BACKGROUND: We evaluated the prevalence and outcomes of competitive flow in the terminal right coronary artery (RCA) graft after coronary artery bypass grafting (CABG) with left internal thoracic artery-based Y-composite grafting at 1 year after CABG.
METHODS: We enrolled 642 patients who underwent Y-composite graft-based off-pump CABG with in situ left internal thoracic artery between 2014 and 2022. All patients underwent early postoperative angiography, and 1-year postoperative angiography was performed in 81.2% (522/642) of patients.
RESULTS: The early occlusion rate of distal anastomoses with Y-composite graft was 2.1%. Competitive flow was observed in 69 of 642 anastomoses (10.7%). Multivariate analysis showed that the maximal degree of target vessel stenosis (odds ratio [OR], 0.909; 95% CI, 0.886-0.931; P < .001), maximal degree of non-terminal target vessel in Y-arm grafts (OR, 1.103; 95% CI, 1.047-1.172; P < .001), and diabetes mellitus (OR, 0.535; 95% CI, 0.303-0.934; P = .029) were factors associated with competitive flow to the RCA territory. The optimal cutoff value for the degree of terminal target vessel stenosis predicting competitive flow to the RCA territory was 92.5%. The 1-year graft failure rate of anastomoses with competitive flow of the terminal anastomosis was 30.9% (17/55). The presence of competitive flow on early angiography was the only factor associated with graft occlusion of the terminal anastomosis at 1 year (OR, 2.339; 95% CI, 1.165-4.481; P = .013).
CONCLUSIONS: For terminal anastomosis to the RCA territory in Y-composite graft-based CABG, the presence of competitive flow on early angiography was associated with graft occlusion of the terminal anastomosis at 1 year. Notably, 30.9% of these grafts demonstrated failure on 1-year follow-up angiography.

OBJECTIVE: To evaluate the clinical effectiveness of bilateral internal mammary artery grafting over long-term (15 years) postoperative period.
METHODS: There were 276 patients divided into two groups: 135 patients (group A) underwent bilateral internal mammary artery grafting and 141 patients (group B) underwent unilateral internal mammary artery grafting together with venous bypass grafts. On-pump surgeries and cardioplegia, parallel CPB and on-pump procedures were performed in equal proportions. Mean age of patients was 57.3±7.6 years. Diabetes mellitus was detected in 21 (15.5%) and 24 (19.1%) patients, respectively (p>0.05). Mean LV ejection fraction was 55.4±9.9%, revascularization index - 3.1±0.8 and 3.0±0.7, respectively. In the 1st group, 43 patients underwent bilateral internal mammary artery grafting alone. Autovenous grafts were additionally used in other 84 patients.
RESULTS: Ten-year survival exceeded 90% in both groups. Freedom from adverse cardiac events after 15 years was significantly higher in group A (77.3% vs. 59.3%, p=0.018). In group A, 16 patients died throughout this period due to cancer (50%), myocardial infarction (12.5%), stroke (18.8%) and complications of diabetes mellitus (6.3%). In group B, 22 patients died mainly from cardiac causes (myocardial infarction - 40.9%, cancer - 27.3%).
CONCLUSIONS: Bilateral internal mammary artery grafting has obvious advantages over traditional coronary artery bypass grafting. If we take into account higher proportion of cardiac causes in structure of mortality in group B, we can talk about positive impact of bilateral internal mammary artery grafting not only on the quality of life, but also on life expectancy in long-term postoperative period.
UNASSIGNED: Оценить клиническую эффективность бимаммарного коронарного шунтирования на протяжении длительного (15 лет) послеоперационного периода.
UNASSIGNED: Исследованы 276 пациентов, разделенных на две группы: 135 пациентов группы А после реваскуляризации миокарда с использованием двух внутренних грудных артерий (ВГА) (БиМКШ) и 141 пациент группы Б, у которых использовали одну ВГА (МКШ) в сочетании с венозным шунтированием. Операции в условиях искусственного кровообращения (ИК) и кардиоплегии, параллельного ИК и без ИК на работающем сердце проводили в равном соотношении. Средний возраст больных составил 57,3±7,6 года. Сахарный диабет выявлен у 21 (15,5%) и 24 (19,1%) больных соответственно (p>0,05). Средняя фракция выброса составила 55,4±9,9%, индекс реваскуляризации — 3,1±0,8 и 3,0±0,7 соответственно. В группе БиМКШ 43 пациентам выполнили аутоартериальную реваскуляризацию миокарда только двумя ВГА, у остальных 84 пациентов дополнительно использовали аутовенозные трансплантаты.
UNASSIGNED: Отдаленная выживаемость к 10-му году наблюдения превышала 90% в обеих группах. Свобода от неблагоприятных кардиальных событий к 15-му году после операции была достоверно выше в группе A (77,3% против 59,3%, p=0,018). В группе А за 15-летний период наблюдения умерли 16 пациентов. Среди причин летальности преобладали онкологические заболевания (50%), инфаркт миокарда (12,5%), инсульт (18,8%), осложнения сахарного диабета (6,3%). В группе Б умерли 22 пациента преимущественно по кардиальным причинам (инфаркт миокарда — 40,9%, онкологические заболевания — 27,3%).
UNASSIGNED: БиМКШ обладает несомненными преимуществами перед традиционным коронарным шунтированием с использованием одной ВГА. Если принимать во внимание больший удельный вес кардиальных причин в структуре летальности в группе Б, можно говорить о позитивном влиянии БиМКШ не только на качество жизни, но и ее продолжительность в поздние сроки после операции.

