CABG Conduit

European Journal of Cardio-Thoracic Surgery 2023, 64(2), ezad163 REVIEW
https://doi.org/10.1093/ejcts/ezad163
REVASCULARIZATION
Cite this article as: Gaudino M, Bakaeen FG, Sandner S, Aldea GS, Arai H, Chikwe J et al. Expert systematic review on the choice of conduits for coronary artery bypass
grafting: endorsed by the European Association for Cardio-Thoracic Surgery (EACTS) and The Society of Thoracic Surgeons (STS). Eur J Cardiothorac Surg 2023;
MYOCARDIAL
doi:10.1093/ejcts/ezad163.
Expert systematic review on the choice of conduits for coronary

artery bypass grafting: endorsed by the European Association for
Cardio-Thoracic Surgery (EACTS) and The Society of Thoracic
Surgeons (STS)
Downloaded from https://academic.oup.com/ejcts/article/64/2/ezad163/7235875 by guest on 04 August 2023

Mario Gaudino a,*, Faisal G. Bakaeenb, Sigrid Sandner c, Gabriel S. Aldead, Hirokuni Araie, Joanna Chikwef,
Scott Firestoneg, Stephen E. Fremesh, Walter J. Gomes i, Ki Bong-Kimj, Kalie Kissong, Paul Kurlansky k,
Jennifer Lawtonl, Daniel Naviam, John D. Puskasn, Marc Ruelo, Joseph F. Sabikp, Thomas A. Schwannq,
David P. Taggartr, James Tatoulis s, and Moritz Wyler von Ballmoost
a
Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY, USA
b
Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA
c
Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
d
Division of Cardiothoracic Surgery, University of Washington School of Medicine, Seattle, WA, USA
e
Department of Cardiovascular Surgery, Graduate School of Medical and Dental Science, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
f
Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
g
The Society of Thoracic Surgeons, Chicago, IL, USA
h
Schulich Heart Centre, Sunnybrook Health Sciences Centre, and the Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON,
Canada
i
Cardiology and Cardiovascular Surgery Disciplines, S~ao Paulo Hospital, Escola Paulista de Medicina, Universidade Federal de S~ao Paulo (Unifesp), S~ao Paulo, SP,
Brazil
j
Cardiovascular Center, Myong-ji Hospital, Gyeong-gi-do, Republic of Korea
k
Division of Cardiac Surgery, Department of Surgery, Columbia University, New York, NY, USA
l
Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
m
Department of Cardiac Surgery, ICBA Instituto Cardiovascular, Buenos Aires, Argentina
n
Department of Cardiovascular Surgery, Mount Sinai Saint Luke’s, New York, NY, USA
o
Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, ON, Canada
p
Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
q
Division of Cardiac Surgery, Baystate Health, Springfield, MA, USA
r
Department of Cardiac Surgery, John Radcliffe Hospital, University of Oxford, Oxford, UK
s
Department of Cardiothoracic Surgery, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
t
Division of Cardiothoracic Surgery, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA
* Corresponding author. Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, 525 E 68th St, New York, NY 10065, USA.
Tel: +1-212-7469440; fax: +1-212-7468080; e-mail: mfg9004@med.cornell.edu (M. Gaudino).
Received 4 January 2023; received in revised form 10 March 2023; accepted 20 April 2023
Abstract
Preamble: The finalized document was endorsed by the EACTS Council and STS Executive Committee before being simultaneously
published in the European Journal of Cardio-thoracic Surgery (EJCTS) and The Annals of Thoracic Surgery (The Annals) and the Journal of
Thoracic and Cardiovascular Surgery (JTCVS).
This article has been co-published with permission in the European Journal of Cardio-Thoracic Surgery, The Annals of Thoracic Surgery, and the Journal of Thoracic and
Cardiovascular Surgery. All rights reserved. V C 2023 European Association for Cardio-Thoracic Surgery, The Society of Thoracic Surgeons, and the American
Association for Thoracic Surgery. The articles are identical except for minor stylistic and spelling differences in keeping with each journal’s style. Any of the three
citations can be used when citing this article.
2 M. Gaudino et al. / European Journal of Cardio-Thoracic Surgery

INTRODUCTION
ABBREVIATIONS
Coronary artery bypass grafting surgery (CABG) is the most com-
ART Arterial revascularization trial mon cardiac surgery operation in the USA and worldwide [1].
