Myocardial Revascularization with Four or More Arterial Grafts; Trends in Bilateral Internal Thoracic Artery Configurations

Background: Reflecting improved long-term patency-rates and clinical outcomes, recent interest has focused on increased use of arterial conduits in coronary artery bypass grafting (CABG). However, maximizing the number of arterial grafts remains a technical challenge.

Methods: Between 2006 and 2016, 1,029 patients underwent primary isolated CABG with four or more arterial grafts. Skeletonized bilateral internal thoracic artery (ITA) were used in all patients with or without radial artery (RA). Operative data and trends in bilateral ITA (BITA) configurations are analyzed.

Results: Mean age was 60.2 year (range, 29-86). Female gender, diabetic patients and insulin-treated diabetics comprised 10.7%, 43.1% and 16.9% of patients, respectively. 12.2% had severe left ventricular dysfunction at time of operation. Complete arterial revascularization performed in 93.1%. BITA only and BITA with RA were performed in 18% and 77% of patients, respectively (complete arterial revascularization 93%). The overall mean number of grafts per patient was 4.5 (range, 4-7). The number of arterial grafts/patient and ITA grafts/patient was 4.4 (rang, 4-6) and 3.3 (range, 2-6), respectively. BITA configurations used were T-grafts, (38.5%), left-sided retroaortic right ITA (RITA) (38%), left-sided anteaortic RITA (3.8%), classic RITA to right system (16.8%) and free RITA (2.9%); overall in-situ BITA techniques comprised 58.6%. However, time-frame technique-distribution- analysis has shown significant decline in T-grafting compared to in-situ BITA since 2014 (91% vs9%, p=0.034). Overall, 30-day mortality was 0.7% and early neurological events were documented in 1.4% of patients. Re-exploration for bleeding was performed in 3.3%. Sternoplasty and vaccum-assisted drainage for deep sternal wound infection were required in 0.4% and 0.7 % of patients, respectively.

Conclusion: Complete myocardial revascularization with four or more BITA and RA grafts is feasible, safe and reproducible. The choice of BITA configuration trends towards in-situ BITA techniques.