Outcome Analysis of Arterial Coronary Revascularization: A 30-Year Experience

Purpose: Recent analyses from The Society of Thoracic Surgeons database indicate that only 4-5% of coronary bypass procedures in the United States involve multiple internal mammary arteries. Virtually all studies show significant clinical benefits of multiple mammary grafting, and increasing arterial grafting rates could improve outcomes. This video shows an approach to all-arterial grafting that has been developed over the past three decades, and illustrates techniques in four patients who underwent this procedure.

Methods: For patients with multi-vessel coronary disease, two-thirds have the right internal mammary artery (RIMA) placed to the left anterior descending (LAD) coronary artery, and the left internal mammary artery (LIMA) to the circumflex. Using the RIMA for the LAD is a key feature of optimizing arterial revascularization rates. In one-third, the RIMA is used for the right coronary artery (RCA), and the LIMA for the LAD. In general, the IMAs are placed to the two most important coronary systems in terms of quantity of viable myocardium. Usually, pedicle grafts are favored, but free IMAs are employed whenever necessary. For adjunctive grafts, radial arteries (RA) are favored (harvested, prepared, and inserted with the Brompton Hospital technique). Bilateral IMAs are used liberally in diabetic patients and with topical antibiotic irrigation, sternal infection rates have been low. Using these methods, 70-80% of multi-vessel disease patients can receive all-arterial grafting with low early mortality and complication rates.

Results: Various types of IMA grafts have exhibited 95-100% patency rates in the first postoperative years, and RA patencies are only slightly lower. The patencies of both types of arteries are better than saphenous veins, and late clinical events are improved. Multivariable analyses have shown reduced late myocardial infarction, percutaneous interventions, redo coronary bypass, and all-cause mortality after multiple arterial grafting. Risk-adjusted composite outcome at 15 years of followup was 19% better with multiple IMAs, as compared to single IMAs and vein grafts.

Conclusion: Techniques for all-arterial coronary bypass are now well validated and completely mature. Early results are excellent, and long-term clinical outcomes are significantly improved. A major effort should be made to increase arterial bypass rates in future patients with multi-vessel coronary artery disease.

This video was originally presented at the October 2011 Roland Hetzer Society Meeting, in Lisbon, Portugal.