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Tips and Tricks to Simplify Multiarterial CABG

Tuesday, October 15, 2019

Yadava OP, Barlow C. Tips and Tricks to Simplify Multiarterial CABG. October 2019. doi:10.25373/ctsnet.9955229.

Dr Om P. Yadava, CEO and Chief Cardiac Surgeon of the National Heart Institute in New Delhi, India, and Editor-in-Chief of the Indian Journal of Thoracic and Cardiovascular Surgery, and Mr Clifford Barlow, Senior Consultant Cardiac Surgeon at the University Hospital in Southampton, UK, discuss ways to increase the uptake of multiarterial grafting in CABG through simplification rather than complex configurations.

Dr Yadava laments that despite the literature available, total arterial grafting is not catching up, with less than 5% of coronary artery bypass graft surgery worldwide being multiarterial grafting. Dr Clifford also feels that there is sufficient evidence, implicit or explicit, for the benefit of bilateral internal mammary arteries (IMA), but there has not been sufficient uptake. Exploring reasons for this, Dr Barlow quotes Einstein, “We keep proposing doing the same thing over and over again, expecting a different result.” The main reason for this low uptake, he feels, is the technical complexity of the operation. Dr Clifford proposes a simplified concept – pedicled LIMA to left anterior descending (LAD) and pedicled RIMA through the transverse sinus, behind the aorta, to the circumflex/obtuse marginal (OM) branch. However, if the OM branch is too far off for the RIMA to reach, then a free RIMA can be used, but the top end should not be performed to the aorta (1). Dr Clifford opposes a pedicled RIMA to the right coronary artery (RCA) because the tension on the graft is difficult to predict, especially if there happens to be cardiac dilatation or distention due to a temporary arrhythmia or ischemia in the postoperative phase. To the contrary, a graft via the transverse sinus is not affected by the postoperative distention of the heart. Though bleeding point may be an issue with such a dispensation of the graft, it is easily surmountable.

Dr Yadava proposes taking a pedicled RIMA across the midline to the LAD and a pedicled LIMA to the back of the heart, but Dr Clifford feels redo may be a difficult proposition in this scenario, more so if a patient has to come back for a mitral or aortic valve intervention. Dr Clifford expresses his dislike for composite "T" grafting, because he believes that this is somewhat anti-anatomical. He feels that there are not many instances in the human body where a small artery arises at a right angle from another small artery, though these may arise from big arteries, like the aorta. Even the flow dynamics of the "T" graft and the consequent turbulence is not physiological. He is also concerned for the degree of relative flow in the two limbs of the "T" graft. He seems to accept that an acute angle with the use of "Y" grafting may be a valid technique. However, even here, the potential steal can occur if the degree of stenosis is unbalanced in the two arms. Dr Clifford is strongly in favor of simplifying grafting techniques and configurations to increase the uptake of multiarterial grafting.


Barlow CW. What is the best second conduit for coronary artery bypass grafting? With no silver bullet study we should not ignore good regular bullets when we get them! J Thorac Cardiovasc Surg. 2015;150(6):1535-1536.


1. A sensible no frills surgeon .. a good probing interview - well done Dr Yadava and Mr Barlow 2. Title is misleading - there were no real tips or tricks 3. At 9:58 - do you mean string sign of LIMA - I heard of LAD - probably an oversight 4. I would agree that the technique would benefit by simplification (which is the ultimate sophistication ! - Leonardo da Vinci) - but again not in all cases - one needs to customize - it is amazing that at even advanced levels of skill - one can be still be so dogmatic Thanks again
Congratulation to Mr. Barlow. However, tips for handling the RIMA should be emphasized- especially those, which may relate to bleeding concerns- vessel position behind the aorta. One stresses with good heart - based on experiences of hundreds of BIMA operations - not to use CLIPS in securing the side branches of the RIMA, rather to TRANSFIX them with 6 O prolene (not time consuming). Another practical point to fight off the fear of healing problem of the sternum. (Especially in case of diabetes, poor vascularization of the chest bone- previous angio is mandatory). During the phase of dissection of the two IMA, periodically the spreader should be loosened to decrease the tension on the tiny vessels of the bone, i.e.: to increase flow in the periosteum. The GREEN procedure is to be celebrated next year, the 50th anniversary. In the light of this fact it is more, than sad to acknowledge, that 5% of all CABG have been performed by using BIMA... But of course, interventional cardiologists had detoured millions of patients , but truly have failed to produce 15-20 years of follow up demonstrating functioning stented coronaries, as surgery (BIMA, TAR) long term results are available: (Tector, Taggart, etc.), not to talk the clear cut results of SYNTAX...
Thanx Dr Bedi, Yes it is String sign of LIMA. The Tip and Trick is to avoid complex configurations and do a straight Arterial grafting to LAD and Circumflex Coronary Arteries with a view to increasing its uptake. Thanx Dr Tarr, appreciate your valid comments and suggestions.
Thanj you for the video. Weel done. I practice in a modest midwest US community hospital and have embraced multiple arterial grafting since the mid 1990s, influenced by Tector, Taggart, Califiore. I prefer composite grafting for the flexibility, ease of 'T' or 'Y' anastomoses in the anterior mediastinum before cardiopulmonary bypass. I prioritize the BIMA on the left myocardium, and use SVG, or LRA for the RCA branches, or very distal LCA Cx branches. The IMA to IMA connection is quite easy, and reproducible. Skeletonization of the muscle and fascia adds to usable length and facilitates option. I leave the pleura as intact as possible. Obesity, DM are no longer obstacle to BIMA use. I've not experienced an increase in short term morbidity (incisional or otherwise). I apprerciate the various options available for those seeking to use BIMA more often. Look for reasons and ways to use BIMA, not reasons not to.
We are practising this kind of arterial revascularization for the last 26years and is amazing to see that still, the use of bilateral mammary is so low. The reason I suspect is the mental attitude of the 95 % of the surgeon that focus more on potential immediate postoperative problems related to the arterial conduits that on offering the patients long term precious benefits. The long term benefits are invisible today to the patient, to his cardiologist and the patient family wile short term problems are very visible and at time dramatic for all concern! There are a few tricks and tips on the technical aspect of the procedure. but in general Lima to LAD and Rima to the OM ( generally the first OM under the left atrial appendage is proximal enough to be comfortably approached) remain a standard approach .. The bleeding from the right mammary pedicle can be a concern and of difficult management, when the vessel is positioned under the Aorta and Pulmonary artery, but a suggestion is that rather than using the Liga clips the adoption of the harmonic scalpel will make this complication less likely. The T proximal anastomosis is a " monstrosity" the take-off of the free rima from the pedicled lima, should be similar to a take-off of a sleep road from a motorway. A gentle curve and better if is made to originate from the inferior aspect of the mammary. I suspect the concern of discrepancy in flow is a theoretical speculation. We know from physiology that by having multiple distal anastomosis there is a decrease in peripheral vascular resistance and as a consequence an increase in flow. One common error is to surgically prepare the right internal mammary very high so high that there is a real risk of unknowingly damaging the right phrenic If right phrenic palsy develops the patient will not grateful and your medical insurance either. lastly, I think that using the right mammary on the LAD and the Lima to the OM should be made a banned procedure!!

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