OBJECTIVE: To compare the outcomes of left circumflex artery (LCx) revascularization using an internal thoracic artery (ITA) or radial artery (RA) as the second arterial graft.
METHODS: Patients who underwent primary isolated coronary artery bypass grafting with left anterior descending artery revascularization using an ITA and LCx revascularization using another bilateral ITA (BITA group) or an RA (ITA-RA group) were included. All-cause mortality (primary endpoint), cardiac death, major adverse cardiac events, in-hospital death, and deep sternal wound infection (secondary endpoints) were evaluated.
RESULTS: Among 790 patients (BITA, n = 548 (69%); ITA-RA, n = 242 (31%)), no significant difference in all-cause mortality between the groups was observed (hazard ratio (HR): 0.87; 95% confidence interval (CI): 0.67-1.12; p = 0.27) during follow-up (mean, 10 years). Multivariate analysis revealed that the BITA group exhibited significantly lower rates of long-term all-cause mortality (HR: 0.63; 95% CI: 0.48-0.84; p = 0.01). In the propensity-matched cohort (n = 480, 240 pairs), significantly fewer all-cause deaths occurred in the BITA group (HR: 0.66; 95% CI 0.47-0.93; p = 0.02). There were no significant differences in secondary outcomes.
CONCLUSIONS: When used as second grafts for LCx revascularization, ITA grafts may surpass RA grafts in reducing all-cause mortality 10 years postoperatively.

This case report describes a rare instance of left-sided congenital pericardial agenesis (CPA) encountered during coronary artery bypass grafting (CABG) in a 77-year-old male. In this unique case, the presence of an unusual strip of left pericardium containing the phrenic nerve posed significant surgical challenges. Special attention was required for the graft lay, ensuring adequate filling of the heart during assessment before closure, as well as emphasis on the need for generous graft length. Additionally, the evaluation of graft positioning prior to cardiopulmonary bypass was crucial. Despite these complexities, CABG was successfully performed with no complications to note. This case underscores the importance of adaptability in surgical technique to manage the unique challenges posed by CPA, leading to a positive outcome despite the atypical cardiac anatomy.