BITA Bilateral internal thoracic artery The first choice of conduit and standard of care is use of the left
CABG Coronary artery bypass grafting internal thoracic artery (LITA) to the left anterior descending
CCB Calcium channel blockers (LAD) artery. While the saphenous vein graft (SVG) remains the
CI Confidence interval most commonly used conduit for multivessel CABG, there is a
CON SVG Conventional saphenous vein graft variety of arterial conduits and technical variations of the SVG
DSWI Deep sternal wound infection that may also be used for the operation. Individualization of the
EVH Endovascular vein harvesting grafting strategy to the anatomic and clinical characteristics of
GEA Gastroepiploic artery each patient, as well as to the operating surgeon’s experience
HR Hazard ratio and comfort with the different conduits, is key to the success of
IRR Incidence relative risk the operation. This document reviews and analyzes the existing
ITA Internal thoracic artery evidence for the use of conduits for CABG.
LITA Left internal thoracic artery
LAD Left anterior descending
MACE Major adverse cardiovascular events METHODOLOGY
MI Myocardial infarction
MLD Minimal lumen diameter The leadership of the Society of Thoracic Surgeons (STS), American
NMA Network meta-analysis Association for Thoracic Surgery (AATS) and European Association
NT SVG No touch saphenous vein graft for Cardio-Thoracic Surgery (EACTS) nominated a group of experts
OR Odds ratio to systematically review the data on use of conduits in CABG as a
OVH Open vein graft harvesting comprehensive, international document. This paper reflects the
PICO Population, intervention, comparator, out- opinion of the nominated authors as to how to approach and per-
comes form conduits selection in CABG.
RA Radial artery Each of the members of the writing committee submitted con-
RAO Radial artery occlusion flict of interest disclosure forms, which were then reviewed by
RAPCO Radial artery patency and clinical outcomes the co-Chairs of this document, the STS Joint Guideline Steering
RCA Right coronary artery Committee and STS staff before confirmation for potential con-
RCT Randomized control trial flicts from relevant relationships with industry.
RITA Right internal thoracic artery The writing committee then developed 5 questions for systematic
RGEA Right gastroepiploic artery review in the Population, Intervention, Comparator and Outcomes
SV Saphenous vein (PICO) format primarily related to comparisons of different grafts to
SVG Saphenous vein graft the conventionally harvested SVG and to the use of endoscopic vein
TRC Transradial catheterization harvesting (EVH). The PICO questions were sent to a research
M. Gaudino et al. / European Journal of Cardio-Thoracic Surgery 3
librarian in January 2021 to develop a strategy to identify relevant associated with a 26% relative risk reduction in mortality at 6.6-
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articles published in English with no time restrictions. Reference lists year follow-up [9].
were manually scanned for additional relevant results. After dupli- The aforementioned analysis of 6 RCTs also reported superior-
MYOCARDIAL
cates were removed, this strategy resulted in 1009 potentially rele- ity for the RA in the composite outcome of death, myocardial in-
vant abstracts, which were screened by 2 authors (S.F. and K.K.). A farction (MI) and repeat revascularization at 5 years follow-up
total of 166 articles met the inclusion criteria. (HR 0.67, 95% CI 0.49–0.90) [7]. When the follow-up of the same
The primary reasons for exclusion were invalid patient popula- database was extended to 10 years, use of the RA was associated
tions (e.g. those receiving percutaneous coronary intervention), a with a statistically significant reduction in the incidence of the
focus on non-clinical outcomes and inadequate study design (e.g. composite of death, MI or repeat revascularization (HR 0.73, 95%
lack of a comparison group or expert review). Two authors (S.F. CI 0.61–0.88) and of the composite of death or MI (HR 0.77, 95%
and K.K.) developed an evidence table of the relevant papers and CI 0.63–0.94); a post hoc survival benefit for patients receiving the
rated the studies for risk of bias. The Newcastle–Ottawa scale was RA was also found, although the absolute benefit was small (HR
used for observational studies, and a custom-made checklist was 0.73, 95% CI 0.57–0.93) [10].
