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Medicine » Surgery » "Coronary Artery Bypass Graft Surgery", book edited by Wilbert S. Aronow, ISBN 978-953-51-3710-8, Print ISBN 978-953-51-3709-2, Published: December 20, 2017 under CC BY 3.0 license. © The Author(s).

Chapter 2

The Choice of Graft Conduits in Coronary Artery Bypass Grafting

By Takashi Murashita
DOI: 10.5772/intechopen.70398

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The Choice of Graft Conduits in Coronary Artery Bypass Grafting

Takashi Murashita
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The use of the left internal mammary artery (IMA) has been shown to improve long-term survival and has been a gold standard in coronary artery bypass grafting (CABG). However, the choice of second or third graft conduit is still controversial. Multiple studies demonstrated the benefit of using multiple arterial grafts such as right IMA and radial artery in addition to left IMA in terms of long-term survival and graft patency. However, most of the centers still perform CABG with one IMA and vein grafts in a real world. The challenges for bilateral IMA utilization include longer operative time and concerns for higher rates of perioperative morbidity and mortality associated with increased sternal wound infection. Several studies reported that skeletonization technique can reduce the risk of sternal wound infection. Radial artery is another arterial conduit, which does not increase the risk of sternal wound infection and is easy to harvest. The superiority between radial artery and right IMA has been controversial. In the meantime, multiple trials have been made to improve the patency of vein grafts. The choice of graft conduits in CABG should be well considered preoperatively based on each patient’s backgrounds.

Keywords: graft, conduit, coronary artery bypass grafting, internal mammary artery, greater saphenous vein, radial artery

1. Introduction

Coronary artery bypass grafting (CABG) is one of the most common operations performed in the United States [1], and it has been established as an effective treatment for severe coronary artery disease [2]. In fact, despite the increasing use of percutaneous coronary intervention (PCI) for coronary artery disease during the past decade [3], CABG remains the gold standard for multivessel coronary artery disease or left main disease [4, 5]. A number of major trials such as SYNTAX [6], ASCERT [7], and FREEDOM [8] reported superior long-term survival rates of CABG compared to PCI.

The main factor of the superiority of CABG over PCI is the use of internal mammary artery (IMA) to left anterior descending (LAD) artery [9, 10]. The excellent long-term patency of left IMA (LIMA) to LAD graft has been established [1114] and the use of an IMA graft seems to improve long-term survival [15].

On the other hand, the long-term outcomes of other conduits such as saphenous vein graft, radial artery, and right gastroepiploic artery have been reported to be poorer than those of IMA. The patency rates of saphenous vein grafts were 71–87% at 1 year after surgery in previous studies [1618] and up to 50% at 10 years [1621].

Patients often require more than one bypass graft at the time of CABG. Unfortunately, there has been a lack of evidence for selecting bypass conduits beyond great confidence in the superiority of LIMA to LAD grafting. Therefore, the second best conduit for CABG is still unknown.

2. CABG with bilateral internal mammary arteries (BIMA)

2.1. Rationale for BIMA use

The advantages of arterial grafts over vein grafts include the inherent characteristics of the arterial endothelium of the left IMA graft [2224]. The excellent long-term outcomes of single IMA graft have stimulated the use of a bilateral IMA approach [25]. A number of previous studies have reported the superiority of BIMA use over single IMA use (Table 1) [4143].

