David Taggart of John Radcliffe Hospital, Oxford, United Kingdom, considers the evidence for the best second choice conduit for coronary bypass grafting after the left internal mammary.
This presentation was originally given during the SCTS Ionescu University program at the 2016 Annual Meeting of the Society for Cardiothoracic Surgery in Great Britain and Ireland. This content is published with the permission of SCTS. Please click here for more information on SCTS educational programs.
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We need to look at this issue in a different perspective. Instead of best grafts, I propose to look at it as best graft for a specific target. The problem I find is that it is difficult to interpret results of RA versus SV when I am not told what targets were grafted with what conduit. A left sided target will do better than a right target practically whatever the conduit is.
With that in mind, I see the issue as:
1) LAD takes a LIMA
2) Cx territory takes a RIMA if decent target to justify and patient young enough – for me less than 70. Diabetes is not an issue as “bad” diabetics will have diffuse disease Cx target that I would not use a RIMA on.
RIMA to Cx target through T sinus. 18% of my practice.
If the Cx is not worthy of a RIMA, then a SV graft is best.
3) So only issue is the right side. Here we try to graft wherever possible the origin of the PDA as there is plenty of evidence to show crux will develop disease in 7 years.
So, what is the best conduit for the PDA? Well, with the PDA as the target, the SV scores better than RA in studies I know.
There are huge studies from Australia with over 12000 RA patients, who cast serious doubt in this scenario.
Lastly, as we all suspect the use of statins and ACE inhibitors prolong graft patency and this effect is most profound where there is a problem, ie with the SV.
My 2 pennies worth …
Hi,
Great retrospective. Dr. Taggart however has had not promoted as a major breaktrough the No-Touch vein graft, that is used more and more, and that also has some 10-15 years follow-up data. By Dr. Souza D, Dr. Dashwood, and others.
This graft is superior to “old” saphenous graft form literature, and probably also to RA. I am using this technique for years. The tissue around the graft serves as an outer stent, there is no kinking. Also, there is no distension – only light flush. Look for it.
CORRECTION!!
Sorry, I must have skipped that part while moving cursor. No touch was given credit.