radial
Artery Patency and Clinical Outcomes randomized trial. Ann
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15. Deb S, Cohen EA, Singh SK, Une D, Laupacis A, Fremes SE, etal.
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17. Achouh P, Isselmou KO, Boutekadjirt R, D’Alessandro C, Pagny
JY, Fouquet R, etal. Reappraisal of a 20- year experience with
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18. Possati G, Gaudino M, Prati F, Alessandrini F, Trani C, Glieca F,
etal. Long- term results of the radial artery used for myocardial
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19. Maniar HS, Sundt TM, Barner HB, Prasad SM, Peterson L, Absi
T, etal. Eect of target stenosis and location on radial artery gra
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21. Khot UN, Friedman DT, Pettersson G, Smedira NG, Li J, Ellis
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23. Dimitrova KR, Dincheva GR, Homan DM, DeCastro H, Geller
CM, Tranbaugh RF. Results of endoscopic radial artery harvesting
in 1577 patients. Innovations (Phila). 2013;8(6): 398– 402.
24. Tranbaugh RF, Lucido DJ, Dimitrova KR, Homan DM, Geller
CM, Dincheva GR, etal. Multiple arterial bypass graing should
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1537– 45.
25. Gaudino M, Rahouma M, Abouarab A, Leonard J, Kamel M, Di
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27. Benedetto U, Gaudino M, Caputo M, Tranbaugh RF, Lau C, Di
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36
The right gastroepiploic arterygra
Hisayoshi Suma, Giuseppe Tavilla, and Ki- Bong Kim
Introduction
In the 50- year history of coronary artery bypass gra surgery
(CABG), the choice of conduit has been a centre of interest to obtain a better surgical outcome. Since the saphenous vein conduit
was found to be highly susceptible to vein gra disease following
CABG, the internal thoracic artery (ITA) became the most reliable conduit to bypass the le anterior descending coronary artery.
Consequently, seeking an optimal second arterial conduit became
e right gastroepiploic artery (RGEA) was historically used for
an indirect myocardial revascularization (Vineberg’s procedure) for
the posterior or inferior wall of the heart in the late 1960s. en,
20years later, a direct anastomosis of the RGEA to the coronary
artery was attempted and the rst documentation of successful
systematic use of the RGEA conduit in CABG was made by Pym
and Suma independently. Since then, the RGEA conduit has been
widely applied clinically and investigated for its anatomical and
physiological adaptability as a coronary artery bypass gra.
In the three- decade history of the RGEA conduit, it has shown
excellent short- and long- term outcomes. e RGEA can be used
without increased morbidity, particularly in terms of abdominal
complications, and the late survival rate has been excellent in CABG
with combined RGEA and ITA gras.,
1128 patients who received a RGEA conduit for CABG, showed
that the prevalence of atherosclerotic lesions in the RGEA that precluded using it as a bypass conduit was 6.5% and another 5.3% of
non- atherosclerotic RGEAs were unavailable to use as a conduit because of their small calibre. us, the RGEA appears to be a little
more susceptible to atherosclerosis than the ITA, but taking into account the nding that all patients studied had severe coronary artery
disease, the RGEA is an artery which is relatively protected from
atherosclerosis.
Physiology
e RGEA shows contraction to ergonovine, serotonin, and phenylephrine to a similar degree as the ITA, and is more strongly contracted by potassium chloride, serotonin, and norepinephrine than
the ITA suggesting that it is important to prevent spasm of the
RGEA provoked by platelet aggregators, adrenergic stimulation, or
depolarizing agents in various clinical settings. e RGEA and ITA
have a dierence in response to histamine. is agent causes contraction of the ITA and dilates the RGEA.
Indications forRGEAgrafting
Anatomy andhistology
e RGEA is the largest terminal branch of the gastroduodenal artery, which originates from the common hepatic artery. Occasionally,
the RGEA arises from the superior mesenteric artery. It runs along
the greater curvature of the stomach from right to le and reaches
beyond one- half of the greater curvature in a majority of cases
(Fig. 36.1).