StudyYearNumber of ptsFollow-up (years)Key outcomes
Endo et al. [26]2001BIMA 443, SIMA 6886.15Graft patency was 97.3% in the BIMA group and 94.3% in the SIMA group (p < 0.0001).
Endo et al. [27]2003BIMA 190, SIMA 278.110-year survival rate was significantly better in BIMA group than in SIMA group (87.8 ± 3.5 vs 75.2 ± 3.4%, p = 0.04), and 10-year all death–free or repeat CABG or recurrent MI–free rate was significantly better in BIMA group than in SIMA group (86.6 ± 3.6 vs 69.0 ± 3.7%, p = 0.0086).
Lytle et al. [28]2004BIMA 2001, SIMA 812316.5Survival of BIMA and SIMA groups at 7, 10, 15, and 20 years was 89 vs 87%, 81 vs 78%, 67 vs 58%, and 50 vs 37%, respectively (p < 0.0001).
Calafiore et al. [29]2004BIMA 1026, SIMA 5767.3 ± 4.8BIMA group had better freedom from cardiac death at 10 years (96.5 ± 0.8 vs 91.3 ± 1.4, p = 0.0288), late MI (98.0 ± 0.6 vs 94.3 ± 1.2, p = 0.0180), late MI in a grafted area (98.4 ± 0.6 vs 94.7 ± 1.1, p = 0.0057), and late cardiac events (93.9 ± 1.1 vs 86.3 ± 1.8, p = 0.0388).
Stevens et al. [30]2005BIMA 214, SIMA 41911 ± 3BIMA grafting decreased the risk of death (Hazard Ratio = 0.72 [0.57–0.91, 95% CI]) and coronary reoperation (HR = 0.38 [0.19–0.77]) in both diabetic and nondiabetic patients.
Di Mauro et al. [31]2005Matched; BIMA 476, SIMA 4768.8 ± 4.0BIMA group showed a better 10-year freedom from all-cause death (92.4 ± 2.1 vs 87.5 ± 3.5%, p = 0.0216), cardiac death (97.4 ± 0.9 vs 91.9 ± 1.4%, p = 0.0042), MI (98.7 ± 0.5 vs 94.2 ± 1.2%, p = 0.0034), MI in a grafted area (98.9 ± 0.5 vs 94.7 ± 1.3%, p = 0.0017), cardiac events (95.4 ± 1.2 vs 86.8 ± 1.8%, p = 0.0026), and any events (88.8 ± 2.2 vs 80.7 ± 2.1%, p = 0.0124).
Rankin et al. [32]2007BIMA 377, SIMA 490up to 20 yearsThe composite of mortality, MI, PCI, and redo CABG was lower in BIMA group than in SIMA group (p = 0.013).
Mohammadi et al. [33]2008BIMA 1338, SIMA 95665.7 ± 3.7Survival rates at 5, 7, and 10 years were 98.4, 97.8, and 96.5%, respectively, for patients with BIMA use, which were significantly higher (p < 0.0001) compared to the patients with SIMA use (96.6, 94.3, and 88.9%, respectively).
Kurlansky et al. [34]2010BIMA 2215, SIMA 236911.1–12.7At 15 years, survival for SIMA and BIMA patients was 37.5 ± 1.1% and 53.5 ± 1.2%, respectively; at 25 years, it was 15.7 ± 2.0% for SIMA patients and 28.6 ± 2.2% for BIMA patients (p < 0.001).
Kieser et al. [35]2011BIMA 1038, SIMA 40297.1Patients undergoing BIMA grafting had the lowest 1-year mortality (2.4 vs 4.3% SIMA grafting and 8.2% vein-only grafting; p < 0.0001).
Grau et al. [36]2012Matched; BIMA 928 and SIMA 9289.0 ± 510-year survival for BIMA was 89% and for LIMA was 79% (p < 0.001).
Galbut et al. [37]2012Matched; BIMA 87 and SIMA 87 in EF < 30% group, BIMA 448 and SIMA 448 in EF 30–50% group, BIMA 1137 and SIMA 1137 in EF > 50% group7.0–1310- and 20-year survival, SIMA vs BIMA, in EF 30–50% group was 57.7 ± 0.3 and 19 ± 2.5 vs 62.0 ± 2.3 and 33.1 ± 3.4%, respectively, p = 0.016; and in EF > 50% group, it was 67.1 ± 1.4 and 35.8 ± 1.7 vs 74.6 ± 1.3 and 38.1 ± 2.1%, respectively, p = 0.012.
Locker et al. [38]2012BIMA/SVG 589, BIMA only 271, BIMA-RA 147, LIMA/SVG 74357.6 ± 4.6BIMA/SVG and BIMA only had improved survival (86 and 76%; 82 and 75% at 10 and 15 years [p < 0.001]), and patients with BIMA/RA and LIMA/RA had greater 10-year survival (84 and 78%; p < 0.001) vs LIMA/SVG.
Kinoshita et al. [39]2012BIMA 244, SIMA 2474.3 ± 1.6The 5-year estimated freedom rate from overall death and cardiac event was higher in the BIMA group than in the SIMA group: 86.4 ± 3.2 vs 73.5 ± 3.9% (p = 0.01) and 93.2 ± 2.7 vs 87.5 ± 3.0% (p = 0.01), respectively.
Puskas et al. [40]2012BIMA 812, SIMA 2715n.a.BIMA was associated with a significant overall survival advantage at 8 years of follow-up of 89.3% compared with 68.3% with use of SIMA (p < 0.001).

Table 1.

Previous studies that reported the superiority of bilateral internal mammary artery (BIMA) use over single internal mammary artery (SIMA) use.

MI, myocardial infarction; PCI, percutaneous coronary intervention; CABG, coronary artery bypass grafting; EF, ejection fraction; SVG, saphenous vein graft; RA, radial artery.

Despite these evidences, BIMA use still appears to remain underutilized in the modern era. The challenges for BIMA utilization include longer operative time and concerns for higher rates of perioperative morbidity and mortality associated with increased sternal wound infection. LaPar and colleagues reviewed a total of 43,823 primary, isolated CABG patients in a Society of Thoracic Surgeons Database [44]. They found that the overall BIMA use was 3%, and even in low-risk patients, BIMA was used only in 6%. Importantly, BIMA use was not associated with increased postoperative mortality, morbidity, or hospital length of stay. However, hospital readmission rate was greater in BIMA patients compared with that in single IMA patients.

The configuration of BIMA grafts has also been controversial. Glineur et al. performed a prospective randomized trial that showed that the graft patency of BIMA grafts was similar between in-situ and Y-grafting configuration, whereas the use of BIMA in a Y-grafting configuration was associated in lower rates of major adverse cardiovascular and cerebrovascular events [45].

2.2. A randomized trial of BIMA use

A randomized trial of BIMA use for CABG, the arterial revascularization trial (ART) has been ongoing [46]. The patients were randomly scheduled for CABG to undergo single IMA or BIMA grafting in 28 cardiac surgical centers in 7 countries. A total of more than 3000 patients were enrolled in this study. Their results demonstrated no difference between single IMA use and BIMA use in terms of mortality or the rates of cardiovascular events at 5 years of follow-up [47]. Rates of major bleeding events and the need for repeat revascularization, angina status, and quality-of-life measures did not differ between the two groups, either. On the other hand, there were more sternal wound complications with BIMA use than with single IMA use. The ten-year outcomes are pending.

2.3. Sternal wound infection

One of the reasons of reluctant use of BIMA is a concern for potential sternal wound infection. There are basically two techniques for harvesting IMA: pedicled and skeletonized. Harvesting an ITA with a pedicled fashion can potentially lead to sternal devascularisation; however, Kamiya et al. reported that the damage can be minimized with skeletonization by preserving sternal and intercostal branches of IMA [48]. Boodhwani et al. reported that skeletonization resulted in reduced postoperative pain and increased sternal perfusion [49]. However, skeletonization is more technically demanding and time-consuming, and there is a concern of increased risk of injury of IMA during harvesting. Therefore, there is still a controversy regarding superiority between the two techniques.

Several previous studies reported that the skeletonization technique has a benefit over pedicled technique in terms of the incidence of sternal wound complication. Benedetto et al. reported that the risk of sternal wound infection was similar between skeletonized BIMA and pedicled single IMA [50]. Kai et al. reported that off-pump CABG with skeletonized BMA use resulted in a low incidence of sternal wound infection (0.6%) even in insulin-dependent diabetes patients [51].

3. CABG using radial artery graft

Due to the complexity of BIMA use, radial artery (RA) has been a preferred arterial graft over right IMA. RA is easier to harvest than IMA and not associated with sternal wound infection. Multiple previous studies reported improved long-term survival and patency rates for patients receiving RA as a second arterial graft compared with patients receiving vein grafts only [5255].

