Techniques and Results of Multiple Arterial Bypass Grafting: Towards More "Curative" Coronary Revascularizations

Surgical coronary bypass has evolved continually, and most analyses currently favor performing coronary grafts with autologous living arterial conduits to obtain better long-term patencies and clinical outcomes. With bilateral internal mammary artery grafts and both radial arteries, 4 excellent arterial conduits exist for creating "all-arterial" revascularization in the majority of multivessel disease patients, including those with valve disorders. Using contemporary surgical techniques, it is possible to obtain greater than 95% overall early graft patencies that translate into better late outcomes, including improved survival, freedom from myocardial infarction, fewer percutaneous coronary interventions, and redo coronary bypass procedures. The overall goal is to revascularize the 2 most important coronary systems with internal mammary artery grafts, and the rest with radial arteries, depending on the anatomy, experience, and choice of the surgeon. Using highly validated management strategies, early postoperative complications, including the incidence of sternal infections, are extremely uncommon, and in many practices, multi-arterial grafts currently are used in the majority of multivessel patients, including those with concomitant valve disease. Because patencies and outcomes are significantly better than with saphenous vein bypass or percutaneous coronary interventions, referring physicians frequently favor multi-arterial bypass procedures as the primary therapy for patients with prognostically serious multivessel disease. Thus, coronary bypass using predominantly autologous arterial conduits should play an increasingly important role in the future management of severe coronary atherosclerosis.