Histologically, the media of RGEA contains many smooth muscle
cells, unlike the ITA which is rich in elastic bres in the media.
e severity of atherosclerosis of RGEA and ITA used for CABG,
graded in three degrees (normal to mild, moderate, and severe), was
92%, 6%, and 2% in the RGEA and 99%, 1%, and 0% in the ITA,
respectively, in one study. One previous study, which included
e in situ RGEA is long enough to reach any coronary artery. e
RGEA is most suitable for graing the posterior descending coronary artery because this site is the nearest for the in situ RGEA gra
and the most distant for the in situ right ITA gra. e distal le circumex coronary artery is also a suitable target for the RGEA conduit if needed. e le anterior descending coronary artery which is
a common site for the le ITA is not an exception for RGEA graing
when the ITA is unavailable or dicult to use at reoperation. e
RGEA is advantageous in patients with a diseased ascending aorta
which necessitates in situ arterial gras for the aortic no- touch technique, or who had previous CABG because the abdomen is a virgin
area which makes RGEA preparation easy before re- sternotomy.
Conversely, there are unfavourable conditions for RGEA conduits
such as obese or very elderly patients, unstable haemodynamics in
an emergency situation, and/ or proposed future abdominal surgery.
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Fig.36.1 Abdominal angiogram showing the right gastroepiploic
artery (GEA).
Skeletonized RGEAconduit
e more recent technique of skeletonized harvest for the RGEA,
introduced by Gagliardotto, seems to achieve superior patency in
the early and late postoperative period. To harvest the RGEA, the
midline sternal incision is extended about 5cm below the xiphoid
process. e peritoneum is opened, and harvesting of the RGEA is
performed in a skeletonized manner. To obtain a skeletonized RGEA
conduit, the Harmonic® scalpel (Ethicon, Somerville, NJ, USA)
with a coagulating shears tip is oen used. e anterior layer of the
greater omentum is divided and the RGEA is exposed along its entire length. e small omental and gastric branches of the RGEA are
divided with the harmonic shears. e distal end of the RGEA conduit is then divided, and papaverine or nitroprusside hydrochloride
solution is infused intraluminally to relieve spasm of the RGEA. e
RGEA is brought anterior to the pylorus and in front of the liver, and
introduced into the pericardial cavity through a cruciate hole in the
right hemidiaphragm. e site of the opening is carefully chosen,
dependent on the intended location of the anastomosis.
e RGEA– coronary artery anastomosis may be performed
during cardioplegic arrest or by an o- pump beating heart technique (Fig. 36.2). e skeletonized RGEA achieves a longer conduit
for easier use in sequential anastomoses. Other advantages of using
the skeletonized RGEA gra technique are being able to avoid or detect spasm during surgery. e RGEA can be used as a free or Y- or
Fig.36.2 Skeletonized right gastroepiploic artery (GEA) graft
anastomosed to the posterior descending artery.
I- composite gra instead of an in situ gra if the RGEA has low free
ow, or if intraoperative ow measurement suggests a competitive
ow pattern.
survival rates in 1118 follow- up patients were 91.7%, 81.4%, and
71.3%, respectively. In patients receiving bilateral ITAs to the le
Clinical outcomes and angiographic
patencyresults
coronary artery system, patients receiving a RGEA conduit to the
right coronary artery had signicantly better long- term survival
rates than those who received a saphenous vein conduit. e use
of the RGEA has not only been associated with good survival rates
Twenty- year experience with 1352 CABG patients who received
RGEA conduits demonstrated that 5- , 10- , and 15- year actuarial
but also with excellent 15- and 20- year cardiac event- free survival,
as was recently demonstrated in a patient cohort that underwent
36 The right gastroepiploic arterygraft 283
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Fig.36.3 Angiograms of the 20- year- old saphenous vein, left ITA (LITA), and gastroepiploic artery (GEA) grafts in the same patient. Note a new
stenosis and old stent in the vein graft whereas both LITA and GEA grafts revealed perfect patency. CX, circumflex artery; LAD, left anterior descending
artery; PD, posterior descending artery.
total arterial revascularization using bilateral ITAs and the RGEA.
