Conduits for coronary artery bypass surgery: the quest for second best

Coronary artery bypass grafting is one of the most outstanding surgical achievements of the 20th century. Over its 50-year history patient outcomes have become excellent owing to technical refinements, myocardial protection, the use of antiplatelet and anticholesterol drugs, and the continued search for better conduits. The performance of conduits used for bypass remains the most important prognostic factor, with the left internal mammary artery being the conduit of choice due to its excellent patency rates. There is, however, uncertainty with regards which conduit is second best. The recent resurgence of the radial artery has led to an increase in its use as surgeons lean towards total arterial revascularization but there is emerging evidence that the performance of the long saphenous vein graft is improving. Furthermore, bilateral internal mammary artery grafting is preferred in some centres as an alternative approach to total arterial revascularization, with multiple reports of superior long-term event-free outcome with its use. This extensive review of current literature reveals an absence of clear consensus as to what mix of conduits provides the best long-term outcomes. The quest for second best continues. Arterial conduits appear to be superior when grafted to tight stenosis but veins remain popular with surgeons. More supportive evidence from the concluding Arterial Revascularization trial and the Radial Artery Patency and Clinical Outcomes trial should guide future practice.