Since the first coronary artery bypass was performed on a human in New York in 1961,1 conduits for coronary artery bypass grafting (CABG) remain in a state of evolution. During the early years of CABG development, saphenous venous grafts (SVGs) were standard conduits for CABG. However, it soon became apparent that vein grafts in the majority of patients have limited longevity.2,3 The internal mammary artery (IMA) soon became the ‘gold standard’ with which all conduits are still compared. The left IMA (LIMA) has been definitively established as the conduit of choice in CABG because of superior survival and event-free survival.4 Better clinical outcomes and superior long-term patency with multiple arterial grafts have led to growing interest in the use of total arterial revascularisation in CABG.3–11 This article details the current status of the conduits used to achieve total arterial myocardial revascularisation.
Internal Mammary Artery
Routine use of the IMA has risen from 3% in the early 1970s to above 99%. IMA is very resistant to atherosclerosis, making it superior to any other conduit for CABG. Multiple reasons have been put forward for the low incidence of atherosclerosis in IMA. These include the developed internal elastic lamina, blood supply from the vasa vasorum, the small amount of smooth muscles in the media and its perivascular lymphatic drainage. IMA is currently used in patients of all ages requiring myocardial revascularisation and patients with unstable angina.12 Spasm of distal IMA, usage in non-critical coronary artery stenosis, low flow in IMA and use in hypertrophied left ventricle still remain controversial. Should IMA be used for myocardial revascularisation in these situations? Harvesting of the IMA without any damage or dissection remains very important and utmost care should be taken. If damage to the IMA occurs in the superior or inferior portion and sufficient length is still available for grafting, it can still be used as a free graft. However, the long-term patency of free IMA is not as good as that of the pedicled IMA. The excellent clinical outcomes, long-term patency and fewer repeat procedures of this graft provides a standard with which all other grafts can be compared, and it should be the mainstay of any cardiac surgeon’s coronary artery bypass operation.4,5,13,14
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