CARDIOTHORACIC SURGERY

Evidence for the biologic and prognostic superiority of arterial conduits has accumulated over the past 20 years. The LITA is unequivocally the conduit of choice for the LAD (patencies 95% at 10 years, and 90% at 20 years). The RITA has excellent patencies when used to the LAD or diagonal (96% at 10 years). It is best deployed to the circumflex marginals, either as a skeletonised pedicled artery to a high marginal or as a free conduit to mid and inferior OMs (patency 92% at 10 years). The RITA is not adequately versatile for use in the RCA system, particularly for PDA grafting. The radial artery is the most versatile arterial graft, with patencies of 92% at 5 years to the LAD, 91% at 8 years to the OM, and 88% at 5 years to the PDA, and is an ideal graft in older (>65 years) patients. The gastroepiploic artery has a 62% ten year patency and is a useful conduit to the PDA – especially in off pump and re-operations. Composite pedicled grafts (LITA/RA, LITA/RITA) are efficient, ideal for off pump surgery and have excellent patencies (>90% at 5 years) when confined to the LAD and circumflex systems. Vulnerability from competitive flow limits use of arterial grafts to coronary arteries with stenoses exceeding 80% (50% for LITA). Vein grafts should always be considered especially in older patients when multiple grafts are required and short operating times desirable. Improved harvesting, aspirin and anti-cholesterol medications have all enhanced the VG patency (90% at 5 years, 60% at 10 years). Bilateral ITA grafting improves survival (over single ITA), by up to 10% at 10 years and by 20% at 20 years post-operatively. With ideal use of bilateral ITAs to the LAD and OM, leaving RA, VG or GEA for the RCA system.