Safety and efficacy of sequential and composite arterial grafting to more than five coronary branches in off-pump coronary revascularisation: assessment of intra-operative and angiographic bypass flow

Objective: We sought to delineate the safety and efficacy of sequential and composite coronary artery bypass grafting (CABG) with exclusively arterial grafts to more than five coronary branches including small coronary vessels.

Methods: We reviewed the clinical records of 633 consecutive patients with 2617 bypass grafts who underwent total arterial off-pump complete revascularisation for three-vessel coronary regions without aortic manipulation. Group I consisted of 263 patients with a single in situ internal thoracic artery (ITA), while group II consisted of 370 patients with bilateral in situ ITA. Subgroups I-A and I-B consisted of 242 patients with three or four distal anastomoses and 21 patients with more than five distal anastomoses, respectively. Subgroups II-A and II-B consisted of 199 patients with three or four anastomoses and 171 patients with more than five anastomoses, respectively.

Results: The early mortality and morbidity rate and the angiographic graft patency in the groups I and II were similar, while the rate of antegrade flow in group II (92.4%, 1349/1460) was significantly higher than that in group I (89.4%, 638/714, p=0.02). Intra-operative graft flow measured at the proximal portion of the in situ ITA in group II (79+/-35 ml min(-1)) was significantly larger that that in group I (53+/-31 ml min(-1), p<0.0001). The patency rate of bypass grafts to small coronary vessels (1.25 mm or less in diameter) was 97.4% (626/643). The early mortality rates in subgroups I-A and I-B were 1.2% (3/242) and 0% (0/21), respectively (p=0.61). The graft flow and incidence of competitive flow was comparable in subgroups I-A and I-B. The early mortality rates in subgroups II-A and II-B were 0.5% (1/199) and 0.6% (1/177), respectively (p=0.91). The graft flow to five or more coronary branches (81+/-35 ml min(-1)) was significantly greater than that to three branches (67+/-30 ml min(-1), p=0.01).

Conclusions: For more than five target branches, sequential and composite arterial grafting with the ITA and a radial artery was safe and reliable, even when the target vessels were small. Bilateral in situ ITA would be feasible for the patients with multiple stenotic lesions, because of abundant bypass flow and less incidence of competitive flow. Durable completeness of revascularisation can be expected.