used for randomized control trials (RCTs) and meta-analyses. A Veteran Administration trial of 757 patients found no differ-

ence in patency rate at 1 year between the RA and the SV [odds
Ethics statement ratio (OR) 0.99, 95% CI 0.56–1.74] and no difference in survival at
14.6 years of follow-up (HR 1.12, 95% CI 0.91–1.38) [11, 12]. No
Ethics approval was not requested as no individual patient data data on cardiac events were available. The Radial Artery Patency
were included. and Clinical Outcomes (RAPCO) trial found better patency rate at
10 years for the RA compared to the free right internal thoracic
artery (RITA) (HR 0.45, 95% CI 0.23–0.88) and the SV (HR 0.40,
Left internal thoracic artery to left anterior 95% CI 0.15–1.00) [13]: at 15 years of follow-up, the rate of the
composite of death/MI and repeat revascularization were signifi-
descending
cantly lower in the RA arm (HR 0.74, 95% CI 0.55–0.97 vs the
RITA and HR 0.71, 95% CI 0.52–0.98 vs the SV).
The LITA-LAD anastomosis represents the universally accepted
gold standard for CABG. In the USA, it is the only recognized
CABG quality metric related to the technique of the procedure. Hand function
The evidence in support of the use of the LITA to graft the LAD is
based on observational studies from the ‘80s and ‘90s showing bet- It is generally accepted that assessing the adequacy of ulnar col-
ter patency rate and clinical outcomes compared to the SVG, as lateral circulation should always be performed before RA harvest-
well as on the unique morphologic and biological properties of ing—assessing RA morphology by ultrasound allows also
the LITA [2–4]. While no appropriately powered RCT has formally detection of potential calcification and measurement of the RA
tested the LITA-LAD hypothesis, there is no professional nor indi- diameter. Comparative studies on different methods of evalu-
vidual equipoise in the surgical community for such a study. ation are lacking, but the clinical Allen test is highly operator de-
pendent and is best complemented by an objective assessment
[14]. The site of harvesting should be the one with better ulnar
RADIAL ARTERY compensation and artery quality—there is no evidence to support
the concept that the artery should be harvested from the non-
Patency dominant arm although this has been the logical default ap-
proach. Harvesting of the RA is generally well tolerated; while
Multiple RCTs and meta-analyses of RCTs have reported an arm paresthaesia and pain have been reported, symptoms are
improved patency rate for the radial artery (RA) compared to the generally transient and self-limited [15], although long-term com-
saphenous vein (SV) at mid- and long-term follow-up [5, 6]. plications in some studies have been as high as 9% [16].
An individual participant data meta-analysis of 6 RCTs found Ischaemic hand complications, or changes in arm grip strength
that the use of the RA rather than the SV was associated with a or dexterity are extremely rare, although there may be a publica-
statistically significant reduction in graft occlusion [hazard ratio tion bias.
(HR) 0.44, 95% confidence interval (CI) 0.28–0.70; P < 0.001] at a Vascular diseases of the upper extremities are generally con-
mean follow-up of 4.2 years [7]. It is important to note that the sidered a contraindication to RA harvesting. Previous forearm
RAs were used to bypass mainly circumflex arteries with severe trauma is a relative contraindication, especially if operative repair
stenotic lesions with very few patients receiving radial grafting was needed, as well as previous surgery on the forearm or the
to the right coronary system. While these RCTs include a rela- wrist.
tively limited number of patients for a procedure as common In patients with chronic renal failure the potential benefits of
as CABG, the reported benefit is consistent starting in as few as using the RA for CABG must be weighed against the possible
4 years [8]. need for an upper arm arteriovenous fistula for dialysis, but evi-
dence is lacking.
Long-term clinical outcomes
Proximal anastomosis
Several observational series have found improved short- and
long-term outcomes in patients who received the RA rather than The RA can be anastomosed directly onto the aorta or to another
the SV as the second conduit. In a meta-analysis of 14 adjusted conduit, typically the internal thoracic artery (ITA) as a Y or T
observational studies (20 931 patients), the use of the RA was graft—other configurations have been described but are seldom
used [17–19]. Most of the available evidence on the RA is based publication biases and no clear conclusion on RA patency and
on aorta-anastomosed grafts, while some studies have indicated outcomes using the endoscopic technique can be drawn.
higher radial graft patency with the aortic anastomosis approach
[20, 21], other data did not reveal a difference [22–25]. The aortic Transradial catheterization
anastomosed configuration is probably less at risk of failure due
to competitive flow [26]. Previous catheterization of the RA is a contraindication to RA use
From a technical point of view, concerns relating to high wall for CABG, as there is evidence that the patency rate of RA grafts
tension resulting from anastomosis of the RA directly onto the used for transradial procedures is significantly reduced compared
aorta have led some surgeons to craft a short interposition seg- to non-catheterized grafts [36] and it is known that transradial
ment of SV, to which the RA is connected in end-to-end fashion. catheterization (TRC) produces significant endothelial damage [37].
