Total Arterial Revascularization for Multi-Vessel Coronary Artery Disease

This article is part of CTSNet’s Guest Editor Series, “Robotic-Assisted Coronary Artery Bypass Graft Surgery—Techniques and Procedures”  Dr. M. M. Yusuf brought together cardiac surgery experts from around the world to contribute procedure videos on various techniques.

The left internal mammary artery (LIMA) has been a mainstay of coronary artery bypass grafting (CABG) for several decades. Total arterial revascularization (TAR) is a type of CABG that uses only arterial conduits for revascularization of coronary targets. The right internal mammary artery (RIMA) is the first choice for the second arterial conduit for CABG because it does not require further incisions and has advantages from not being spasmodic. Evidence over the years has clearly established the supremacy of bilateral internal mammary artery (BIMA) grafts over single IMA grafts in terms of long-term patency and durability, which leads to significant improvement in long-term survival. Using multiple arterial grafts can be technically demanding. The double docking technique (DDT) helps harvest both right and left ITAs using robotic arms docked on the respective sides (first left and then right). It is possible to procure a lengthier RITA graft using the DDT. Evidence suggests that BIMA grafting using a traditional sternotomy technique increases the risk of deep sternal wound infections. Robotic-assisted BIMA harvest completely negates the infection risk. 

References

1. Yusuf MM, Bansal V, Gunasekaran S, Kaliyamoorthy D, Kumar AM. Total arterial revascularization using robot assisted minimally invasive coronary artery bypass: an Indian experience. Indian J Thorac Cardiovasc Surg. 2024;40(1):42-49. doi:10.1007/s12055-023-01593-6.
2. Pevni D, Mohr R, Kramer A, Paz Y, Nesher N, Ben-Gal Y. Are two internal thoracic grafts better than one? An analysis of 5301 cases. Eur J Cardiothorac Surg. 2019;56(5):935-941. doi:10.1093/ejcts/ezz094.
3. Lytle BW, Cosgrove DM, Saltus GL, Taylor PC, Loop FD. Multivessel coronary revascularization without saphenous vein: long-term results of bilateral internal mammary artery grafting. Ann Thorac Surg. 1983;36(5):540-547. doi:10.1016/s0003-4975(10)60684-4.

Disclaimer

The information and views presented on CTSNet.org represent the views of the authors and contributors of the material and not of CTSNet. Please review our full disclaimer page here.