Total Arterial Revascularization with Internal Mammary Artery or Radial Artery π Graft Configuration

Summary： To investigate the clinical use of π graft in total arterial revascularization and its outcomes, a retrospective analysis of 23 patients out of 1000 patients undergoing total arterial coronary bypass surgery with a π graft between September 1994 and December 2004 was performed. In the selected patients for the management of triple vessel disease with middle diagonal/intermediate ramus disease such that a skip with the left internal mammary artery （LIMA） or radial artery （RA）, the main stem of π graft, to the left anterior descending coronary artery （LAD） will not work and the right internal mammary artery （RIMA） or right gastroepiploic artery （RGEA） cannot pick up the diagonal/intermediate ramus, hence the LAD and diagonal/intermediate ramus were grafted with a mini Y graft using the distal segment of LIMA, RIMA, RA or RGEA, together with the bilateral internal mammary artery （BIMA） or LIMA-RA T graft to compose π graft. Twenty-three patients （18 males, 5 females） underwent the π graft procedure. There were no deaths or episodes of myocardial infarction, stroke, and deep sternal wound infection. One patient required reopening for controlling bleeding. Until the end of 2004, during a mean follow-up of 81.0±28.4 months, no angina needing re intervention or operative therapy or coronary related death occurred. In conclusion, in patients with specific coronary artery anatomy/stenosis, the BIMA （sometimes LIMA with RA or RGEA） π graft can be successfully performed for total arterial revascularization with good midterm outcomes.

Clinical application of individualized total arterial coronary artery bypass grafting in coronary artery surgery

BACKGROUND Total arterial revascularization is associated with increased patency and long-term efficacy and decreased perioperative morbidity and mortality and incidence of cardiac-related events and sternal wound infection compared with conventional coronary artery bypass surgery(CABG),in which the left internal mammary artery(LIMA)is typically grafted to the left anterior descending artery with additional saphenous vein grafts often used.This study determined whether these favorable clinical results could be realized at the authors’institute.AIM To summarize the early efficacy and clinical experience of individualized total arterial coronary artery bypass grafting surgery.METHODS CABG was performed on 35 patients with non-single-vessel coronary artery disease by adopting total arterial grafts at Fourth Affiliated Hospital of Harbin Medical University between April 2016 and December 2019.LIMA was used in 35 patients,radial artery(RA)was used in 35 patients,and right gastroepiploic artery(RGEA)was used in 9 patients.Perioperative complications were observed,short-term graft patency rate was followed-up,and quality of life was assessed.RESULTS All patients underwent off-pump coronary artery bypass and the surgeries were successful.All of them were discharged without any complications or deaths.During the follow-up,it was found that patients’angina symptoms were relieved and New York Heart Association classification for cardiac function was class I to class II.A total of 90 vessels were grafted with no occlusion for internal mammary artery,three occlusions for RA,and one occlusion for RGEA.CONCLUSION The individualized total arterial strategy based on the vessels targeting individual anatomic characteristics can achieve complete revascularization with satisfactory short-term grafting patency rate.

Total Arterial Revascularisation in Left Ventricular Dysfunction

The feasibility and safety of total arterial coronary revascularization with 2 arterial conduits in patients with impaired left ventricular function was evaluated. Data were prospectively collected on all patients with multiple vessel disease and moderately or severely impaired left ventricular function, who underwent coronary surgery with the intention of total arterial revascularization with 2 conduits between March 1995 and August 2002. One hundred and seventy-nine patients were included in the study. Acute coronary insufficiency was present in 3 patients and 43 had unstable angina. Severe left ventricular impairment was present in 29 patients. There were 17 redo operations including 3 redo-redo procedures. Eighty-two percent of patients had a Y graft configuration from the left internal mammary artery （right internal mammary artery 40. 8 %, radial artery 33. 5 %, other 7.8 % ）. The perioperative mortality was 2. 2 %, myocardial infarction 1.7 % and stroke 0. 6 %. Total arterial revascularization in patients with ischaemic left ventricular dysfunction can be safely performed with 2 arterial conduits. The radial artery provides conduit length greater than the right internal mammary artery and allows full revascularization despite left ventricular dilatation.