Whether this configuration negates some of the benefits of using After TRC complete radial artery occlusion (RAO) may occur in
the RA is not known. up to 38% [38]. Measures to reduce RAO include, smaller hydro-
Overall, data are currently insufficient to provide meaningful philic sheaths, nitroglycerine solution flushes and larger doses of
guidance on a preferred anastomotic technique.

heparin. Nevertheless, most current RAO rates are between 3%
and 10% [39, 40]. Recanalization occurs but it may take months,
Target vessel selection or the RAO may remain permanent [38–40].
5F and 6F sheaths used for TRC are 7–10 cm long and the
Three factors are commonly considered: the degree of proximal guidewires and catheters progressively traumatize the RA endo-
coronary artery stenosis, the myocardial territory to be grafted thelium. Ultrasound, intravascular ultrasound [41] and optical co-
and the size of the target vessel. There is ongoing controversy as herence tomography studies [42, 43] have documented intimal
to whether the RA should be used to graft target arteries with tears in 37–80%, media dissection in 10–37% and an increase in
>_90% proximal stenosis or >_70% stenosis. In the RAPCO trial, intima and media thickening, a marker of RA endothelial and
grafted arteries required at least 70% proximal stenosis and a vascular wall trauma, and a precursor to atherosclerosis [41–43].
minimum diameter of 1.5 mm [13]. Similar inclusion criteria were Histological and immunohistochemical examination of TRC-
used in the Radial Artery Patency Study (RAPS) [27]. Only 21 late RA distal segments showed endothelial damage in all samples,
radial graft failures occurred in RAPCO, therefore limiting correl- with changes most pronounced if the instrumented RA was used
ational analyses. Observational series, often long-term, have within 24 h, still persisting though less prominent after several
showed that >_90% proximal target stenosis correlates with better months [36, 37, 44, 45].
graft patency than >_70%, and a right coronary territory target Excessive intimal hyperplasia in 68–73%, periarterial inflammation
with lower patency, a finding observed with most arterial grafts in 33%, fat and tissue necrosis in 26% were additional sequalae,
[23, 28–31]. Limited information exists on ideal target vessel size, most prominent in the 3 cm immediately upstream from the RA
as trial patients were often selected to meet a minimum size. It is puncture, becoming less severe and less frequent proximally. These
possible but unproven that the RA in comparison with a SVG, changes were not present in the non-instrumented RA [44, 45].
may be particularly suitable on small coronary targets—especially The diameter of the TRC-RA suffers a 10% reduction, most ap-
those with a high degree of proximal stenosis—due to the RA’s parent in the distal 3 cm, which persists beyond 6 months [36, 37,
more favourable match. 46]. As most RA punctures for TRC are 3–5 cm above the wrist [38],
The Impact of Preoperative Fractional Flow Reserve on Arterial and the vascular trauma affecting the most distal 3 cm adjacent to
Bypass Graft Function (IMPAG) trial provided information on the puncture, 6–8 cm of a 20 cm length RA may be ‘unavailable’
composite radial grafts, whereas a fractional flow reserve cut-off for use as a conduit—confining any potential instrumented RA use
of 0.78 was predictive of anastomotic functionality at 6 months; to a proximal coronary or as a Y graft. However, endothelial dam-
however, most of the grafts used in IMPAG were ITA, not RA, age and dysfunction may not be confined to the distal portion of
grafts [17]. Available data remain susceptible to expertise, selec- the artery, and the effect on graft patency is unknown.
tion, recall, and publication biases. Flow mediated dilatation assessed by ultrasound using the
other RA as a control shows a significant 10% reduction com-
pared to preinstrumentation and to the control, lasting up to
Harvesting method
1 year after TRC [36, 37, 39, 47]; longer follow-up have not been
investigated and there is no evidence that endothelial function
The RA can be harvested in open fashion or endoscopically, the
ever return to normal.
latter typically performed through small incisions at the distal
Nitrate-mediated vasodilatation is also impaired—maximally
and proximal ends of the in situ conduit. While open harvest is
impaired early after TRC. The impairment gradually lessens over
not usually associated with major pain locally, its incision is long
the next 9–26 weeks [37, 46–51]. Endothelium dependent vaso-
and can be unsightly. Endoscopic harvesting involves a learning
dilation is also impaired for up to a year [37].
curve and may be associated with harvest-related spasm, less
Instrumented RAs used in CABG have reduced patency in the
thorough clipping of branches and endothelial dysfunction [32].