Another study demonstrated that the 5- and 10- year event- free survival rates were similar in patients receiving either a right ITA or
RGEA composite gra based on the in situ le ITA to revascularize
the whole ischaemic myocardium.
Regarding the patency rate of the in situ RGEA gra, subocclusive
(>90%) stenosis of the target coronary artery is essential to maximize patency rates. In one of the largest RGEA series, the cumulative patency rates of RGEA conduits were 97.1% at 1month, 92.3% at
1year, 85.5% at 5years, 80.9% at 7years, and 66.5% at 10years aer
surgery. is relatively low patency rate at late follow- up has been
improved by using a skeletonized RGEA gra only to target vessels
with greater than 90% stenosis. Using this approach, 97.8%, 94.7%,
and 90.2% cumulative patency rates were reported in the early postoperative period, and at 5, and 8years aer surgery, respectively.
Fig. 36.3 shows a widely patent RGEA conduit anastomosed to the
posterior descending coronary artery 20years aer surgery. In another study comparing patient groups that received either a right
ITA or RGEA composite gra based on the in situ le ITA, no signicant dierences were observed in 5- year gra patency rates, in-
sternotomy. is incision is long enough to excise the xiphoid process, to position a standard sternal retractor, to obtain adequate exposure of the inferior wall of the heart, and to allow for easy access
to the upper abdomen for RGEA harvesting. e diaphragmatic surface of the heart is then dissected free to facilitate exposure of the
inferior wall of the heart. e distal parts of the right coronary artery are identied to choose the target coronary artery for the anastomosis. e peritoneum is opened at this stage, and harvesting of
the RGEA is performed. Once the RGEA is placed intrapericardially,
a suction stabilizer is xed cranially on the retractor and the suction branches are placed as close as possible near the target coronary
artery. Aer completion of the anastomosis, 1 mL of brin glue is
injected around the anastomosis to avoid any torsion of the RGEA
conduit. At the end of the procedure, a small drainage tube is placed
into the pericardium and the incision is routinely closed.
In conclusion, the RGEA is the third available in situ arterial conduit for CABG and can facilitate all- arterial graing. It provides
excellent short- and long- term patency when harvested in a skeletonized fashion and when it is graed to coronary arteries with severe
native stenosis.
cluding second- limb conduit patency, between the RGEA and right
ITA groups (RGEA vs right ITA, 92.1% vs 93.4%). One network
meta- analysis stated that the RGEA conduit has a higher risk of gra
occlusion compared with other types of conduits. However, those
RGEA conduits studied have rarely included the skeletonized gras.
Transabdominal off- pump CABG using
theRGEA inreoperations
At repeat CABG involving solely the right coronary artery territory,
a small laparotomy approach using the RGEA can be performed with
the o- pump technique without sternotomy. Above the xiphoid,
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3. Suma H, Fukumoto H, Takeuchi A. Coronary artery bypass
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in three- vessel disease using exclusively pedicled bilateral internal
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13. Glineur D, D’hoore W, Price J, Dorméus S, de Kerchove L, Dion
R, etal. Survival benet of multiple arterial graing in a 25- year
single- institutional experience:the importance of the third
arterial gra. Eur J Cardiothorac Surg. 2012;42(2):284– 91.
14. Tavilla G, Bruggemans EF, Putter H. Twenty- year outcomes of
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15. Hwang HY, Cho KR, Kim K-B. Equivalency of right internal
thoracic artery and right gastroepiploic artery composite
gras:ve- year outcomes. Ann orac Surg. 2013;96(6):2061– 8.
