The 10 Commandments for Multiarterial Grafting

Take Home Message

The guidelines are given so that the use of mutiarterial grafts (MAG), is used more frequently in coronary arterial bypass surgery (CABG), new generations of surgeons, have to know and start from the basics so that they adapt more in these techniques, and especially if we provide a greater long - term benefit to our patients.


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The 10 Commandments for Multiarterial Grafting

Rami Akhrass, MD and Faisal G. Bakaeen, MD 

Innovations. 2021 00(0)1-5 doi:10.1177/15569845211003094


Keywords: Coronary Arterial Bypass Graft (CABG), Multiarterial Grafting (MAG), Left Internal Mammary Artery (LIMA), Saphenous Vein Graft (SVG), Bilateral Internal Torácica Artery (BITA), Artery Radial (AR), Left Anterior Descending (LAD)

My commentary by Jose A. Heredia, MD

After the Syntax trial in 2009 (1), the use of arterial grafts was emphasized and this as one of the possible explanations for the improvement in results in patients undergoing surgery of CABG. In previous years Cameron et al. proved that SVG exhibit lower patency and higher mortality arte compared with those of IMAs. They saw that the VSG was occluded up to 50% at 10 years after its implantation (2). Unlike anastomosis of the LIMA- LAD that the 15 - year survival is around 95 to 98%, a feature that was attributed to their reduced incidence of atherosclerosis develoment (< 4% of cases)( 3,4).

The observational evidence strongly suggests, that the use of 2 or 3 arterial grafts at the time of CABG is associated, with long-term survival benefits (5). As already mentioned, the anastomosis of LIMA - LAD is the standard goal in the management of the CABG, The second arterial graft should be considered depending on the life expectancy of the patient, the risk factors of complication of sternal wound, coronary anatomy, degree of stenosis of the target vessel, the quality of the graft, and surgical experience (6).

But the use of arterial grafts in coronary artery bypass surgery (CABG) , has been somewhat equivocal and not much used by cardiosurgeons. but why is it not used?

The paper by Gaudino et al. (7) is forceful: they have seen that in the USA more that 80% of the grafts are saphenous vein and less than 7% of patients undergoing CAGB receive more than one Arterial graft (7), and about 20% in Europe (8). As the authors of this paper say well, there are other factors to consider when deciding to utilize the use of BITA, such as poor radiation exposure, use of steroids or immunosuppression, diabetic women receiving insulin, fragile patients with osteoporosis, heavy smokers with COPD and the nutritional status of the patient are also all very important; and in addition to this, the reluctance of using BITA grafting routinely stem is sharpened by several factors, the mayor ones being that BITA grafting is technically more challenging and time consuming and is associated with small, but increased risk of sternal wound infections (9-11). This causes the surgeon to leave his comfort zone, which he is used to. The risk of sternal wound infection can be minimized, with a good dissection from both ITAs, in skeletonization or semi- skeletonization form, and this has been seen both in diabetic and non-diabetic patients (12-15). Although the control of your blood sugar should be adequate to reduce the risk of infection.

In my technical experience, we emphasize the harvesting of BITA in semiskeletonization form 16, placing vascular hemoclips close to the emergence of their collateral and removal of xiphoid cartilage at the end of surgery and initiating sternal closure (17-19). The distal harvesting of BITA dose not do beyond its bifurcation (the superior epigastric artery and the musculopherenic artery), and in the proximal portion we release it 1 cm below the subclavia vein, so as not to injure phrenic nerve, with the intention of linking hig collateral branches and we do not have blood flow theft. Adding that doing this way facilitates the mobilization and displacement of grafts to distal areas. Assuming length and deree of lesion of the diseased vessel, we anastomate BITA to the left system, preserving its native flow, to optimize it. In the right system we use VSG (no touch technique) or AR. Prioritize the use of the extracorporeal pump for the implant of grafts and we agree with the authors that the technique must be mastered before making variations in daily practice, likewise the use of the post-surgical flow meter is mandatory to ensure success in the realization of your anastomoses.

In special circumstances, specifically emergency procedures we do not perform the use of BITA, since emergency revascularization in the context of ACS or when complications have arisen due to coronary intervention, in these cases, it is usually vital to ensure an immediate and sufficient coronary perfusion, that the ducts arterial vessels can not always guarantee (20). Finally, we would include an eleventh commandment, the proper management of anesthesia in the surgical room, maintaining good myocardial perfusion as well as posoperative care of de patient, committing amog other functions, to the rational use of inotropic vasopressor, generating that grafts do not spasm and dysfunction.


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