Arterial revascularisation with two or more arterial conduits

In the last decade arterial revascularisation has become more popular due to the routine use of the left internal mammary artery (LIMA). Left internal mammary artery grafting to the left anterior descending (LAD) coronary artery is widely recognised as the most important single determinant of improved results from coronary revascularisation. However, a question remains as to whether results can be further improved by using other arterial grafts in territories other than the LAD, or increasing the number of arterial anastomoses per patient. Although long-term results do not conclusively prove that arterial anastomoses to vessels other than the LAD increase the quality of late results, there are no results to disprove this hypothesis. In our institution we ensure that all mammary grafts are placed on the left coronary system. To achieve this we use skeletonised mammary conduits to increase graft length, and Y grafts to minimise the number of aortic anastomoses. We use the gastroepiploic artery as an in situ graft. With the radial artery we avoid aortic anastomoses by joining the radial artery to the internal mammary artery. With the increased use of skeletonised internal mammary arteries we use the inferior epigastric artery less frequently. This strategy for arterial revascularisation is based on results of 2236 patients undergoing myocardial revascularisation between October 1991 and June 2000. Of these, 75% had total arterial revascularisation where the early mortality was 2% and survival 93% at 7 years. We conclude that total arterial revascularisation using bilateral mammary grafts supplemented by other arterial conduits provides optimal results for myocardial revascularisation.