16. Suzuki T, Asai T, Nota H, Kuroyanagi S, Kinoshita T, Takashima
N, etal. Early and long- term patency of in situ skeletonized
gastroepiploic artery aer o- pump coronary artery bypass gra
surgery. Ann orac Surg. 2013;96(1):90– 5.
17. Benedetto U, Raja SG, Albanese A, Amrani M, Biondi- Zoccai
G, Frati G. Searching for the second best gra for coronary
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37
Total arterialrevascularization
Bobby Yanagawa, David P. Taggart, and John D. Puskas
Introduction
e superiority of coronary artery bypass graing (CABG) with a
single internal thoracic artery (SITA) and saphenous vein gras
(SVGs) over percutaneous coronary intervention has been demonstrated in large, multicentre randomized controlled trials (RCTs),
particularly for patients with diabetes and complex coronary disease.
Long- term gra patency is critical to the benet that CABG provides,
since gra failure begets recurrent angina, need for repeat intervention, myocardial infarction, and diminished survival. SVGs have
signicant rates of early and late gra failure. Loop etal. rst demonstrated the long- term survival benet of internal thoracic artery
gras over vein gras. Since then, multiple large observational series
and meta- analyses have clearly demonstrated a long- term survival
benet of bilateral internal thoracic artery (BITA) over SITA gras.,
e Arterial Revascularisation Trial (ART), a large, multicentre
randomized controlled trial of SITA versus BITA gras, demonstrated that the use of BITA was not associated with increased early
mortality or myocardial infarction but did lead to a small increase
in the risk of sternal wound complication (largely in patients with
diabetes and obesity) and that this dierence was avoided by skeletonized harvest of the BITA gras. ART reported similar 5- year
survival between randomized groups according to an intentionto- treat analysis, but interpretation of this result is complicated by
a high (>14%) incidence of crossover from BITA to SITA, a 4%
crossover from SITA to BITA, and a 22% use of a second (radial)
arterial conduit in the SITA group. Given this 40% incidence of
bidirectional crossover, a very large treatment eect would be required to demonstrate a signicant survival benet of BITA over
SITA in an intention- to- treat analysis, especially given the fact that
excellent adherence to optimal medical management in this trial
was associated with unexpectedly low adverse event rates in both
groups. Not surprisingly, recently presented 10- year outcomes of
the ART study demonstrated no dierence in mortality or major
adverse cardiac and cerebrovascular events by intention- to- treat
analysis, but when an as- treated analysis was performed, there was
a striking 10- year survival benet (hazard ratio (HR) 0.81, 95%
condence interval (CI) 0.68– 0.95) as well as a reduced composite
of death/ myocardial infarction/ stroke (HR 0.80, 95% CI 0.69–
0.93) for multiple arterial graing.
Large randomized controlled trials and observational series have
demonstrated that the radial artery (RA) graed to the second- best
coronary artery target confers improved gra patency and clinical
outcomes compared to a SITA- plus- SVG only strategy.– Despite
this evidence base, multiple arterial gras are used during surgical revascularization in only approximately 10% of CABG cases
in North America; BITA graing was performed in 5.7% and a RA
conduit was used in 5.7% of all isolated primary CABG cases in the
2018 Society of oracic Surgeons (STS) National Cardiac Database.
Total arterial revascularization (TAR) is even less commonly performed (approximately 1% of all CABG cases). e randomized
and registry data from the Synergy between Percutaneous Coronary
Intervention with Taxus and Cardiac Surgery (SYNTAX) trial, conducted among premier centres worldwide, reveal that multiple arterial graing was performed in 17% and 33% of patients in the
United States and Europe, respectively, and TAR was performed in
5% of patients in the United States and 18% in Europe. Importantly,
TAR may oer an even greater survival benet over percutaneous
coronary intervention than conventional CABG with SITA and
SVGs. us, the ongoing comparison of percutaneous coronary
intervention versus CABG for multivessel coronary artery disease
could be profoundly impacted by broader adoption of multiple arterial graing. In this chapter, we critically review the literature and
current practice guidelines for surgical coronary revascularization
with total arterial graing.
