What has happened to multiple arterial grafting in coronary artery bypass grafting surgery?

Abstract

Coronary artery bypass grafting (CABG) is a well-established therapy for patients with multivessel coronary artery disease, with excellent short- and medium-term results. This is best illustrated by studies comparing percutaneous coronary interventions (PCIs) with CABG surgery, where CABG continues to offer better event-free survival. However, there has been increasing concern about the long-term patency of vein grafts utilized for CABG when compared with arterial grafts. Some have suggested that revascularization with arterial grafts rather than vein grafts may result in improved outcomes following CABG. This is particularly important when one considers that graft occlusion can result in recurrence of disabling angina, rehospitalization, reintervention and death. To date, however, multiple arterial grafts have yet to become the standard approach for patients undergoing CABG. This is best exemplified by reports from large registries suggesting that the use of multiple arterial grafting is limited to approximately 10% of all patients undergoing CABG. In this article, we will provide some of the evidence outlining the risk and benefits of multiple arterial grafting, but more importantly, begin to explore why the utilization of multiple arterial grafting does not appear to be increasing significantly.

A pilot randomized controlled trial comparing CABG surgery performed with total arterial grafts or without

“…The primary objectives of our pilot study were to evaluate the feasibility of a larger randomized trial in current cardiac surgical practice in which individual surgeon preferences have been suggested to play a large role in choosing grafting strategies [ 1 ]. Feasibility was defined as our ability to recruit more than 20% of eligible patients and assess completion of CT-coronary angiography in greater than 80% of patients at 6 month follow-up.…”

“…Grafting of the left internal mammary artery (LIMA) to left anterior descending artery (LAD) is the established standard of care during coronary artery bypass graft (CABG) surgery [ 1 ]. However, grafting strategies to territories other than the LAD, involving the use of either arterial grafts versus saphenous vein(s) is still a matter of debate.…”

The cardiovascular system and the biochemistry of grafts used in heart surgery

“…The right part of the heart receives deoxygenated blood from the peripheral tissues through the venae cavae and pumps it into the pulmonary artery and thence the pulmonary circulation. The left part of the heart receives oxygenated blood via the pulmonary veins and then distributes it to all the peripheral tissues through the aorta (Skwarek et al 2006;Elghobary and Légaré2010). While the heart is thus employed, the coronary arteries can become constricted due to atherosclerosis and their blood supply is impaired (Elghobary and Légaré 2010;Miller et al 2010).…”

“…Atherosclerosis is characterized by the accumulation of cholesterol, coagulation factors and cells on the vessel wall, weakening the underlying tunica media layer, followed by the formation of intimal atheromatous plaques, which bring about a series of complications (Elghobary and Légaré 2010;Miller et al 2010;Cullen et al 2005). These plaques cause the vessel walls to thicken, whereby the lumen is narrowed, reducing the blood flow.…”

“…In this treatment, artery or vein graft materials are used to restore the blood supply to the myocardium, the area affected by atherosclerosis of the coronary artery (Aydin 2011;Elghobary and Légaré2010). The grafting in this operation is performed by stopping the heart, a “cardiopulmonary bypass”; or, if the grafting is carried out without stopping the heart, or off pump, the procedure is called “beating heart technique” (Skwarek et al 2006;Creswell et al 2005).…”