Many groups, including our own, reported suboptimal results when an in situ RITA was grafted to the right coronary system 50 and equivalent patency rates when comparing a free ITA and the RA grafted in a non-LAD territory It is likely that the best outcomes from BITA grafting are seen when the ITAs are used to graft the left system and the right coronary supplemented with a radial graft.
There are a number of perceived disadvantages to BITA grafting, including the increased length of operative time and the requirement for an in situ RITA to cross the midline or to go through the transverse sinus to reach the LAD or circumflex systems.
Probably the most frequently cited reason for not using BITA is the increased risk of sternal wound breakdowns. It is apparent that in certain groups harvesting bilateral ITAs may lead to an increased risk of sternal wound problems from sternal devascularization and surgical trauma associated with harvest.
This is particularly apparent in those with severe airways disease, the obese and in diabetics The use of a skeletonized harvest technique, however, has been shown to reduce the risk of sternal wound complications Many groups have reported no significant increase in the risk of sternal problems in BITA grafting using a skeletonized technique in higher risk patients including diabetics when compared to a standardized single pedicled ITA Despite this there remain concerns about sternal devascularization with BITA grafting, and the 1-year results from the ART trial have shown a minor increase 1.
The inconsistent use of skeletonization, coupled with concerns of wound problems, have contributed to variable uptake in the BITA grafting technique.
Other arterial grafts, including the gastroepiploic, inferior epigastric, and ulnar arteries, have been employed by many groups. However the ease of harvest and the excellent clinical results associated with RA and ITA use means that these conduits are rarely used. They are mostly chosen when there is a paucity of conduit options or by enthusiasts who require an additional arterial conduit to achieve TAR in selected patients. A number of auxiliary arterial grafting techniques pioneered by surgeons such as Barner 59 and Tector 60 , 61 have facilitated the extent and use of arterial conduits.
The SYNTAX trial is probably the most important contemporary trial that will influence the future practice of coronary surgery. If, as surgeons, we adopt a strategy of optimizing and maximizing the use of arterial grafts to improve outcomes we will hopefully see even stronger recommendations for surgery in future guidelines and reinforce CABG as the preferred and recommended treatment for most forms of CAD.
The ART trial is the largest randomized study over 3, patients to date designed to compare outcomes in single versus bilateral ITA use The preliminary reported 1-year results have suggested similar outcomes in the single and bilateral ITA groups but with a small increase 1. The final year outcomes from the ART trial will indicate whether the survival benefits and reduction in cardiovascular events in the BITA group will justify the routine use of both ITAs.
While it is apparent that the use of at least one ITA graft improves survival even in octogenarians 64 , the advantages of BITA grafting appears to reduce with advancing age For these reasons some groups suggest that there is no benefit to using both ITAs in patients over 70 years of age Longer follow-up and increased experience and reporting will dictate the use of these techniques in the elderly group of patients.
Total arterial, anaortic OPCAB grafting is being advocated by many groups as the optimal operative strategy for coronary revascularization.
In a recent meta-analysis there has been a suggestion that anaortic OPCAB is associated with a reduction in neurological events due to avoidance of aortic manipulation When coupled with the survival advantage associated with TAR it is an attractive alternative to conventional on-pump surgery.
However, due to a concern regarding reduced patency rates with OPCAB surgery 68 , 69 , this technique has not gained widespread acceptance and many surgeons limit its use to patients with heavily calcified aortas in whom the risk of stroke with clamping is the greatest. Radial access coronary angiography RA-CA is exerting a major influence on the use of the RA in our current surgical practice. Cardiology literature has shown that RA-CA is associated with decreased mortality in patients with ST-elevation myocardial infraction and is associated with fewer vascular complications when compared to the trans-femoral route However, from a surgical perspective RA-CA has significant adverse effects on the RA and is associated with increased intimal and medial thickness and intimal hyperplasia 71 , abnormal endothelial responses 72 and causes occlusion and stenosis of the RA Worryingly, these findings are not limited to the access point in the RA and appear to affect its entire course Also, if the RA is used as a graft following RA-CA it demonstrates significantly reduced rates of patency even on short-term follow-up Kafka, A.
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Joseph et al. Alexis Carrel, in , performed the first experience in dogs, using carotid anastomosis with the left coronary artery [ 1 1 Jones DS. CABG at 50 or ? N Engl J Med. However, he discouraged other surgeons to perform this procedure, because he believed the anastomosis should be performed in less than three minutes.
In the 's and 's, other surgeons studied myocardial revascularization, such as Gordon Murray, in Toronto, and Vladimir Demikhov, in Moscow.
In the s, although several groups were studying revascularization, Michael DeBakey did not believe in its success and did not think it should be performed in humans. Robert Goetz was the one who performed and published the first coronary artery bypass graft surgery in humans in , using a tantalum ring [ 2 2 Kolesov VI, Potashov LV. Operation on the coronary arteries. Exp Chir Anaesth.
Saphenous vein autograft replacement of severe segmental coronary artery occlusion: operative technique. Ann Thorac Surg. The history of surgery for ischemic heart disease.
Robert H. Goetz: the surgeon who performed the first successful clinical coronary artery bypass operation. Direct myocardial revascularization without cardiopulmonary bypass. Thorac Cardiovasc Surg.
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