Patient satisfaction, however, appears enhanced by endoscopic only 2 published studies: 70% patency for TRC–RA versus 98% in
harvesting [33]. Both techniques have been shown to be safe in pristine RAs 1 month postoperatively (P = 0.017) [36], and a marked-
expert hands [31, 34, 35]. ly reduced patency for TRC-RAs (59% vs 78%) at 18 months [52].
Randomized data are sparse, involve small series and reveal
short-term outcomes only. Most of the published RA trials Calcium channel blockers
employed open harvesting which, consequently, should be con-
sidered the standard. Available evidence with endoscopic radial Prevention of perioperative RA spasm is key for successful RA
harvest may be fraught with major expertise, selection, recall and grafting. Perioperative regimens, though varied, are well
established and include topical and intraluminal RA papaverine, with >_4 years of angiographic follow-up, the SVG (n = 377) was
REVASCULARIZATION
nitroglycerine, nitroprusside, diltiazem, verapamil, milrinone and significantly associated with a 4-fold increased risk (OR 0.25,
phenoxybenzamine [53, 54]. 95% CI 0.05–0.78) of functional graft occlusion when compared
MYOCARDIAL
Some surgeons also use intravenous nitroglycerine or intraven- with the RITA (n = 145). In a rank probability analysis that also
ous calcium channel blockers (CCBs) during surgery and for the included the RA and the gastro-epiploic artery (GEA), the RITA
first 12–24 h [53, 54]. The optimum CCBs may be nifedipine and achieved the highest probability (74%) to be the best conduit.
amlodipine. Both are up to 30 times more efficacious than diltia- More recently, however, Gaudino et al. [6] conducted an
zem [55, 56] whereas verapamil depresses myocardial function updated NMA of 14 RCTs that included 3396 patients and
and conduction. There is less agreement regarding potential ben- 3651 grafts from 5 additional studies comparing the angio-
efits of longer-term use of nitrates and CCBs. graphic patency of the RITA, RA, GEA, conventional SVG (CON-
There is no study evaluating the subacute or chronic use of SVG) as well as the no-touch SVG (NT-SVG). The patency rates
oral or topical nitrates with respect to graft patency (including of the CON-SVG (n = 1362) and RITA (n = 399) after a mean
RA) and survival post CABG. Early small observational and angiographic follow-up of 5.1 years were 81.8% (95% CI 74.8–
randomized trials of postop CCBs (up to 12 months) reported in- 87.3) and 90.9% (95% CI 72.1–97.5), respectively. The RITA was

consistent outcomes. However, most were underpowered, and not associated with a significantly lower rate of graft occlusion
used various CCBs. compared with the CON-SVG [incidence relative risk (IRR) 1.02,
In postoperative RA angiograms, areas of localized RA stenosis 95% CI 0.39–0.78].
that dilated instantly with intragraft nitroglycerine were occasion-
ally noted [57]. The meta-analysis of RCTs of RA versus SVG as a Long-term clinical outcomes
second graft by Gaudino et al. [58] showed significantly improved
outcomes for death, MI, revascularization and patency in those
In the Arterial Revascularization Trial (ART), no difference was
patients taking CCBs for at least 12 months postoperatively, al-
found in 10-year survival and event free survival among patients
though a treatment allocation bias may be present.
randomized to single vs bilateral ITA to the 2 most important
CCBs reduce preload, afterload and blood pressure. These actions
left-sided targets [60]. There was a relatively high crossover rate
may also contribute to better long-term outcomes. Drawbacks of
from bilateral to single ITA and the RA was used in 20% of the
CCBs, especially amlodipine are potential for headache, and mild
patients, potentially diluting the treatment effect. In an observa-
peripheral oedema (up to 20%) [54, 57]. The use of CCB may also
tional comparison, patients who received multiple arterial graft-
prevent the use of other important secondary prevention therapies
ing (including the RA) had better survival and event free survival
(beta-blockers, angiotensin-converting enzyme-inhibitors).
compared to patients who received a single ITA.
