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Background We compared early outcomes, at a single academic institution, of implementing full coronary revascularization in coronary artery bypass grafting using multiarterial Y-composite grafts with multiple sequential anastomoses. Methods and Results Clinical records of 425 consecutive patients who underwent coronary artery bypass grafting using Y-grafting with left internal mammary artery and radial artery (Y-RA group) or right internal mammary artery (Y-RIMA group) from 2015 to 2019, were reviewed. These were compared with the institutional experience of isolated coronary artery bypass grafting cases (in situ on pump/off pump) for the same period of time. When comparing the 4 groups, the Y-RIMA/RA groups revealed a higher number of distal anastomosis than the in situ on- or off-pump groups. When the number of distal arterial anastomosis was analyzed, there was a superiority of using the Y-configuration compared with the in situ approach. Moreover, there were no significant differences among groups for mortality and/or major adverse cardiac and cerebrovascular events in hospital or at 30-day follow-up. A subanalysis comparing the Y-RIMA group with the Y-RA group showed that complementary grafts to the Y-construct were required to accomplish full revascularization more frequently in the Y-RIMA group. Full-arterial revascularization was achieved in 92.2% of the Y-RA group and 72.0% of the Y-RIMA group ( P <0.001). In 82.8% of the Y-RA group and 30.8% of the Y-RIMA group, revascularization was completed as an anaortic procedure ( P <0.001). Conclusions The 2 types of arterial Y-composite grafting were able to be introduced in the routine practice of our institution showing comparable results to the established institutional practice. This procedure allowed for more arterial distal anastomosis to be performed safely without compromising outcomes.

Objectives: There is growing interest in the use of bilateral internal thoracic arteries (BITAs) for myocardial revascularization. This study sought to compare the balance between early benefits and long-term outcomes of skeletonized or non-skeletonized conduits and to determine whether differences in outcomes are affected by other patient risk factors., Methods: BITAs were used in 1504 cases with either SK or NSK conduits. Propensity matching was completed using 22 covariates identifying 441 pairs of patients. The primary outcomes are the sternal wound infection in the short term and the composite outcome of all-cause mortality, myocardial infarction, revascularization and congestive heart failure. Outcomes were assessed using paired analysis techniques and Cox proportional hazards regression models stratified using the matched pairs., Results: Incidences of in-hospital mortality and perioperative myocardial infarction were similar in both groups. There were fewer sternal wound infections in the SK group (5.4 vs 9.1%, P = 0.033). Homogeneity testing of the relative risk estimates confirmed that there was a protective effect of skeletonization in men that was not demonstrated in women (P = 0.020). SK had a protective effect in diabetics not seen in non-diabetics (P = 0.048). The composite outcome of all-cause mortality, myocardial infarction, revascularization and congestive heart failure at a median of 5.6 years was comparable in both groups (hazard ratio 0.81, 95% confidence interval 0.57-1.15)., Conclusion: Skeletonization results in better perioperative outcomes and comparable cardiac outcomes in patients undergoing BITA with the greatest benefit in men and patients with chronic obstructive pulmonary disease.

Purpose of Review: Bilateral internal thoracic arteries (BITAs) have demonstrated their superiority over all other types of graft in terms of patency and survival benefit. BITA implementation requires the surgeon's evaluation of the patient's coronary anatomy and demographics. There is no single ideal approach to BITA utilization, but instead a variety of configurations that can be implemented based on the patient characteristics., Recent Findings: This article details the advantages and disadvantages of several BITA configurations in the setting of left-sided myocardial revascularization and right-sided myocardial revascularization. Different BITA configurations will be described and will ultimately serve as a guide to avoiding technical difficulties and helping surgeons construct decision-making trees to direct the implementation of BITA grafts., Summary: BITA grafting provides long-term clinical benefit over conventional grafting. Efforts should be directed toward a more efficient use of internal thoracic arteries, reducing the need for a third complementary graft, and toward identification of the best alternative to the saphenous vein graft as the third graft material for complete revascularization. Surgeons should ask their cardiologists to be as accurate as possible regarding the severity of the coronary lesion. If the severity of the lesion is not obvious upon an informal qualitative assessment, a functional flow reserve of the lesion should be performed, in order to identify the optimal graft.

