How I deploy arterial grafts

Abstract

There are currently around one million coronary artery bypass graft (CABG) procedures performed worldwide annually and despite two decades of evidence to support the use of a second arterial graft, if not total arterial grafting, the stark reality is that in contemporary practice 80% of all grafts used for CABG are saphenous vein grafts (SVG). The following description of how I deploy arterial grafts has been developed over more than two decades of clinical practice and largely self-taught by a process of "trial and error" and most importantly dictated by "ease of use" rather than personal robust angiographic data of long-term patency (although there is other such existing data in the literature for some of these techniques). The fact that there are numerous potential variants of deploying multiple arterial grafts underpins the fact that there is no single operation that is ideal in every patient-it is not a case of "one size fits all" as would be the situation for the use of a single internal thoracic artery (ITA) and supplemental vein grafts.

Keywords: Internal thoracic artery (ITA); coronary artery bypass graft (CABG); off-pump; radial artery (RA).

Figure 1

Skeletonized harvest of the ITA. ITA, internal thoracic artery.

Figure 2

In situ RITA to LAD and LITA to circumflex system. RITA, right internal thoracic artery; LITA, left internal thoracic artery; LAD, left anterior descending.

Figure 3

LITA to an obtuse marginal with a composite RITA as a free graft to the LAD. RITA, right internal thoracic artery; LITA, left internal thoracic artery; LAD, left anterior descending.

Figure 4

Composite sequential RITA from LITA. RITA, right internal thoracic artery; LITA, left internal thoracic artery; LAD, left anterior descending.

Figure 5

Composite RITA from lateral wall of LITA with additional “T graft”. RITA, right internal thoracic artery; LITA, left internal thoracic artery; LAD, left anterior descending.

Figure 6

LITA to LAD, RITA through the transverse sinus to the obtuse marginal. RITA, right internal thoracic artery; LITA, left internal thoracic artery; LAD, left anterior descending; RA, radial artery; SVG, saphenous vein graft.

Figure 7

Radial artery from aorta to PDA. PDA, posterior descending artery.

Figure 8

In situ RITA with extension by radial artery. RITA, right internal thoracic artery; PDA, posterior descending artery.

Figure 9

Sequential saphenous vein graft on the inferior wall of the heart. LV, left ventricular; RCA, right coronary artery; SVG, saphenous vein graft; PDA, posterior descending artery.

Figure 10

Use of a gastroepiploic artery (GEA) for the inferior wall. RITA, right internal thoracic artery; LITA, left internal thoracic artery; PDA, posterior descending artery; OM, obtuse marginal coronary artery; LAD, left anterior descending.

Figure 11

Radial artery jump graft from distal LAD to proximally occluded PDA. RITA, right internal thoracic artery; LITA, left internal thoracic artery; LAD, left anterior descending; PDA, posterior descending artery.