Giant leaps in surgical myocardial revascularisation

There have been dramatic advances in Coronary Artery Bypass graft surgery over the past 45 years. Coronary artery bypass grafting with saphenous vein grafts, was a highly reproducible procedure effective in alleviating angina. Its usefulness was compromised by myo proliferative change and atheromatous changes in the saphenous vein grafts resulting in reduced graft patency (50-60%) and survival (60-70%) at 10 years. Introduction of the left internal thoracic artery to the left anterior ascending artery was a significant advance resulting in less recurrent angina, fewer cardiac events improved patency (> 90%) and survival (80-90%) 10 years postoperatively. The left internal thoracic artery to the left anterior descending artery and saphenous vein graft to other vessels remains the standard operation today. Off-pump coronary artery bypass grafting provides equivalent results in routine patients but is of particular value in those with a calcified or atheromatous ascending aorta. Bilateral internal thoracic arteries are better than one internal thoracic artery, especially in the 10-20 year time frame. Multiple arterial grafting and total arterial grafting, facilitated by the use of bilateral internal thoracic arteries, T or Y-Grafts, use of the radial artery, right gastroepiploic artery and sequential anastomosis are consistently associated with even further improvements in symptoms and prognosis with survival greater than 90% at 10 years despite increase in patient age and co morbidities in recent series. Overall patencies for other arterial grafts at 10 years are - the right internal thoracic artery 90%, the radial artery 89%, and the right gastroepiploic artery 70%. Contemporary randomised studies consistently show superior patencies for arterial grafts over saphenous vein grafting. In summary, the left internal thoracic artery to the left anterior descending artery is essential; two or more arterial grafts are preferable, especially to the left anterior descending and the circumflex, and total arterial vascularisation is ideal.