OBJECTIVE: Performance of a technically sound left internal thoracic artery to left anterior descending artery (LITA-LAD) anastomosis during coronary artery bypass grafting (CABG) is critically important. We used prospectively collected data from the multicentre, randomized REGROUP (Randomized Endograft Vein Perspective) trial to investigate CABG outcomes based on whether a resident or an attending surgeon performed the LITA-LAD anastomosis.
METHODS: This was a post hoc subanalysis of the REGROUP trial, which randomized veterans undergoing isolated on-pump CABG to endoscopic versus open vein harvest from 2014 through 2017. The primary end point was major cardiac adverse events, defined as the composite of all-cause deaths, nonfatal myocardial infarctions or repeat revascularizations.
RESULTS: Among 1,084 patients, 344 (31.8%) LITA-LAD anastomoses were performed by residents and 740 (68.2%), by attending surgeons. Residents (compared to attendings) operated on fewer patients with high tercile SYNTAX scores (22.1% vs 37.4%, P < 0.001), performed fewer multiarterial CABGs (5.2% vs 14.6%, P < 0.001) and performed more anastomoses to distal targets with diameters > 2.0 mm (19.0% vs 10.9%, P < 0.001) and non-calcified landing zones (25.1% vs 21.6%, P < 0.001). During a median observation time of 4.7 years (interquartile range 3.84-5.45), major cardiac adverse events occurred in 77 patients (22.4%) in the group treated by residents and 169 patients (22.8%) in the group treated by attendings (unadjusted HR 1.00; 95% confidence interval, 0.76-1.33; P = 0.99). Outcomes persisted on adjusted analyses.
CONCLUSIONS: Based on this REGROUP trial subanalysis, under careful supervision and with appropriate patient selection, LITA-LAD anastomoses performed by the residents yielded clinical outcomes similar to those of the attendings.

The internal mammary artery has become the primary conduit for the surgical revascularisation of the left anterior descending artery. Large side branches of internal mammary artery are typically ligated during cardiac surgery to avoid a potential coronary steal phenomenon. However, ligation of side branches can be unsuccessful due to the technically difficult surgical exploration of internal mammary artery branches. In this article, we present a case of a man who suffered from exertion angina pectoris despite successful surgical revascularisation of occluded left anterior descending artery by the internal mammary artery bypass. The coronary steal syndrome caused by the mighty side branch of internal mammary artery, that is, lateral costal artery was concluded as the reason of exertional angina. The endovascular procedure was performed and the lateral costal artery was successfully occluded using vascular plug. The occlusion of lateral costal artery has led to a complete disappearance of the exertional angina.

OBJECTIVE: Reimplanting the radial artery in the left internal thoracic artery as a composite graft allows total arterial revascularization (TAR) without aortic manipulation. The limitation of this strategy is the length of the radial artery required to reach distal right coronary artery (RCA) branches. Our analysis focuses on the feasibility of this strategy.
METHODS: A total of 169 patients underwent TAR using the radial artery in a composite grafting configuration. Length of the radial artery, number of sequential anastomoses, heart size, target location, length of the arm, patient height, body surface area, and flow in the composite graft were prospectively collected.
RESULTS: The mean length of the radial artery was 18.02 cm. Patients with a mean length of the radial artery of 15.9 cm needed an extension of the radial artery with another conduit to reach the RCA distal branches. When T-configuration is used, the length of the radial artery should be 0.53 cm per sequential anastomosis to reach the RCA distal branches.
CONCLUSIONS: Our study shows that an average length of 18.02 cm of radial artery is needed to reach targets on the RCA distal branches in composite grafting. In T-configuration, we need 0.53 cm more length per anastomosis to achieve TAR.