However, RA is muscular and vulnerable to spasm and competitive flow. A previous study reported that the lower capacity of nitric oxide release may contribute to the susceptibility of RA to the vasospasm and may have an impact on the long-term patency [56].

There is a big controversy about which is the second best arterial graft between RA and right IMA [57] (Table 2). Tranbaugh et al. conducted a propensity matched study comparing RA and right IMA grafts to bypass the left circumflex coronary artery [58]. They concluded RA had fewer major adverse events, a similar patency to right IMA, and improved survival in older and chronic obstructive pulmonary disease patients. Caputo et al. reported that RA provided better early and mid-term outcomes compared to right IMA [59]. Hayward et al. conducted a randomized study and concluded that, when patients receive a left IMA graft to the LAD, the next target may be grafted with a RA or a free right IMA to achieve similar clinical outcomes based on a mean of 6-year follow-up [60]. To the contrary, Ruttman et al. reported a superiority of right IMA graft compared to RA in terms of both survival and cardiac-related morbidity [62]. Raja et al. also reported the superiority of RIMA over RA [63].

StudyYearNumber of ptsSurvivalGraft patencyConclusions
Tranbaugh et al. [58]2014Matched 52810 year: 85% for RA and 80% for RIMA (p = 0.060)83.9% for RA and 87.4% for RIMA at 5.1 ± 3.8 years (p = 0.155)RA > RIMA
Caputo et al. [59]2003325 for RA, 336 for RIMA18 months: 99.7% for RA and 98.4% for RIMA (p = 0.07)n.a.RA > RIMA
Hayward et al. [60]2007198 for RA, 196 for RIMAMean of 6.0 years follow-up: 13 deaths in RA and 18 deaths in RIMA (p = 0.36)n.a.RA = RIMA
Hayward et al. [61]2010198 for RA, 196 for RIMAn.a.5-years; 89.8% for RA, 83.2% for RIMA (p = 0.06)RA = RIMA
Ruttman et al. [62]2011724 for RA, 277 for RIMA5 years: 93.0% for RA and 98.9% for RIMA (p = 0.022)RA occlusion was found in 37.9%; IMA occlusion was found in 10.2% (p < 0.001)RA < RIMA
Raja et al. [63]2015Matched; 779 for RA and 747 for RIMA10 years: 87.8% for RA and 93.4% for RIMA (p = −0.008)n.a.RA < RIMA

Table 2.

Previous studies that compared right internal mammary artery (RIMA) and radial artery (RA).

4. CABG using saphenous vein grafts

Despite the potential benefits of multiple arterial grafts [41], saphenous vein graft (SVG) is still the most frequently used conduit in CABG. However, the long-term patency of SVG is reported to be poor [1621]. The late-term SVG failure is mainly due to atherosclerotic obstruction occurring on a foundation of neointimal hyperplasia [64]. Attempts to mitigate intimal hyperplasia and SVG failure have been made; however, only persistent use of statin therapy and beta-blockers have been shown to reduce intimal hyperplasia in vein grafts [65]. Edifoligide [16] and aspirin plus clopidogrel have failed to reduce the process of SVG intimal hyperplasia [66].

Mechanical external stenting with polyester has shown potential benefits in preclinical testing with reduction of both neointima formation and early atherosclerosis, both of which are key aspects of SVG disease [67, 68]. The outcomes of initial trials of external stents for SVG were poor. Murphy et al. reported 100% occlusion of external stented SVG at 6 months [69]. Schoettler et al. reported that the patency rate of mesh-supported SVG was 27.8% at 9 months, whereas conventional SVG showed 85.7% patency [70]. Rescigno et al. reported 66.9% occlusion at 12 months of SVG supported with nitinol mesh [71]. Taggart et al. performed a randomized study comparing the one-year patency rate of stented SVG vs nonstented SVG [72]. They reported that the overall SVG failure rates did not differ between the stented SVG and nonstented SVG (30 vs 28.2%); however, stented SVG had less intimal hyperplasia and better lumen uniformity.

On the other hand, a previous study showed that the “nontouch technique,” in which SVG is harvested with a pedicle of surrounding tissue, was associated with a decreased vascular smooth muscle cell activation, which affects long-term patency of SVG [73]. Souza et al. conducted a randomized study comparing graft patency of SVGs using nontouch technique and those using conventional technique [74]. They concluded that harvesting SVG with surrounding tissue provided excellent short- and long-term patency, which was comparable to the IMA [75].

5. CABG using right gastroepiploic artery

The successful use of right gastroepiploic artery (GEA) in CABG was reported in 1980s [7678]. Histologically, GEA contains many smooth muscle cells in the media, whereas IMA has rich elastic fibers in the media [79]. Therefore, GEA is considered as a muscular artery, whereas IMA is an elastic artery. This difference becomes important when harvesting a graft, because GEA is more vulnerable to spasm than IMA.

GEA is most suitable for grafting to the distal right coronary artery and the posterior descending artery because this site is the nearest for the in-situ GEA graft and the most distant from the in-situ right IMA graft. In addition, in-situ GEA grafting can avoid manipulation of the aorta and can result in less neurological complications [80, 81].

Suma et al. reported that the cumulative patency rate of GEA graft was 92.3% at 1 year, 85.5% at 5 years, and 66.5% at 10 years after surgery, and skeletonization technique can improve the graft patency [82]. Suzuki et al. reported that skeletonized GEA grafting to the right coronary artery provided better survival and lower adverse cardiac events than SVG grafting [83].

In a real world, although multiple studies also demonstrated excellent surgical outcomes of CABG using GEA graft [8487], GEA is rarely used in the United States mainly due to technical complexity.