Does total arterial revascularization
improve outcomes?
ere is now a burgeoning literature, mostly from expert revascularization centres, supporting the overall benet of TAR in
improving long- term survival. Apropensity- matched analysis of
a large multicentre database found that TAR was associated with
improved adjusted 15- year survival compared with conventional
CABG (54% ± 3.3% vs 41% ± 3.0%; P=0.0004; Fig. 37.1). Most
TAR procedures utilize BITA but the survival benet of TAR holds
true when performed with SITA and RA conduits.
Given that the use of two arterial gras is associated with a survival benet over SITA plus SVGs, it is not surprising that TAR
SECTION 6 Conduits forcoronary artery bypass graft surgery286
Survival
Years
574
191
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1.0
0.8
0.6
0.4
0.2
0.0
Fig.37.1 Unadjusted 15- year survival. SITA, single internal thoracic
artery; SV, saphenous vein; TAR, total arterial revascularization.
Reproduced from Buxton BF, Shi WY, etal. Total arterial revascularization with internal
thoracic and radial artery grafts in triple- vessel coronary artery disease is associated
with improved survival. J Thorac Cardiovasc Surg. 2014;148:1238– 43 with permission
from Elsevier.
At 15 years:
TAR: 62 ± 1.1%
35 ± 1.9%SITA + SV:
p < 0.0001
2988
786
0510
2505
601
1634
360
15
also has a survival benet over conventional CABG with SITA
plus SVGs. However, when performing TAR, arterial gras are
not only preferentially placed on the best targets but on all coronary targets, some of which may be smaller vessels with smaller
areas of myocardial perfusion or less severe proximal stenoses.
Arterial gras on such targets may oer smaller incremental additional benet to patients. Furthermore, accomplishing TAR oen
requires composite and sequential graing which is technically
more challenging. us, it is not a foregone conclusion that TAR
would result in demonstrably improved long- term gra patency
and survival over multiple arterial graing with selective use
of SVGs.
e majority of the TAR literature is composed of single- centre,
observational reports. ere are important sources of bias that must
be considered when interpreting such reports. First, the surgeon’s
decision to perform TAR is an important unmeasured confounder.
Patients with poor overall prognoses, small coronary targets with
small perfusion beds or diuse disease may not be oered TAR.
is is suggested by the observation that in most non- randomized
series, TAR patients are generally younger with fewer comorbidities than the non- TAR group. Even with propensity matching or
multivariate risk adjustment, these studies may suer from residual
confounding, which can only be eliminated by randomization. In
summary, data from experienced centres strongly support TAR
versus conventional CABG but higher- quality prospective randomized data with long- term follow- up are needed.
Is there anadvantage oftotal arterial
revascularization overrevascularization
withtwo arterial grafts?
It is clear that addition of a second arterial gra is associated with
improved outcomes compared with conventional CABG (SITA and
SVGs) and that TAR is superior to conventional CABG. Is there
an incremental improvement in outcomes with TAR compared to
revascularization with two arterial gras?
Several studies have attempted to determine the incremental
benet of adding a third arterial gra to a two- arterial- gra
revascularization with mixed results. Shi etal. showed that the
addition of a RA to BITA was associated with an improved riskadjusted long- term survival (82 ± 5.2% vs 72 ± 6.0%; P=0.021).