Role of radial artery in total arterial myocardial revascularization in coronary bypass surgery

Background Total arterial revascularization （TAR） was widely utilized in coronary artery bypass grafting （CABG） as a result of its better long-term effect compared with vein grafts. Of the arterial conduits, radial artery （RA） gained popularity for its easy availability and reported long-term patency. Thus, the objective of this study was to investigate the effect of RA in TAR in CABG. Methods From January 2000 to December 2006, 85 patients （56 male and 29 female） at a mean age of 57.0 ± 5.2 years, underwent TAR in CABG. RA and left internal mammary artery （LIMA） with composite Y or T and sequential grafting techniques were used. Post-operative complications were recorded and follow-up was performed. Results Eighty-five LIMA and 149 RA grafts including 21 single and 64 bilateral RA were collected. A total of 87 distal anastomoses were done with the LIMA and another 152 were done with the RA, with the mean number of distal anastomosis per patient of 2.81 ± 0.47. The proximal RA ends were anastomsed directly to the aorta in 140 grafts with Y or T graft off in situ LIMA in 9, Y or T graft off RA in 9. The distal end was anastomsed to right coronary artery system in 92 to obtuse margina in 46, to diagonal in 19 and to ramous intermedius in 5. Nine sequential anastomoses were performed with RA. Nine composite Y or T grafts were constructed with RA and LIMA while another 9 were constructed with RA and RA. One （1.2%） patient died, 3 patients （3.5%） experienced acute renal failure and 2 （2.4%） developed stroke. All patients were still alive and no patient had evidences of newly occurred myocardial infarction or angina after a mean follow-up of 36.5 ＋ 4.1 months （6-67 months）. Postoperatively at 6 month, mean left ventricular ejective fraction was increased to 0.49 ±0.09, compared with that of 0.43 ± 0.11 preoperatively （P=-0.027）. Postoperative mean New York Heart Association class was 2.5±0.5, compared with that of 3.0±0.4 preoperatively （P=-0.003）. Conclusions TAR with arterial conduits of which RA was mainly used was proved in this study to be effective and safe in CABG.

Total Arterial Off-Pump Coronary Artery Bypass Grafting： A 1O-Year Experience

Background： Arterial grafts had better mid-term and long-term patency than saphenous vein grafts in coronary artery bypass grafting （CABG）. We summarized our experience with total arterial off-pump coronary artery bypass grafting （OPCAB） and assessed the early clinical results, surgical complications, and follow-up. Methods： From January 2007 to May 2017,508 coronary artery disease patients undergoing total arterial OPCAB were enrolled. Clinical features, approaches, outcomes of surgical treatments, and follow-up data of these patients were studied retrospectively. A total of 122 patients underwent single left internal mammary artery （IMA）-left anterior descending artery grafts, whereas the other 386 patients underwent multiple vessel grafts. Results： The average distal anastomosis was 2.34 ± 0.97 （range： 1-4）. All the patients were discharged from hospital except one died. A total of 457 （90.32%） patients were followed up. In the 4-, 7-, and 10-year follow-up groups, the rate of death from any cause was 1.19%, 6.47%, and 10.67%; rate of cardiac death was 0.60%, 2.88%, and 3.33%; rate of repeat revascularization was 0.00%, 3.60%. and 8.67%; rate ofischemic symptoms was 1.79%, 7.91%, and 11.33%; and incidence of stroke was 2.38%, 4.32%, and 6.67%, respectively. Poor medication adherence was observed in 9.38% of the follow-up population. Conclusions： Total arterial OPCAB with bilateral IMA, radial artery, and right gastroepiploic artery grafting yielded satisfactory early and midterm outcomes in this patient group, without a significant increase in early mortality or morbidity. Moreover, the long-term outcomes are also positive.