6. Conclusions

CABG has been a gold standard for severe multivessel coronary artery disease. There is a conclusive evidence of a benefit of using IMA in CABG surgery. Therefore, arterial grafts are thought to provide better outcomes than vein grafts. In a real world, however, multiple arterial revascularization is still underutilized. There are multiple studies that showed a survival benefit of using right IMA or radial artery as a second arterial graft compared to using vein grafts. The superiority of right IMA vs radial artery is still controversial. Some studies suggested skeletonization technique can minimize the risk of sternal wound infection, which is the main concern for using bilateral IMAs. In the meantime, multiple trials or techniques have been tried to improve the long-term patency of vein grafts.


1 - ElBardissi A, Aranki S, Sheng S, O’Brien S, Greenberg C, Gammie J. Trends in isolated coronary artery bypass grafting: An analysis of the Society of Thoracic Surgeons adult cardiac surgery database. Journal of Thoracic and Cardiovascular Surgery 2012;143:273-281. DOI: 10.1016/j.jtcvs.2011.10.029
2 - Yusuf S, Zucker D, Peduzzi P, Fisher L, Takaro T, Kennedy J, Davis K, Killip T, Passamani E, Norris R. Effect of coronary artery bypass graft surgery on survival: Overview of 10-year results from randomised trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration. Lancet 1994;344:563-570.
3 - Epstein AJ, Polsky D, Yang F, Yang L, Groeneveld PW. Coronary revascularization trends in the United States, 2001-2008. Journal of the American Medical Association 2011;305:1769-1776. DOI: 10.1001/jama.2011.551
4 - Serruys PW, Morice MC, Kappetein AP, Colombo A, Holmes DR, Mack MJ, Ståhle E, Feldman TE, van den Brand M, Bass EJ, Van Dyck N, Leadley K, Dawkins KD, Mohr FW, SYNTAX Investigators. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. New England Journal of Medicine 2009;360:961-972. DOI: 10.1056/NEJMoa0804626
5 - Benedetto U, Gaudino M, Ng C, Biondi-Zoccai G, D’Ascenzo F, Frati G, Girardi L, Angelini G, Taggart D. Coronary surgery is superior to drug eluting stents in multivessel disease. Systematic review and meta-analysis of contemporary randomized controlled trials. International Journal of Cardiology. 2016;210:19-24. DOI: 10.1016/j.ijcard.2016.02.090
6 - Mohr FW, Morice MC, Kappetein AP, Feldman TE, Ståhle E, Colombo A, Mack MJ, Holmes DR, Jr., Morel MA, Van Dyck N, Houle VM, Dawkins KD, Serruys PW. Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial. Lancet 2013;381:629-638. DOI: 10.1016/S0140-6736(13)60141-5
7 - Weintraub WS, Grau-Sepulveda MV, Weiss JM, O’Brien SM, Peterson ED, Kolm P, Zhang Z, Klein LW, Shaw RE, McKay C, Ritzenthaler LL, Popma JJ, Messenger JC, Shahian DM, Grover FL, Mayer JE, Shewan CM, Garratt KN, Moussa ID, Dangas GD, Edwards FH. Comparative effectiveness of revascularization strategies. New England Journal of Medicine. 2012;366:1467-1476. DOI: 10.1056/NEJMoa1110717
8 - Farkouh ME, Domanski M, Sleeper LA, Siami FS, Dangas G, Mack M, Yang M, Cohen DJ, Rosenberg Y, Solomon SD, Desai AS, Gersh BJ, Magnuson EA, Lansky A, Boineau R, Weinberger J, Ramanathan K, Sousa JE, Rankin J, Bhargava B, Buse J, Hueb W, Smith CR, Muratov V, Bansilal S, King S, 3rd., Bertrand M, Fuster V, FREEDOM Trial Investigators. Strategies for multivessel revascularization in patients with diabetes. New England Journal of Medicine 2012;367:2375-2384. DOI: 10.1056/NEJMoa1211585
9 - Wrigley BJ, Dubey G, Spyt T, Gershlick AH. Hybrid revascularisation in multivessel coronary artery disease: Could a combination of CABG and PCI be the best option in selected patients? EuroIntervention 2013;8:1335-1341. DOI:10.4244/EIJV8I11A202
10 - Harskamp RE, Zheng Z, Alexander JH, Williams JB, Xian Y, Halkos ME, Brennan JM, de Winter RJ, Smith PK, Lopes RD. Status quo of hybrid coronary revascularization for multi-vessel coronary artery disease. Annals of Thoracic Surgery 2013;96:2268-2277.
11 - Shah PJ, Durairaj M, Gordon I, Fuller J, Rosalion A, Seevanayagam S, Tatoulis J, Buxton BF. Factors affecting patency of internal thoracic artery graft: Clinical and angiographic study in 1434 symptomatic patients operated between 1982 and 2002. European Journal of Cardio-Thoracic Surgery 2004;26:118-124. DOI: 10.1016/j.ejcts.2004.02.037
12 - Cameron A, Davis KB, Green G, Schaff HV. Coronary bypass surgery with internal-thoracic-artery grafts--effects on survival over a 15-year period. New England Journal of Medicine. 1996;334:216-219. DOI: 10.1056/NEJM199601253340402
13 - Loop FD, Lytle BW, Cosgrove DM, Stewart RW, Goormastic M, Williams GW, Golding LA, Gill CC, Taylor PC, Sheldon WC. Influence of the internal-mammary-artery graft on 10-year survival and other cardiac events. New England Journal of Medicine. 1986;314:1-6. DOI: 10.1056/NEJM198601023140101
14 - Cameron A, Green G, Brogno D, Thornton J. Internal thoracic artery grafts: 20-year clinical follow-up. Journal of the American College of Cardiology. 1995;25:188-192