OBJECTIVE: Data on bilateral internal mammary artery (BIMA) versus single internal mammary artery (SIMA) on diabetics were analyzed; This is the only meta-analysis, the last 7 years.
METHODS: Medline through PubMed/EMBASE/CINHAL and the Cochrane Central Register of Controlled Trials; 179 articles were studied; 19 studies deemed suitable and were included in the analysis.
RESULTS: The mortality was 2.41% for BIMA versus 1.71% for SIMA (odds ratio [OR] =  0.95; 95% confidence interval [CI]: 0.74-1.22). Postoperative reopening for bleeding was higher at 3.75% for BIMA versus 2.91% for SIMA (OR =  1.49; 95% CI: 1.15-1.93). The incidence of MI was 0.87% for BIMA versus 0.83% for SIMA (OR =  0.73; 95% CI: 0.37-1.44). Deep sternal wound infection was 3.02% for BIMA and 1.95% for SIMA (OR =  1.57; 95% CI: 1.26-1.95). When skeletonized, the incidence of DSWI was 2.5% for BIMA versus 2.41% for SIMA. There was a significant difference at 5-year survival favoring the BIMA, 85.15% BIMA versus 80.77% SIMA (OR =  1.79; 95% CI: 1.60-2.01). The 10-year overall survival was 74.04% BIMA versus 61.57% SIMA (OR =  1.79; 95% CI: 1.61-1.98). The 15-year survival was 47.08% for BIMA versus 37.06% for SIMA (OR =  1.69; 95% CI: 1.52-1.88).
CONCLUSIONS: Postoperative bleeding was higher in BIMA group. Bilateral internal mammary artery in diabetic patients should be carried out in a skeletonize fashion, to reduce DSWI. There is a survival benefit of using BIMA in diabetics within 5 years of surgery; it remains significant up to 15 years.

OBJECTIVE: Coronary events and disease recurrence following coronary artery bypass (CABG) surgery could derive from either failure in the internal thoracic artery (ITA) graft, failure in other conduits or progressive disease in the coronaries. We aim to estimate the contribution of ITA graft failure to the recurrence of symptoms after CABG surgery.
METHODS: Within the Swedish Web System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies registry, we identified patients who had coronary artery bypass grafting from 1997 to 2020 with a single-vessel ITA graft bypass. Deaths, postoperative incidence of coronary angiography and the presence of a failed graft at the time of the angiography were recorded.
RESULTS: The study population consisted of 1939 patients with a mean follow-up time (SD) of 17.2 (5.6) years. The cumulative incidence (95% CI) at 20 years for a first clinically-driven postoperative angiography was 38.6% (36.2-41.1). A failed ITA graft was reported in 16.4% of the angiographies.
CONCLUSIONS: A substantial part of recurrent symptoms of coronary artery disease do not seem to be related to ITA failure. Disease progression in the native coronary vessels may instead be the main driver of symptom recurrence.

OBJECTIVE: It is unclear if a second or third arterial graft can improve clinical outcomes in coronary artery bypass graft surgery. We compared the outcomes of bilateral internal thoracic artery (BITA) plus radial artery (RA) grafting versus left internal thoracic artery (LITA) plus RA grafting after off-pump coronary artery bypass grafting.
METHODS: Between January 2009 and December 2020, a total of 3007 patients with three-vessel coronary artery disease who underwent off-pump coronary artery bypass were analyzed. Among them, 971 patients received total arterial grafting using LITA. We divided the patients into two groups [group A, BITA+RA grafting (n=227) and group B, LITA+RA grafting (n=744)], and compared the survival and major adverse cardiac and cerebrovascular event (MACCE) rates between the two groups at 10 years.
RESULTS: After risk adjustment with inverse probability treatment weighting methods, the freedom from all-cause mortality was 93.1% and 88.3% in groups A and B, respectively (p=0.140). The freedom from MACCE rates were 68.3% and 89.0%, respectively (p<0.0001). LITA plus RA grafting [hazard ratio (HR): 1.3, 95% confidence interval (CI): 1.05-2.37, p=0.025] and incomplete revascularization (HR 1.2, 95% CI: 0.70-2.15, p=0.046) were significant risk factors for MACCEs in multivariable Cox regression analysis.
CONCLUSIONS: The rates of MACCEs were lower with LITA plus RA grafting than with BITA plus RA grafting in total arterial revascularization. Furthermore, complete revascularization improved long-term outcomes following total arterial grafting.