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Ann Thorac Surg 2006;82:73
© 2006 The Society of Thoracic Surgeons
Midwest Heart Surgery Institute, 2901 W Kinnickinnic River Parkway, Suite 511, Milwaukee, WI 53215
(Email: tector{at}execpc.com).
Multiple arterial grafts improve outcomes in patients with obstructive coronary artery disease, particularly after 10 years, and they reduce the need for reintervention in patients when compared with bypassing with a single internal thoracic artery and saphenous vein grafts (SVGs). Total coronary artery revascularization has become possible in many patients by using bilateral internal thoracic artery grafts (ITA), "T" or "Y" grafts, the radial artery (RA), the gastroepiploic artery (GEA), and the construction of composite arterial grafts.
Dr Takahashi and associates [1, 2] are well versed in the utilization of GEA as a bypass graft for coronary revascularization with the aorta no-touch technique. The current report [3] is an expansion of their vast experience with utilization of abdominal arteries as composite bypass conduits focusing on a difficult subset of patients with porcelain aortas. The techniques of utilizing abdominal visceral arteries as inflow conduits and the mobilization of the triangular ligament of the left lobe of the liver to maximize conduit length and eliminate kinking are well thought out and clearly described. This information can be beneficial to the surgeon when reoperating patients with extensive and diffuse vascular disease involving the aorta. However, it should be noted that in many of the cases presented, alternative strategies could have been easily used. Although the authors avoid the usage of "T" grafts because they state there is a high incidence of string sign bilateral ITA grafting and "T" or "Y" grafts have clearly demonstrated an acceptable early and late mortality [4, 5]. Moreover in 6 of the cases presented, SVGs were utilized as part of the composite graft. In 8 other patients who underwent primary coronary artery bypass grafting with abdominal visceral arteries as inflow grafts, 2 had SVG aortic proximal anastomoses and 3 had composite SVG grafts. It should be noted that in each of these cases that if the aorta was truly "porcelain," then there are other inflow options for the construction of composite arterial or SVG grafts. These include the innominate artery, descending aorta, and the construction of an ITA "T" or "Y" graft.
Even though Takahashi and associates [1, 2] have vast experience in the utilization and creation of abdominal visceral grafts, most cardiothoracic surgeons are much more comfortable with avoidance of entering the abdominal cavity. They would rather create inflow anastomoses within the mediastinum or left chest. Moreover, the abdominal visceral grafts could be threatened if a later abdominal operation was required for cancer, inflammatory process, or rupture of a hallow viscus. The author's conclusions are based on a small number of patients and sufficient data on graft quality is not available. The authors have shown that in experienced hands the use of abdominal visceral arteries for inflow conduits is safe and should be part of the thoracic surgeon's armamentarium with limited graft inflow options.
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