15 - Hlatky M, Shilane D, Boothroyd D, Boersma E, Brooks M, Carrié D, Clayton T, Danchin N, Flather M, Hamm C, Hueb W, Kahler J, Lopes N, Pocock S, Rodriguez A, Serruys P, Sigwart U, Stables R. The effect of internal thoracic artery grafts on long-term clinical outcomes after coronary bypass surgery. Journal of Thoracic and Cardiovascular Surgery. 2011;142:829-835. DOI: 10.1016/j.jtcvs.2010.09.063
16 - Alexander JH, Hafley G, Harrington RA, Peterson ED, Ferguson TB, Jr., Lorenz TJ, Goyal A, Gibson M, Mack MJ, Gennevois D, Califf RM, Kouchoukos NT, PREVENT IV Investigators. Efficacy and safety of edifoligide, an E2F transcription factor decoy, for prevention of vein graft failure following coronary artery bypass graft surgery: PREVENT IV: A randomized controlled trial. Journal of the American Medical Association. 2005;294:2446-2454. DOI: 10.1001/jama.294.19.2446
17 - Harskamp RE, Lopes RD, Baisden CE, de Winter RJ, Alexander JH. Saphenous vein graft failure after coronary artery bypass surgery: Pathophysiology, management, and future directions. Annals of Surgery 2013;257:824-833. DOI: 10.1097/SLA.0b013e318288c38d
18 - Puskas JD, Williams WH, Mahoney EM, Huber PR, Block PC, Duke PG, Staples JR, Glas KE, Marshall JJ, Leimbach ME, McCall SA, Petersen RJ, Bailey DE, Weintraub WS, Guyton RA. Off-pump vs conventional coronary artery bypass grafting: Early and 1-year graft patency, cost, and quality-of-life outcomes: A randomized trial. Journal of the American Medical Association 2004;291:1841-1849. DOI: 10.1001/jama.291.15.1841
19 - Tatoulis J, Buxton BF, Fuller JA. Patencies of 2127 arterial to coronary conduits over 15 years. Annals of Thoracic Surgery. 2004;77:93-101
20 - Goldman S, Zadina K, Moritz T, Ovitt T, Sethi G, Copeland JG, Thottapurathu L, Krasnicka B, Ellis N, Anderson RJ, Henderson W, VA Cooperative Study Group. Long-term patency of saphenous vein and left internal mammary artery grafts after coronary artery bypass surgery: Results from a Department of Veterans Affairs Cooperative Study. Journal of the American College of Cardiology 2004;44:2149-2156. DOI: 10.1016/j.jacc.2004.08.064
21 - Fitzgibbon G, Kafka H, Leach A, Keon W, Hooper G, Burton J. Coronary bypass graft fate and patient outcome: Angiographic follow-up of 5065 grafts related to survival and reoperation in 1388 patients during 25 years. Journal of the American College of Cardiology 1996;28:616-626.
22 - Glineur D, Poncelet A, El Khoury G, D’hoore W, Astarci P, Zech F, Noirhomme P, Hanet C. Fractional flow reserve of pedicled internal thoracic artery and saphenous vein grafts 6 months after bypass surgery. European Journal of Cardio-Thoracic Surgery. 2007;31:376-381. DOI: 10.1016/j.ejcts.2006.11.023
23 - Gurné O, Chenu P, Buche M, Louagie Y, Eucher P, Marchandise B, Rombaut E, Blommaert D, Schroeder E. Adaptive mechanisms of arterial and venous coronary bypass grafts to an increase in flow demand. Heart. 1999;82:336-342
24 - Walpoth B, Schmid M, Schwab A, Bosshard A, Eckstein F, Carrel T, Hess O. Vascular adaptation of the internal thoracic artery graft early and late after bypass surgery. Journal of Thoracic and Cardiovascular Surgery. 2008;136:876-883. DOI: 10.1016/j.jtcvs.2008.05.029
25 - Glineur D, Papadatos S, Grau J, Shaw R, Kuschner C, Aphram G, Mairy Y, Vanbelighen C, Etienne P. Complete myocardial revascularization using only bilateral internal thoracic arteries provides a low-risk and durable 10-year clinical outcome. European Journal of Cardio-Thoracic Surgery. 2016;50:735-741. DOI: 10.1016/j.ejcts.2004.01.001
26 - Endo M, Nishida H, Tomizawa Y, Kasanuki H. Benefit of bilateral over single internal mammary artery grafts for multiple coronary artery bypass grafting. Circulation. 2001;104:2164-2170
27 - Endo M, Tomizawa Y, Nishida H. Bilateral versus unilateral internal mammary revascularization in patients with diabetes. Circulation. 2003;108:1343-1349. DOI: 10.1161/01.CIR.0000085995.87982.6E
28 - Lytle B, Blackstone E, Sabik J, Houghtaling P, Loop F, Cosgrove D. The effect of bilateral internal thoracic artery grafting on survival during 20 postoperative years. Annals of Thoracic Surgery. 2004;78:2005-2012. DOI: 10.1016/j.athoracsur.2004.05.070
29 - Calafiore A, Di Giammarco G, Teodori G, Di Mauro M, Iacò A, Bivona A, Contini M, Vitolla G. Late results of first myocardial revascularization in multiple vessel disease: Single versus bilateral internal mammary artery with or without saphenous vein grafts. European Journal of Cardio-Thoracic Surgery 2004;26:542-548. DOI: 10.1016/j.ejcts.2004.05.028
30 - Stevens L, Carrier M, Perrault L, Hébert Y, Cartier R, Bouchard D, Fortier A, Pellerin M. Influence of diabetes and bilateral internal thoracic artery grafts on long-term outcome for multivessel coronary artery bypass grafting. European Journal of Cardio-Thoracic Surgery. 2005;27:281-288. DOI: 10.1016/j.ejcts.2004.10.048
31 - Di Mauro M, Iacò A, Contini M, Vitolla G, Weltert L, Di Giammarco G, Calafiore A. First time myocardial revascularization in patients younger than 70 years. Single versus double internal mammary artery. Italian Heart Journal. 2005;6:390-395
32 - Rankin J, Tuttle R, Wechsler A, Teichmann T, Glower D, Califf R. Techniques and benefits of multiple internal mammary artery bypass at 20 years of follow-up. Annals of Thoracic Surgery. 2007;83:1008-1014. DOI: 10.1016/j.athoracsur.2006.10.032