Subgroup analysis of an observational study found that patients
with BITA and right gastroepiploic artery showed improved overall
survival (HR 0.41; P = 0.0032) and cardiac survival (HR 0.18;
P= 0.004) compared to those with BITA and SVGs. However,
Grau etal. found no signicant dierence in overall 14- year survival between CABG with BITA and vein gras versus BITA and
RA with or without vein gras but did report a trend towards improved survival aer 10years conferred by the addition of a RA
conduit to a BITA strategy. Gaudino etal. performed a metaanalysis of propensity- matched observational studies to demonstrate a lower hazard for late death with the use of three versus two
arterial gras (HR 0.8, 95% CI 0.75– 0.87; P <0.001). Similarly,
our meta- analysis of mostly observational studies found that when
compared to two- arterial- gra revascularization, TAR was still associated with reduced long- term all- cause mortality (incident rate
ratio 0.85, 95% CI 0.73– 0.99; P=0.04). In summary, it is logical
to believe that the improved long- term patency of arterial conduits
compared to venous gras would translate into better long- term
event- free survival aer TAR than aer CABG with two arterial
gras plus SVG(s). However, the incremental benet is likely
smaller with each additional arterial conduit and to denitively answer this question, a large prospective trial with long- term followup would be necessary.
Do diabetic patients benefit fromtotal
arterial revascularization?
e proportion of patients undergoing surgical revascularization
who have diabetes mellitus continues to increase and has passed
50% in 2017 according to the STS Adult Cardiac Surgery Database.
Two important questions are (1)do patients with diabetes mellitus benet from TAR, and (2)when performed with BITA, what
is the risk of sternal complications? We and others have shown
that the use of BITA confers a survival benet over SITA in diabetic patients (Fig. 37.2). In a large propensity- matched analysis, diabetic patients who received total arterial graing had
improved long- term survival at 1, 5, and 10years compared to
diabetic patients who had conventional revascularization with
SITA plus SVGs (96.2% vs 95.4%, 88.9% vs 87.5%, and 82.2% vs
78.3%, respectively; P=0.036). us, data from observational
studies have shown that diabetic patients do benet from a TAR
approach. Whether they benet more or less than non- diabetic
patients is an unanswered question; however, it is known that the
benet of BITA is at least as great for diabetic patients as it is for
non- diabetic patients.
e overall risk of mediastinitis post sternotomy is 0.5– 2%. Use of
BITA does reduce sternal blood supply, causing sternal ischaemia,
leaving patients at a higher risk of deep sternal wound infection
37 Total arterialrevascularization 287
1.00
Survival
Years
9
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BITA, non-diabetes mellitus
BITA, diabetes mellitus
0.75
0.50
Patients at risk
SITA non-diabetes
0.25
BITA non-diabetes
SITA diabetes
BITA diabetes 217 209 192 192
0.00
012345
0 yr 1 yr 3 yr 5 yr 8 yr
1461 1389 1322 1230 1076
557 545 535 520 503
1156 1085 991 901 701
220
SITA, non-didbetes millitus
SITA, didbetes millitus
678
Fig.37.2 Kaplan– Meier survival estimates for 9years of follow- up
among subgroups show a survival benefit with bilateral internal thoracic
artery (BITA) grafting in diabetic and non- diabetic patients compared
with single internal thoracic artery (SITA) grafting.
Reproduced from Puskas JD, Sadiq A, etal. Bilateral internal thoracic artery grafting is
associated with significantly improved long term survival, even among diabetic patients.
Ann Thorac Surg. 2012. 94:710– 715 with permission from Elsevier.