Objectives: Bilateral internal thoracic artery (BITA) bypass provides long-term survival benefits over strategies that use single internal mammary arteries during coronary artery bypass grafting (CABG). However, the rate of adoption of this strategy remains very low. Moreover, optimal BITA configuration and the use of cardiopulmonary bypass still remain a matter of debate. We investigated the long-term results of a coronary revascularization strategy, utilising exclusively BITA-Y composite grafts using off-pump platform and sequential anastomoses., Methods: From March 2000 to November 2010, all isolated CABGs (n = 2057 patients) were performed using an off-pump platform. Of these, 1240 patients had three-vessel coronary disease (60.3%), with severe coronary disease defined as >70% stenosis and three-vessel disease defined as the presence of 3 vessels with >70% stenosis, of which 784 (63.2%) were treated with two internal thoracic artery grafts in a composite fashion with a no-touch technique avoiding any manipulation of the ascending aorta. The primary end-point was the long-term survival and freedom from major adverse cerebral and cardiovascular events (MACCEs). The follow-up was completed using the annual anniversary method., Results: The mean number of anastomoses per patient was 4.0. Hospital mortality occurred in 8 patients (1%). Ninety-day stroke, myocardial infarction and repeat revascularization rates were respectively 0.7, 0.6 and 0.3%. The mean follow-up was 6.6 ± 3.2 years and was obtained for 99% of the patients. The 5- and 10-year survival rates were 93.1 ± 1.6 and 83.8 ± 3.2%, respectively. Freedom from major adverse cardiac and cardiovascular event (MACCE) at 5 and 10 years was: cardiovascular event: 98.7 ± 1.6 and 96.1 ± 1.7%, documented ischaemia: 90.5 ± 2 and 80.2 ± 3.8%, revascularization: 94.0 ± 1.5 and 89.7 ± 2.5%, infarction: 98.1 ± 0.8 and 96.0 ± 1.6%. The patency of left and right internal thoracic artery in a BITA-Y configuration was 91.1 and 88.8% at 5 ± 3 years, respectively., Conclusion: Performance of an exclusive composite BITA off-pump revascularization strategy optimal and sustained long-term protection from MACCE., (© The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Bilateral internal thoracic arteries (BITA) have demonstrated superior patency and improved survival in patients undergoing coronary artery bypass grafting. However, the optimal configuration for BITA utilization and its effect on long-term outcome remains uncertain., Methods and Results: We randomly assigned 304 patients undergoing coronary artery bypass grafting using BITA to either in situ or Y grafting configurations. The primary end point was 3-year angiographic patency. Secondary end points included major adverse cardiac and cerebrovascular events (ie, death from any cause, stroke, myocardial infarction, or repeat revascularization) at 7 years. More coronary targets were able to be revascularized using internal thoracic arteries in patients randomized to Y grafting versus in situ group (3.2±0.8 versus 2.4±0.5 arteries/patient; P<0.01). The primary end point did not show significant differences in graft patency between groups. Secondary end points occurred more frequently in the in situ group (P=0.03), with 7-year rates of 34±10% in the in situ and 25±12% in the Y grafting groups, driven largely by a higher incidence of repeat revascularization in the in situ group (14±4.5% versus 7.4±3.2% at 7 years; P=0.009). There were no significant differences in hospital mortality or morbidity or in late survival, myocardial infarction, or stroke between groups., Conclusions: Three-year systematic angiographic follow-up revealed no significant difference in graft patency between the 2 BITA configurations. However, compared with in situ configuration, the use of BITA in a Y grafting configuration results in lower rates of major adverse cardiovascular and cerebrovascular events at 7 years., Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01666366., (© 2016 The Authors.)

Purpose of Review: Competition flow is a common finding in arterial grafting. This phenomenon can lead to graft occlusion., Recent Findings: Internal thoracic arteries are the best equipped arterial conduit to withstand the competition flow thanks to their endothelial function. Radial as well as right gastroepiploic arteries support much less flow competition because of their different anatomy, histology and endothelial function than that of internal thoracic artery, leading to spasm and occlusion. Therefore, these two arterial conduits should be used only in case of critical lesion to avoid graft occlusion. Saphenous vein graft is the only conduit that is not significantly affected by flow competition, mainly because of its nonresistivity and common reimplantation in the aorta. Graft configuration is the second important factor influencing the equation between graft flow and native coronary flow. Therefore, composite grafting should be reserved for the case of severely stenotic coronary target, especially if multiple arterial sequential anastomoses have to be performed on the lateral-inferior wall of the heart. Finally, an accurate tool such as the fractional flow reserve to evaluate the stenosis severity should be the milestone of coronary surgery in order to decrease the rate of flow competition and improve arterial grafting functionality., Conclusion: Competition flow plays a crucial role in arterial grafting functionality. Grafting strategy should address this by appropriate graft choice and configuration in order to avoid graft attrition.