33 - Mohammadi S, Dagenais F, Doyle D, Mathieu P, Baillot R, Charbonneau E, Perron J, Voisine P. Age cut-off for the loss of benefit from bilateral internal thoracic artery grafting. European Journal of Cardio-Thoracic Surgery. 2008;33:977-982. DOI: 10.1016/j.ejcts.2008.03.026
34 - Kurlansky P, Traad E, Dorman M, Galbut D, Zucker M, Ebra G. Thirty-year follow-up defines survival benefit for second internal mammary artery in propensity-matched groups. Annals of Thoracic Surgery. 2010;90:101-108. DOI: 10.1016/j.athoracsur.2010.04.006
35 - Kieser T, Lewin A, Graham M, Martin B, Galbraith P, Rabi D, Norris C, Faris P, Knudtson M, Ghali W, APPROACH Investigators. Outcomes associated with bilateral internal thoracic artery grafting: The importance of age. Annals of Thoracic Surgery. 2011;92:1269-1275. DOI: 10.1016/j.athoracsur.2011.05.083
36 - Grau J, Ferrari G, Mak A, Shaw R, Brizzio M, Mindich B, Strobeck J, Zapolanski A. Propensity matched analysis of bilateral internal mammary artery versus single left internal mammary artery grafting at 17-year follow-up: Validation of a contemporary surgical experience. European Journal of Cardio-Thoracic Surgery 2012;41:770-775. DOI: 10.1093/ejcts/ezr213
37 - Galbut D, Kurlansky P, Traad E, Dorman M, Zucker M, Ebra G. Bilateral internal thoracic artery grafting improves long-term survival in patients with reduced ejection fraction: A propensity-matched study with 30-year follow-up. Journal of Thoracic and Cardiovascular Surgery. 2012;143:844-853. DOI: 10.1016/j.jtcvs.2011.12.026
38 - Locker C, Schaff H, Dearani J, Joyce L, Park S, Burkhart H, Suri R, Greason K, Stulak J, Li Z, Daly R. Multiple arterial grafts improve late survival of patients undergoing coronary artery bypass graft surgery: Analysis of 8622 patients with multivessel disease. Circulation 2012;126:1023-1030. DOI: 10.1161/CIRCULATIONAHA.111.084624
39 - Kinoshita T, Asai T, Suzuki T, Kuroyanagi S, Hosoba S, Takashima N. Off-pump bilateral skeletonized internal thoracic artery grafting in elderly patients. Annals of Thoracic Surgery. 2012;93:531-536. DOI: 10.1016/j.athoracsur.2011.09.077
40 - Puskas J, Sadiq A, Vassiliades T, Kilgo P, Lattouf O. Bilateral internal thoracic artery grafting is associated with significantly improved long-term survival, even among diabetic patients. Annals of Thoracic Surgery. 2012;94:710-715. DOI: 10.1016/j.athoracsur.2012.03.082
41 - Taggart D, D’Amico R, Altman D. Effect of arterial revascularisation on survival: A systematic review of studies comparing bilateral and single internal mammary arteries. Lancet 2001;358:870-875. DOI: 10.1016/S0140-6736(01)06069-X
42 - Yi G, Shine B, Rehman S, Altman D, Taggart D. Effect of bilateral internal mammary artery grafts on long-term survival: A meta-analysis approach. Circulation 2014;130:539-545. DOI: 10.1161/CIRCULATIONAHA.113.004255
43 - Smith T, Kloppenburg G, Morshuis W. Does the use of bilateral mammary artery grafts compared with the use of a single mammary artery graft offer a long-term survival benefit in patients undergoing coronary artery bypass surgery? Interactive Cardiovascular and Thoracic Surgery. 2014;18:96-101. DOI: 10.1093/icvts/ivt423
44 - LaPar D, Crosby I, Rich J, Quader M, Speir A, Kern J, Tribble C, Kron I, Ailawadi G, Investigators for the Virginia Cardiac Surgery Quality Initiative. Bilateral internal mammary artery use for coronary artery bypass grafting remains underutilized: A propensity-matched multi-institution analysis. Annals of Thoracic Surgery 2015;100:8-14. DOI: 10.1016/j.athoracsur.2015.02.088
45 - Glineur D, Boodhwani M, Hanet C, de Kerchove L, Navarra E, Astarci P, Noirhomme P, El Khoury G. Bilateral internal thoracic artery configuration for coronary artery bypass surgery: A prospective randomized trial. Circulation Cardiovascular Interventions. 2016;9:7. DOI: 10.1161/CIRCINTERVENTIONS.115.003518
46 - Taggart D, Altman D, Gray A, Lees B, Nugara F, Yu L, Campbell H, Flather M, ART Investigators. Randomized trial to compare bilateral vs. single internal mammary coronary artery bypass grafting: 1-year results of the Arterial Revascularisation Trial (ART). European Heart Journal. 2013;31:2470-2481. DOI: 10.1093/eurheartj/ehq318
47 - Taggart D, Altman D, Gray A, Lees B, Gerry S, Benedetto U, Flather M, ART Investigators. Randomized trial of bilateral versus single internal-thoracic-artery grafts. New England Journal of Medicine 2016;375:2540-2549. DOI: 10.1056/NEJMoa1610021
48 - Kamiya H, Akhyari P, Martens A, Karck M, Haverich A, Lichtenberg A. Sternal microcirculation after skeletonized versus pedicled harvesting of the internal thoracic artery: A randomized study. Journal of Thoracic and Cardiovascular Surgery 2008;135:32-37. DOI: 10.1016/j.jtcvs.2007.09.004
49 - Boodhwani M, Lam B, Nathan H, Mesana T, Ruel M, Zeng W, Sellke F, Rubens F. Skeletonized internal thoracic artery harvest reduces pain and dysesthesia and improves sternal perfusion after coronary artery bypass surgery: A randomized, double-blind, within-patient comparison. Circulation 2006;114:766-773. DOI:10.1161/CIRCULATIONAHA.106.615427