(DSWI) and sternal dehiscence. Importantly, surgeon experience
and surgical technique during BITA harvest signicantly impact
the risk of DSWI aer BITA graing. Indeed, among all patients
enrolled in the ART study, skeletonized harvest of BITA resulted
in an incidence of DSWI similar to that occurring aer pedicled
harvest of SITA. ere is a small but signicant increase in incidence of sternal complications following BITA in diabetic patients
compared to patients without diabetes. Adjuncts to lower the risk
of DSWI include internal thoracic artery skeletonization, use of
Harmonic® scalpel, and use of topical vancomycin paste and sternal
stabilization devices. Perioperatively, smoking cessation and glycaemic control may also improve sternal healing. Careful patient
selection can mitigate against the risk of devastating sternal complications. Evidence strongly suggests that BITA harvest entails an
increased risk of DSWI in patients with poorly controlled diabetes
(HbA1c >8%), morbid obesity (body mass index >35kg/ m), female sex, immunosuppression, and chronic pulmonary disease
(e.g. chronic obstructive pulmonary disease). Avoidance of BITA
and preferential use of SITA with a single or bilateral RA approach
in high- risk diabetic patients is a reasonable strategy. Nonetheless,
TAR may avoid problematic healing of leg incisions in this highrisk cohort; this potential advantage is weighed against the risk of
DSWI, especially in patients with severe peripheral vascular disease. ese competing risks should be discussed with the diabetic
patient during the preoperative consent process. Endoscopic RA
harvest may oer an attractive alternative to allow use of at least
two arterial conduits in this scenario. In summary, diabetic patients do have comparable improvement in outcomes with TAR
compared to patients without diabetes. ere does appear to be an
increased risk of sternal wound complications with BITA use but
this can be mitigated by multiple protective techniques (especially
skeletonized harvest of internal thoracic arteries) or obviated by
preferential use of one or two radial arteries.
Do elderly patients benefit fromtotal
arterial revascularization?
e long- term benets of TAR are controversial in the higher- risk
cohort of elderly patients in whom there is a competing risk of noncardiac mortality and in whom complex, longer operations may be
undesirable. However, most Kaplan– Meier survival curves for TAR
compared to conventional CABG begin to diverge almost immediately in most series, supporting the use of TAR even in older patients. Furthermore, TAR with BITA can facilitate a minimal or
no- aortic touch procedure that can reduce the risk of stroke in this
high- risk population. is may be one of the most important benets of the TAR approach— the unique opportunity to provide highrisk patients with a no- aortic touch, all- arterial bypass procedure,
which has been conclusively associated with the lowest perioperative risk of death and stroke.
A prospective randomized study enrolled 200 patients over
70 years of age to TAR versus SITA plus SVGs, both performed
on- pump. ere was a trend to lower stroke with TAR (1% vs 5%;
P=0.21) and fewer leg wound complications (0% vs 9%) but other
perioperative complications were not statistically dierent in this
underpowered trial. TAR was associated with lower mid- term
angina recurrence (3% vs 12%; P <0.001). Angiography demonstrated higher patency in the TAR cohort (99% for LITA, 100% for
RITA, and 96.7% for RA gras) compared with SVGs in conventional CABG (100% for LITAs and 84% for saphenous vein gras).
Apropensity- matched analysis of TAR versus non- TAR in patients
over 75years of age showed no dierence in mortality, no dierence
in sternal complications, but lower perioperative myocardial infarction and stroke in the TAR group. Notably, this surgical team performed on- pump CABG with proximal anastomoses constructed
using an additional side- biting clamp. As such, the major benet of
reduction in cerebral embolism with TAR in this series was likely
related to elimination of multiple aortic manipulation. us, elderly patients with reasonable life expectancy may enjoy an eventfree survival benet from a TAR approach. ey may also benet
from reduction in risk of stroke from a no- or minimal- touch aortic
technique.
No- aortic- touch all- arterialbypass
Zhao and colleagues performed a network meta- analysis of 13
studies including 37,720 patients and compared risk- adjusted incidence of stroke with varying degrees of aortic manipulation during
CABG. Ano- aortic- touch o- pump CABG technique was associated with a 50% reduction in perioperative mortality, a 78% reduction in risk of perioperative stroke, and a 63% reduction in new
renal failure compared to conventional CABG on cardiopulmonary
bypass. Fig. 37.3 shows a convenient pattern of gra conguration to accomplish all- arterial no- aortic- touch o- pump CABG
in the setting of atherosclerosis of the ascending aorta. Albert etal.
reported an impressive reduction in early perioperative stroke aer
switching from a conventional CABG strategy to a routine allarterial no- aortic- touch technique for all CABG patients in a large
surgical centre.
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