Surgical Myocardial Revascularization With a Composite T-Graft From the Left Internal Mammary Artery—Comparison of the Great Saphenous Vein with the Radial Artery

Myocardial infarction due to coronary artery disease (CAD) is the leading cause of death worldwide. Percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) are the primary treatment modalities of choice for patients with CAD. Surgical myocardial revascularization remains the gold standard for patients with more complex CAD. For decades, surgical myocardial revascularization, using the in situ left internal mammary artery (LIMA) bypass for the anterior wall of the heart and single aortocoronary venous bypasses for the lateral and posterior areas of the heart, have been the standard cardiac surgical procedure. The dynamics of increasingly older and sicker patients, along with the efforts of cardiac surgeons to perfect the surgical treatment of CAD, have led to a variety of different surgical revascularization concepts. The primary goal is to complete revascularization of all coronary arteries compromised by significant stenoses. In many cardiac surgery centers, there is a trend toward extended arterial revascularization, especially in younger patients, because arterial coronary bypasses are considered to have better long-term openness rates than venous bypasses. In situ bypass with the LIMA to the left anterior descending (LAD) artery, combined with an additional arterial bypass with proximal anastomosis to the LIMA to the affected branches of the circumflex system and the right coronary artery, have been established by many surgeons. 
The proximal anastomosis of the right internal mammary artery (RIMA) as a free graft of the radial artery (RA) with the LIMA is performed in a T- or Y-shape (fig. 1), respectively, to be able to supply all cardiac regions with the limited available arterial graft material in terms of length. However, complete arterial revascularization cannot be achieved in every patient and should not be forced under any circumstances.