50 - Benedetto U, Altman D, Gerry S, Gray A, Lees B, Pawlaczyk R, Flather M, Taggart D, Arterial Revascularization Trial Investigators. Pedicled and skeletonized single and bilateral internal thoracic artery grafts and the incidence of sternal wound complications: Insights from the Arterial Revascularization Trial. Journal of Thoracic and Cardiovascular Surgery. 2016;152:270-276. DOI: 10.1016/j.jtcvs.2016.03.056
51 - Kai M, Hanyu M, Soga Y, Nomoto T, Nakano J, Matsuo T, Umehara E, Kawato M, Okabayashi H. Off-pump coronary artery bypass grafting with skeletonized bilateral internal thoracic arteries in insulin-dependent diabetics. Annals of Thoracic Surgery. 2007;84:32-36. DOI: 10.1016/j.athoracsur.2007.02.095
52 - Zacharias A, Habib R, Schwann T, Riordan C, Durham S, Shah A. Improved survival with radial artery versus vein conduits in coronary bypass surgery with left internal thoracic artery to left anterior descending artery grafting. Circulation. 2004;109:1489-1496. DOI: 10.1161/01.CIR.0000121743.10146.78
53 - Collins P, Webb C, Chong C, Moat N, Radial Artery Versus Saphenous Vein Patency (RSVP) Trial Investigators. Radial artery versus saphenous vein patency randomized trial: Five-year angiographic follow-up. Circulation 2008;117:2859-2864. DOI: 10.1161/CIRCULATIONAHA.107.736215
54 - Tranbaugh R, Dimitrova K, Friedmann P, Geller C, Harris L, Stelzer P, Cohen B, Hoffman D. Radial artery conduits improve long-term survival after coronary artery bypass grafting. Annals of Thoracic Surgery. 2010;90:1165-1172. DOI: 10.1016/j.athoracsur.2010.05.038
55 - Schwann T, Tranbaugh R, Dimitrova K, Engoren M, Kabour A, Hoffman D, Geller C, Ko W, Habib R. Time-varying survival benefit of radial artery versus vein grafting: A multiinstitutional analysis. Annals of Thoracic Surgery 2014;97:1328-1334. DOI: 10.1016/j.athoracsur.2014.09.078
56 - He G, Liu Z. Comparison of nitric oxide release and endothelium-derived hyperpolarizing factor-mediated hyperpolarization between human radial and internal mammary arteries. Circulation. 2001;104:1344-1349
57 - Tatoulis J. Total arterial coronary revascularization-patient selection, stenoses, conduits, targets. Annals of Cardiothoracic Surgery. 2013;2:499-506. DOI: 10.3978/j.issn.2225-319X.2013.07.02
58 - Tranbaugh R, Dimitrova K, Lucido D, Hoffman D, Dincheva G, Geller C, Balaram S, Ko W, Swistel D. The second best arterial graft: A propensity analysis of the radial artery versus the free right internal thoracic artery to bypass the circumflex coronary artery. Journal of Thoracic and Cardiovascular Surgery 2014;147:133-140. DOI: 10.1016/j.jtcvs.2013.08.040
59 - Caputo M, Reeves B, Marchetto G, Mahesh B, Lim K, Angelini G. Radial versus right internal thoracic artery as a second arterial conduit for coronary surgery: Early and midterm outcomes. Journal of Thoracic and Cardiovascular Surgery 2003;126:39-47
60 - Hayward P, Hare D, Gordon I, Matalanis G, Buxton B. Which arterial conduit? Radial artery versus free right internal thoracic artery: Six-year clinical results of a randomized controlled trial. Annals of Thoracic Surgery 2007;84:493-497. DOI: 10.1016/j.athoracsur.2007.03.053
61 - Hayward P, Gordon I, Hare D, Matalanis G, Horrigan M, Rosalion A, Buxton B. Comparable patencies of the radial artery and right internal thoracic artery or saphenous vein beyond 5 years: Results from the Radial Artery Patency and Clinical Outcomes trial. Journal of Thoracic and Cardiovascular Surgery. 2010;139:60-65. DOI: 10.1016/j.jtcvs.2009.09.043
62 - Ruttmann E, Fischler N, Sakic A, Chevtchik O, Alber H, Schistek R, Ulmer H, Grimm M. Second internal thoracic artery versus radial artery in coronary artery bypass grafting: A long-term, propensity score-matched follow-up study. Circulation 2011;124:1321-1329. DOI: 10.1161/CIRCULATIONAHA.111.030536
63 - Raja S, Benedetto U, Jothidasan A, Jujjavarapu R, Ukwu U, De Robertis F, Bahrami T, Gaer J, Amrani M, Harefield Cardiac Outcomes Research Group. Right internal mammary artery versus radial artery as second arterial conduit in coronary artery bypass grafting: A case-control study of 1526 patients. International Journal of Surgery. 2015;16:183-189. DOI: 10.1016/j.ijsu.2014.08.342
64 - Motwani J, Topol E. Aortocoronary saphenous vein graft disease: Pathogenesis, predisposition, and prevention. Circulation 1998;97:916-931
65 - Une D, Kulik A, Voisine P, Le May M, Ruel M. Correlates of saphenous vein graft hyperplasia and occlusion 1 year after coronary artery bypass grafting: Analysis from the CASCADE randomized trial. Circulation 2013;128:S213-S218 DOI: 10.1161/CIRCULATIONAHA.112.000328
66 - Kulik A, Le May M, Voisine P, Tardif J, Delarochelliere R, Naidoo S, Wells G, Mesana T, Ruel M. Aspirin plus clopidogrel versus aspirin alone after coronary artery bypass grafting: The clopidogrel after surgery for coronary artery disease (CASCADE) Trial. Circulation. 2010;122:2680-2687. DOI: 10.1161/CIRCULATIONAHA.110.978007
67 - Angelini G, Lloyd C, Bush R, Johnson J, Newby A. An external, oversized, porous polyester stent reduces vein graft neointima formation, cholesterol concentration, and vascular cell adhesion molecule 1 expression in cholesterol-fed pigs. Journal of Thoracic and Cardiovascular Surgery. 2002;124:950-956