Objectives: The long-term advantages of multiple arterial grafts, particularly a third arterial conduit, for coronary artery bypass (CABG) are not clear. This study was designed to test whether multiple arterial grafts would provide better long-term outcomes when compared with approaches using fewer arterial conduits., Methods: Between 1985 and 1995, prospective data were collected for 588 patients undergoing isolated CABG at our institution. We examined long-term survival and freedom from cardiac death. The primary analysis compared patients receiving bilateral internal thoracic artery (BITA) vs. single ITA (SITA). In a subgroup analysis, BITA patients receiving a right gastroepiploic artery (RGEA) were compared with those receiving a saphenous vein graft (SVG) as a third conduit. Cox proportional hazard modelling was used to adjust for relevant confounders. The Kaplan-Meier method was used to create survival curves over the follow-up period., Results: The mean age was 59 ± 9 years and 49% received BITA. Mean follow-up was 16.1 ± 5.4 years. Multivariable analysis revealed that overall survival [hazard ratio (HR): 0.74, P = 0.017] and cardiac survival (HR: 0.61, P = 0.004) was significantly improved in the presence of BITA compared with SITA. The survival at 10 and 20 years was 90.2 ± 3.4 and 56.9 ± 6.4% for the BITA vs. 82 ± 4.4 and 40.9 ± 6% for the SITA, respectively. In the subgroup of BITA patients, those receiving the RGEA as a third conduit had superior overall survival (HR: 0.41, P = 0.0032) and cardiac survival (HR: 0.18, P = 0.004) compared with those receiving an SVG. The survival at 10 and 20 years was 98.9 ± 2 and 68.9 ± 18% for the BITA/RGEA vs. 87.2 ± 4.6 and 50.3 ± 7% for the BITA/SVG, respectively., Conclusions: In a single-institution experience, the use of multiple arterial grafting is independently associated with superior outcomes. Furthermore, the use of a third arterial conduit (RGEA) targeted to the right coronary artery should be considered to improve long-term survival.

Objective: Saphenous vein, in situ right gastroepiploic artery, and right internal thoracic artery grafts are routinely used to revascularize the right coronary artery. Little is known about the predictive value of objective preoperative angiographic parameters on midterm graft patency., Methods: We prospectively enrolled 210 consecutive patients undergoing coronary revascularization. Revascularization of the right coronary artery was randomly performed with the saphenous vein grafts in 81 patients and the right gastroepiploic artery in 92 patients. During the same study period, 37 patients received right coronary artery revascularization with the right internal thoracic artery used in a Y-composite fashion. All patients underwent a protocol-driven coronary angiogram 3 years after surgery. Preoperative angiographic parameters included minimum lumen diameter percent stenosis measured by quantitative angiography. A graft was considered "not functional" with patency scores of 0 to 2 and "functional" with patency scores of 3 or 4., Results: Angiographic follow-up was 100% complete. A significant difference in the distribution of flow patterns was observed in the 3 groups. In multivariate analysis, the use of a saphenous vein graft was associated with superior graft functionality compared with the other conduits (odds ratio, 6.1; 95% confidence interval, 2.4-15). Graft function was negatively influenced by the minimum lumen diameter (odds ratio, 0.11; confidence interval, 0.05-0.25). In the right gastroepiploic artery and right internal thoracic artery groups, the proportion of functional grafts was higher when the minimum lumen diameter was below a threshold value in the third minimum lumen diameter quartile (0.64-1.30 mm)., Conclusions: Preoperative angiography predicts graft patency in the right gastroepiploic artery and right internal thoracic artery, whereas the flow pattern in saphenous vein grafts is significantly less influenced by quantitative angiographic parameters., (Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: The manner in which a blood vessel is for used as a coronary graft may be important in maintaining a viable and functional endothelial lining. Composite internal thoracic arteries (ITAs) in a Y-graft configuration are characterized by the connection of an in situ left ITA with preserved innervation and lymphatics and of a free semi-skeletonized right ITA., Methods: To determine whether endothelial function differs between left and right ITA segments in a Y-graft configuration, 11 patients were studied 3 years after surgery. The endothelium-dependent vasodilator substance P was selectively infused (1.4-22.4 pmol min⁻¹ in doubling dose increments) in the ostium of ITA Y-grafts. A maximal endothelium-independent vasodilatory response was then obtained by intragraft infusion of 2mg isosorbide dinitrate (ISDN). Biplane angiograms obtained at 3-min intervals using an automated contrast injection system with fixed preset volume and pressure parameters were analyzed off-line using a quantitative analysis system (CAAS, Pie Medical)., Results: A similar dose-dependent vasodilatory response to substance P was observed in the left and in the right ITA. No difference in maximal endothelium-dependent response to substance P (7.4 ± 4.3% in the left ITA and 8.1 ± 5.3% in the right ITA) or in maximal endothelium-independent response to ISDN (12.2 ± 4.4% in the left ITA and 10.6 ± 8.1% in the right ITA) was observed., Conclusions: The endothelium-dependent and the endothelium-independent vasodilator capacity of the two branches of a Y-graft ITA configuration appear similar 3 years after bypass surgery. This suggests that the preservation of the ITA pedicle does not significantly affect basal vasomotor tone, long-term endothelial function, or vasodilator reserve., (Copyright © 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

