Graft Planning

Abstract

With the development of the OPCAB technique, the current trend in CABG is toward in situ arterial reconstruction because of the benefit of the aorta no-touch technique and the better long-term clinical outcomes (Endo M, Nishida H, Tomizawa Y, Kasanuki H, Circulation 104:2164–2170, 2001). An arterial graft produces better late graft patency and better long-term patient outcomes than vein graft. Now we have three reliable in situ arteries (both internal thoracic arteries (ITA) and right gastroepiploic artery (GEA)) and one free graft (radial artery). As we all know, the use of the ITA is associated with low rates of mortality and reintervention. Furthermore, some recent reports demonstrate that bilateral internal thoracic artery grafting to the left anterior descending and circumflex coronary arteries offers the best long-term survival and lowest rates of reintervention (Rizzoli G, Schiavon L, Bellini P, Eur J Cardiathorac Surg 22:781–786, 2002; Taggart DP, D’Amico R, Altman DG, Lancet 358:870–875, 2001; Lytle BW, Blackstone EH, Loop FD et al., J Thorac Cardiovasc Surg 117:855–872. 1999). In the decade since Buxton and coworkers (Buxton BF, Komeda M, Fuller JA, Gordon I, Circulation 98:II-1–II-6, 1998) and Lytle and coworkers (Lytle BW, Blackstone EH, Loop FD et al., J Thorac Cardiovasc Surg 117:855–872. 1999) revealed the long-term efficacy of bilateral ITA grafting, it has been gaining acceptance among surgeons, and there is no doubt that it affords the best long-term outcome. CABG with grafting of the bilateral ITAs to the left coronary system and additionally the GEA to the distal RCA has been reported to provide good long-term outcome (Chavanon O, Durand M, Hacini R et al., Ann Thorac Surg 73:499–504, 2002; Tavilla G, Kappetein AP, Braum J, Gopie J, Tjien ATJ, Dion RAE, Ann Thorac Surg 77:794–799, 2004; Suzuki T, Asai T, Matsubayashi K et al., Ann Thorac Surg 91:1159–1164, 2011).

For high-quality OPCAB, the skeletonization technique is now essential that makes the arterial graft into optimum condition. Skeletonization has many advantages, such as avoidance of early spasm, easy identification of potential bleeding, quality of the vessel, functionally lengthened and larger graft with maximum flow, ease in performing sequential anastomosis, and preservation of sternal blood flow and venous drainage.

In this chapter, I discuss the optimal grafting model using multiple arterial conduits.