In an observational analysis of 7223 patients comparing long-
Bilateral radial artery use term (>15 years) survival in 490 2:1 propensity-matched pairs of
RITA-right coronary artery (RCA) versus SVG-RCA, time-seg-
Few reports exist regarding the use of bilateral radial arteries (BRAs), mented cox regression showed that during the first 9 years of
mostly in cases of redo CABG, and conduit shortage [32, 33]. Due to follow-up the 2 strategies were associated with a similar risk of
the increasing use of TRC and its potential clinical benefits, the use death (HR 1.13, 95% CI 0.67–1.90; P = 0.65) [61]. However, be-
of bilateral radial artery should be balanced with the potential need yond 9 years, RITA-RCA was associated with a significantly lower
for percutaneous coronary imaging or interventions [59]. risk of death (HR 0.43, 95% CI 0.22–0.84; P = 0.01). A NMA of 31
adjusted observational studies and 4 RCTs including 149 902
patients (SVG 112 018; RITA 21 683) found that use of the RITA
was associated with lower long-term mortality (IRR 0.80, 95% CI
Key messages 0.73–0.86) at 8.5 years of follow-up when directly compared
with the SVG [62]. This was confirmed in the NMA, showing that
• Randomized data support better patency rate and a reduction
use of the SVG was associated with higher late mortality (IRR
in adverse cardiac events for the RA compared to SVG.
1.26, 95% CI 1.17–1.35), operative mortality (OR 1.45, 95% CI
• RA harvesting is generally well tolerated; there is limited 1.14–1.84), and perioperative MI (OR 1.30, 95% CI 1.06–1.61)
evidence in support of the endoscopic harvesting method. compared with the RITA [62]. There was no difference in the risk
• The RA should be used to graft target vessel with low of perioperative stroke (OR 1.24, 95% CI 0.93–1.64), while the
competitive coronary flow and should not be used after TRC. risk of deep sternal wound infection (DSWI) (OR 0.71, 95% CI
• Observational evidence supports the use of vasodilators for 0.55–0.91) was lower with SVG compared with the RITA.
the first year in patients with RA grafts. However, when limiting the analysis to studies in which the ske-
letonized harvesting technique for the ITA was used, no differ-
ence in DSWI between RITA and SVG was found in pairwise
comparison [62].
In summary, although long-term data do not currently show
RIGHT INTERNAL THORACIC ARTERY a consistent difference in terms of graft patency, adjusted ob-
servational data suggest superior long-term survival with use of
Patency the RITA compared with the SVG, and support use of the RITA
over the SVG, particularly in patients with long life-expectancy.
Benedetto et al. [8] in a network meta-analysis (NMA) of 9 A volume to outcome effect for the use of bilateral internal
RCTs comparing angiographic outcomes of second conduits in thoracic artery (BITA) has been suggested in observational stud-
CABG showed that when the analysis was restricted to 6 RCTs ies [63].
Patient selection Target vessel selection

Selective use of BITA grafting is essential for safe and effective ap- In addition to demographic factors, morphology and extent of
plication. Because BITA harvesting is associated with increased cardiac disease may influence the outcome for BITA use.
sternal wound complications, alternative conduit options to BITA Bypassing with BITA multiple non-LAD target vessels that perfuse
are recommended in patients at increased risk for such compli- a large myocardial mass has been associated with improve long-
cations. In addition, patients with a limited life expectancy or term survival [84]. Additionally, a recent study suggests larger tar-
those with severe comorbidities may not benefit from longevity get vessels may be better suited for BITA use with a reduced rate
associated with multiarterial grafting [64, 65]. Three common pa- of graft occlusion (OR 0.18, 95% CI 0.05–0.62; P = 0.007) and a
tient groups where a thoughtful application of BITA grafting is cut-off of 1.93 mm [85]. Target vessel size, however, was not a
particularly pertinent are discussed below: factor in a previous analysis [86].