68 - Ben-Gal Y, Taggart D, Williams M, Orion E, Uretzky G, Shofti R, Banai S, Yosef L, Bolotin G. Expandable external support device to improve Saphenous Vein Graft Patency after CABG. Journal of Cardiothoracic Surgery 2013;8:122. DOI: 10.1186/1749-8090-8-122
69 - Murphy G, Newby A, Jeremy J, Baumbach A, Angelini G. A randomized trial of an external Dacron sheath for the prevention of vein graft disease: The Extent study. Journal of Thoracic and Cardiovascular Surgery 2007;134:504-505. DOI: 10.1016/j.jtcvs.2007.01.092
70 - Schoettler J, Jussli-Melchers J, Grothusen C, Stracke L, Schoeneich F, Stohn S, Hoffmann G, Cremer J. Highly flexible nitinol mesh to encase aortocoronary saphenous vein grafts: First clinical experiences and angiographic results nine months postoperatively. Interactive Cardiovascular and Thoracic Surgery 2011;13:396-400. DOI: 10.1510/icvts.2010.265116
71 - Rescigno G, Aratari C, Matteucci S, Parisi R, Gironi G, Schicchi N, D’Alfonso A, Cola V, Torracca L. Saphenous vein graft wrapping by nitinol mesh: A word of caution. Thoracic and Cardiovascular Surgeon. 2015;63:292-297. DOI: 10.1055/s-0034-1393705
72 - Taggart D, Ben Gal Y, Lees B, Patel N, Webb C, Rehman S, Desouza A, Yadav R, De Robertis F, Dalby M, Banning A, Channon K, Di Mario C, Orion E A randomized trial of external stenting for saphenous vein grafts in coronary artery bypass grafting. Annals of Thoracic Surgery. 2015;99:2039-2045. DOI: 10.1016/j.athoracsur.2015.01.060
73 - Verma S, Lovren F, Pan Y, Yanagawa B, Deb S, Karkhanis R, Quan A, Teoh H, Feder-Elituv R, Moussa F, Souza D, Fremes S. Pedicled no-touch saphenous vein graft harvest limits vascular smooth muscle cell activation: The PATENT saphenous vein graft study. European Journal of Cardio-Thoracic Surgery 2014;45:717-725. DOI: 10.1093/ejcts/ezt560
74 - Souza D, Johansson B, Bojö L, Karlsson R, Geijer H, Filbey D, Bodin L, Arbeus M, Dashwood M. Harvesting the saphenous vein with surrounding tissue for CABG provides long-term graft patency comparable to the left internal thoracic artery: Results of a randomized longitudinal trial. Journal of Thoracic and Cardiovascular Surgery 2006;132:373-378. DOI: 10.1016/j.jtcvs.2006.04.002
75 - Samano N, Geijer H, Liden M, Fremes S, Bodin L, Souza D. The no-touch saphenous vein for coronary artery bypass grafting maintains a patency, after 16 years, comparable to the left internal thoracic artery: A randomized trial. Journal of Thoracic and Cardiovascular Surgery. 2015;150:880-888. DOI: 10.1016/j.jtcvs.2015.07.027
76 - Mills N, Everson C. Right gastroepiploic artery: A third arterial conduit for coronary artery bypass. Annals of Thoracic Surgery. 1989;47:706-711.
77 - Pym J, Brown P, Charrette E, Parker J, West R. Gastroepiploic-coronary anastomosis. A viable alternative bypass graft. Journal of Thoracic and Cardiovascular Surgery. 1987;94:256-259
78 - Suma H, Fukumoto H, Takeuchi A. Coronary artery bypass grafting by utilizing in situ right gastroepiploic artery: Basic study and clinical application. Annals of Thoracic Surgery. 1987;44:394-397.
79 - van Son J, Smedts F, Vincent J, van Lier H, Kubat K. Comparative anatomic studies of various arterial conduits for myocardial revascularization. Journal of Thoracic and Cardiovascular Surgery 1990;99:703-707.
80 - Suma H. The right gastroepiploic artery graft for coronary artery bypass grafting: A 30-year experience. Korean Journal of Thoracic and Cardiovascular Surgery. 2016;49:225-231. DOI: 10.5090/kjtcs.2016.49.4.225
81 - Suma H. Coronary artery bypass grafting in patients with calcified ascending aorta: Aortic no-touch technique. Annals of Thoracic Surgery 1989;48:728-730
82 - Suma H, Tanabe H, Takahashi A, Horii T, Isomura T, Hirose H, Amano A. Twenty years experience with the gastroepiploic artery graft for CABG. Circulation. 2007;116:I188-I191. DOI: 10.1161/CIRCULATIONAHA.106.678813
83 - Suzuki T, Asai T, Matsubayashi K, Kambara A, Kinoshita T, Takashima N, Hosoba S. In off-pump surgery, skeletonized gastroepiploic artery is superior to saphenous vein in patients with bilateral internal thoracic arterial grafts. Annals of Thoracic Surgery. 2011;91:1159-1164. DOI: 10.1016/j.athoracsur.2010.12.031
84 - Nishida H, Tomizawa Y, Endo M, Koyanagi H, Kasanuki H. Coronary artery bypass with only in situ bilateral internal thoracic arteries and right gastroepiploic artery. Circulation. 2001;104:I76-I80
85 - Hirose H, Amano A, Takanashi S, Takahashi A. Coronary artery bypass grafting using the gastroepiploic artery in 1000 patients. Annals of Thoracic Surgery 2002;73:1371-1379.
86 - Formica F, Ferro O, Greco P, Martino A, Gastaldi D, Paolini G. Long-term follow-up of total arterial myocardial revascularization using exclusively pedicle bilateral internal thoracic artery and right gastroepiploic artery. European Journal of Cardio-Thoracic Surgery. 2004;26:1141-1148. DOI: 10.1016/j.ejcts.2004.08.027
87 - Tavilla G, Kappetein A, Braun J, Gopie J, Tjien A, Dion R. Long-term follow-up of coronary artery bypass grafting in three-vessel disease using exclusively pedicled bilateral internal thoracic and right gastroepiploic arteries. Annals of Thoracic Surgery. 2004;77:794-799. DOI: 10.1016/S0003-4975(03)01659-X