Background: Selected patients, presenting for reoperative coronary surgery with patent internal thoracic arteries (ITAs), may benefit from techniques to salvage and reuse these ITA grafts. We have termed this practice the recycling of ITAs. The purpose of this study is to report our short-term and midterm results using various recycling techniques., Methods: Between April 1996 and February 2009, 60 patients underwent ITA recycling at our institution. Information regarding survival and cardiac events was obtained from a prospectively maintained, institutional database. Survival and freedom from major adverse cardiac events were calculated using Kaplan-Meier analysis. Mean follow-up duration was 60 ± 36 months., Results: Mean age was 64 ± 9 years and the mean time to reoperation was 117 ± 68 months. The patent ITA served as an inflow for a composite Y graft in 39 patients and was distally reimplanted on the same coronary vessel in 9 patients. A combination of these two techniques was used in 8 patients. Other techniques were used in the remaining 4 patients. Freedom from cardiac death was 93% ± 7% and 85% ± 9% at 1 and 5 years and freedom from major adverse cardiac events was 93% ± 7% and 81% ± 11% at 1 and 5 years, respectively., Conclusions: Recycling of ITA grafts during reoperative coronary artery bypass grafting is safe and feasible in selected patients. These techniques can be useful in selected young patients to avoid saphenous vein graft or in patients with a lack of graft conduits., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Composite Y-grafts, using the left internal thoracic artery as the inflow, allow a more efficient use of conduits without the need to touch a diseased ascending aorta. Among other conduits, the saphenous vein graft may be an alternative to the radial artery in elderly patients., Patients and Methods: We evaluated the hemodynamic characteristics of 17 composite Y-grafts made with the left internal thoracic artery anastomosed to the left anterior descending coronary artery in all cases and with either the free right internal thoracic artery (RITA group, n = 10) or a saphenous vein graft (SVG group, n = 7) implanted proximally to the left internal thoracic artery and distally to the circumflex territory 6 months after the operation., Results: At baseline, the pressure gradient measured with a 0.014-inch pressure wire was minimal between the aorta and the internal thoracic artery stem (2 +/- 1 mm Hg), the internal thoracic artery and left anterior descending (4 +/- 2 mm Hg), the internal thoracic artery and left circumflex (3 +/- 1 mm Hg), and the saphenous vein graft and left circumflex (2 +/- 2 mm Hg). During hyperemia induced by adenosine, the pressure gradient increased significantly to 6 +/- 2 mm Hg in the internal thoracic artery stem, 9 +/- 4 mm Hg in the internal thoracic artery and left anterior descending artery, 9 +/- 3 mm Hg in the internal thoracic artery and left circumflex, and 7 +/- 4 mm Hg in the saphenous vein graft and left circumflex. Fractional flow reserve was 0.94 +/- 0.02 in internal thoracic artery stem, 0.90 +/- 0.04 mm Hg in the internal thoracic artery and left anterior descending, 0.91 +/- 0.03 mm Hg in the internal thoracic artery and left circumflex, and 0.92 +/- 0.06 mm Hg in the saphenous vein graft and left circumflex. No difference between the two types of composite Y-grafts was observed for pressure gradients or fractional flow reserve measured in internal thoracic artery stem or in distal branches., Conclusions: Composite Y-grafts with saphenous vein or right internal thoracic arteries allow similar and adequate reperfusion of the left system with minimal resistance to maximal flow and an even distribution of flow in both distal branches., (2010 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Y-graft configuration with left and right ITA (RITA) allows complete arterial revascularisation. We previously compared two types of ITA revascularisation in a prospective randomised trial with a systematic 6-month angiographic follow-up study. The present study is a secondary analysis of these populations to evaluate the angiographic parameters influencing the function of the RITA used in a Y-graft configuration., Methods: The functionality of the RITA was based on the TIMI grade flow: in TIMI grade 0 (occluded graft) and in TIMI grade 1 or 2 (balanced flow), the RITA was considered not functional. RITA was considered functional when a complete opacification (TIMI 3) of all anastomoses of the targeted coronary vessels was observed., Results: A total of 25.3% of RITA were not functional. In univariate analysis, the number of anastomoses, the type and size of grafted coronary segments and the severity of the native coronary stenosis influenced ITA function. In multivariate analysis, the function of the RITA was positively influenced by the number of anastomoses (OR=0.5, 95% CI: 0.4-0.7), and a severely narrowed first circumflex (OR=39.1, CI: 8.1-189.2) and negatively by the presence of a grafted intermediate coronary artery (OR=0.01, CI: 0.003-0.06), and of a grafted RCA (OR=0.08, CI: 0.02-0.35). The size of targeted vessel, history of infarction and regional myocardial function did not influence ITA function., Conclusions: In this systematic angiographic study, the function of the RITA used as a Y-graft was significantly improved when used on several branches of the circumflex artery or on a severely narrowed first circumflex. Grafting of the intermediate branch or of a RCA has a negative prognostic influence on graft function.