Whether to use BITA in target vessels with moderate stenosis
Patients with diabetes. A 2013 meta-analysis of 1 RCT and has long been an issue of debate. The impact of moderate prox-
10 observational studies of patients with diabetes found that imal stenosis varies, with some studies suggesting a mild effect

DSWI occurred in 3.1% and 1.6% for the BITA and single internal [87, 88] to some suggesting significantly reduced patency.
thoracic artery cohorts, respectively (relative risk 1.71, 95% CI Composite grafts may fare particularly poorly compared to free
1.37–2.14) [66]. Likewise, Dai et al. [67] reported higher DSWI in grafts in bypassing these targets [89]. A prospective RCT associ-
diabetic patients in another meta-analysis (relative risk 0.65, 95% ated an fractional flow reserve of <_0.78 with improved RITA pa-
CI 0.52–0.81). A third meta-analysis found a higher rate of DSWI tency [17].
regardless of how the ITAs were harvested [68]. The decision to use an in situ RITA or a free RITA depends on a
Recent retrospective data have not always supported these number of factors, including coronary anatomy, a diseased
findings, failing to demonstrate a higher incidence of DSWI even ascending aorta, or high-risk for a redo sternotomy [90]. In lim-
in diabetic patients [69–72]. While the preponderance of evi- ited data thus far, long-term RITA patency appears independent
dence suggests higher DSWI risk in patients with diabetes, BITA of its inflow configuration [86, 90]. Clinical results have mostly
has been used successfully in diabetic patients with equivalent been comparable between the in situ and composite configura-
safety results by centres experienced with the technique [66, 67]. tions, although composite grafts tend to offer more complete
revascularization at the potential risk of imbalanced flow [91].
Low ejection fraction. Low ejection fraction is strongly asso-
ciated with increased perioperative mortality [73]. The priority in RITA vs LITA to the LAD
patients with ischaemic cardiomyopathy is to mitigate the up-
front risk of surgery [74]. Immediate flow in an arterial graft may The paper by Loop et al. [2] that established the use of the ITA to
not be as high as that in a vein graft with the potential for clinic- the LAD as the gold-standard did not differentiate between LITA
ally significant early coronary hypoperfusion [75, 76]. In addition, and RITA, however both were used in an in situ configuration.
multiple arterial grafting usually adds to the complexity and dur- One small RCT [92] and a few retrospective analyses, mostly from
ation of the operation which may not be well tolerated in single centres, have compared BITA configurations where an in
patients with severe ventricular dysfunction. situ RITA is anastomosed to the LAD vs the standard in situ LITA
Retrospective analyses suggest that the operative safety of to LAD. The evidence suggests that RITA to LAD is similar in
using BITA is equivalent to single internal thoracic artery, al- terms of graft patency [92–95], perioperative, operative [92, 93,
though whether BITA improves long-term survival in this patient 95–97] or longer-term clinical outcomes [96–99].
population is not clear with mixed results derived from observa-
tional studies [77–80].
Patency. A randomized study by Deininger with 100 patients
Although BITA grafting is not routinely recommended for
reported 100% patency after 6 months for both RITA-LAD and
patients with severe ventricular dysfunction, its use may be con-
LITA-LAD [92]. Ji et al. [94] found no significant difference in rate
sidered in select scenarios guided by the patient’s anticipated sur-
of graft failure at mean follow-up of 36.6 ± 12.1 months.
vival and surgeon experience and judgement [74].
A recent study by Ogawa et al. [95] reported that using the
RITA for a vessel other than the LAD led to worse patency (HR
Advanced age. An age-dependent benefit of BITA grafting 2.05, 95% CI 1.08–3.88; P = 0.029). Tatoulis et al. [93] reported
was seen in a post hoc analysis of the ART, with a cut-off at similar overall patency in the RITA and LITA with a mean of
65 years [81]. 100 months of follow-up in over 2000 grafts (RITA 94.6% vs
A meta-analysis of retrospective studies by Deo et al. [82] 96.9%; P = 0.74), although this still represented a small portion of
reported significantly higher DSWI in elderly patients associated the total population. These findings were confirmed in a study by
with use of BITA (OR 1.86, 95% CI 1.3–2.5; P < 0.01) with no het- Bakaeen et al. [90] demonstrating that RITAs grafted to the LAD
erogeneity. Safety outcomes were equivalent, although long-term had patency similar to LITA to LAD.
survival was not quantitatively analysed and reported as mixed. The patency data are at higher risk of bias and generally come
Pevni et al. [83] reported similar safety and survival outcomes for from clinically driven angiograms and many of the studies were
BITA in octogenarians. not principally designed to test the patency of LITA versus RITA
There is insufficient data on a specific age cut-off for use of to the LAD. Another caveat is that use of pedicled ITAs was not
BITA; however, observational studies including 2 large state regis- well-represented in this data, and that many of the patients were
tries suggest that the survival benefit associated with multiarterial operated on off-pump. Thus, the patency data should be inter-
grafting may be lost in patients over the age of 70 years [64]. preted with caution.