Background: Bilateral internal thoracic arteries (BITA) demonstrated superiority over other grafts to the left coronary system in terms of patency and survival benefit. Several BITA configurations are proposed for left-sided myocardial revascularization, but the ideal BITA assemblage is still unidentified., Methods and Results: From 03/2003 to 08/2006, 1297 consecutive patients underwent isolated bypass surgery in our institution. 481 patients met the inclusion criteria for randomization, and 304 (64%) were randomized. Patients were allocated to BITA in situ grafting (n=147) or Y configuration (n=152) then evaluated for clinical, functional, and angiographic outcome after 6 months and 3 years. Patient telephone interviews were conducted every 3 months and a stress test performed twice yearly under the referring cardiologist's supervision. Angiographic follow-up was performed 6 months after surgery. The primary and secondary end points were, respectively, major adverse cerebrocardiovascular events (MACCE) and the proportion of ITA grafts that were completely occluded at follow-up angiography. More arterial anastomoses were performed in patients randomized to the Y than the in situ configuration (3.2 versus 2.4; P<0.001). No significant difference between the 2 groups in terms of hospital mortality or morbidity was found. At follow-up, there was no significant difference in any MACCE rate between the 2 groups. 450 out of 464 anastomosis (97%) in the BITA Y group and 287 of 295 (97%) in the BITA in situ group were controlled patent (P=0.99)., Conclusions: Excellent patency rates were achieved using both BITA configurations with no significant differences in terms of MACCE up to 19 months postoperatively, but longer-term results remain to be established.

Objective: Sequential internal thoracic artery (ITA) grafting allows a more complete arterial revascularization of the myocardium. We wanted to verify whether the excellent clinical and angiographic short term results reported by us before where maintained over 10 years and more., Methods: the first consecutive 500 patients having received at least one sequential ITA graft between October 1985 and August 1991 were reviewed. Age averaged 61 years. Fifty-three patients had a left ventricular ejection fraction less than 40%, 117 were not elective, 35 (7%) were reoperations, 56 (11%) had diabetes. In total 2156 anastomoses were constructed (4.3/patient), among them 1367 arterial anastomoses (2.7/patient) and 1150 sequential ITA anastomoses (2.3/patient). The clinical follow-up was 97.4% complete and averaged 9.6 (range 8.6-13.6) years. One hundred and sixty-one patients consented to a late angiographic restudy after a mean interval of 7.4 (range 1-12.2) years., Results: At 5 and 10 years, 89 and 72% of the patients were still alive. At 10 years 82% are still asymptomatic and 71% free of any type of ischaemia. Only four patients (0.8%) needed a repeat surgical revascularization, and 11 (2.3%) a percutaneous coronary angioplasty. At 5 and 10 years, 92.8 and 69% of the patients remained free of any cardiac event. Overall, 95.5% of the arterial anastomoses were patent and 96.1% of the sequential ITA were patent. There was a significant difference between the patency rate of pedicled ITA and free ITA anastomoses: 96.3 vs. 86.5% (P=0.02). There was no difference in patency between left ITA and right ITA anastomoses for the LAD and Cx areas. Sequential ITA anastomoses showed excellent patency rates to all coronary vessels but the very distal circumflex and the distal branches of right coronary artery (85%). There was no significant difference between the patency of the proximal and the distal sequential ITA anastomoses. The sequential anastomoses constructed in the length tend to remain more patent than the diamond-shaped ones: 97.2 vs. 91.5% (P=0.004)., Conclusions: Sequential ITA grafting optimizes arterial revascularization. The long-term patency is excellent, is identical to that of single ITA grafting, and appears not much different from postoperative patency. The need for repeat surgical and interventional revascularization has been extremely low: 3.1% over the whole follow-up.