Long-term clinical outcomes. Deininger et al. [92] reported Skeletonized ITA harvesting
REVASCULARIZATION
no adverse operative outcomes in either for both RITA-LAD
and LITA-LAD groups, although it was clearly underpowered to Evidence on skeletonized ITA harvesting has been mixed and
MYOCARDIAL
find any differences for these rarer endpoints. Observational generally highly dependent on retrospective and anecdotal ex-
data, both matched and unmatched, have yet to find a signifi- perience. Randomized control data has documented that careful-
cant difference in either operative or longer-term major ad- ly harvested skeletonized ITA grafts can maintain structural
verse cardiovascular events (MACE) outcomes, individually or as integrity [102, 103], physiological response to vasoactive stimula-
a composite endpoint [92]. Raja et al. [98] reported a significant tion [104, 105] and acute graft flow that is at least comparable if
increase in perioperative mortality for LITA to LAD patients, but not greater than that achieved with a pedicled approach [106–
this unusual finding has not been reproduced in subsequent 108]. Postanastomotic flow appears to be comparable or possibly
larger studies. increased [109, 110]. Moreover, even though acute sternal micro-
Ogawa et al. [95] reported a significant benefit to using the circulation is clearly impaired with either approach [111, 112],
RITA for the LAD during their 6 years of follow-up in the com- sternal perfusion has been demonstrated to be better preserved
posite outcome of death, MI, and revascularization (27.8% vs over time with skeletonization [113–115]. Although this provides

41.5%; P = 0.029). Raja et al. [98] combined death and revasculari- a rational substrate for fewer sternal wound complications, the
zation and found no significant difference between the groups data regarding reduced sternal wound infection, although abun-
(HR 0.81, 95% CI 0.64–1.14). Jabagi et al. [96] found no difference dant, is generally based on retrospective data without uniform
in 10-year reintervention rates. definition of sternal infection, with or without controls and with
The matched study by Ji et al. [94] combined mortality, MI and minimal if any statistical adjustment [116–119]. Of note, post hoc
stroke and found no significant difference between groups with a analysis of the ITA harvesting technique from the ART revealed
mean follow-up of over 3 years. that pedicled BITA but not skeletonized single internal thoracic
The matched cohort studies by Ogawa et al. [95] and Raja artery or BITA was associated with a significantly increased risk of
et al. [98] both explored mortality with at least 5 years of follow- any sternal wound complication [120]. Careful analysis of the STS
up in nearly 1500 patients and found no significant difference in Adult Cardiac Surgery Database, which reflects over 95% of car-
late death with up to 15 years after surgery. The multivariable diac operations performed in the USA [121], revealed that ske-
analyses by Ben-Gal et al. in 1990 patients and Mohammadi letonized ITA harvesting, although less common than the
et al. in 1977 patients, as well as the entropy-balanced analysis pedicled approach, was associated with a significantly lower risk
by Jabagi et al. of 2050 patients likewise found no significant dif- of DSWI (adjusted OR 0.66, 95% CI 0.44–1.00; P = 0.05) and an
ference in long-term mortality between graft configurations [96, equivalent risk of operative mortality [122]. However, recent
97, 99]. meta-analysis showed that the skeletonized approach did not
eliminate the elevated risk of sternal infection in bilateral internal
Technical considerations: RITA to LAD as part of a BITA mammary artery grafting [123].
revascularization strategy. The strategy and use of the in Graft patency studies are generally retrospective, based on
situ RITA to revascularize the LAD territory (and the LITA to by- clinical indication and vary greatly in the length of follow-up, but
pass the circumflex territory) requires several important technical have historically demonstrated comparable graft patency be-
and clinical considerations: tween the 2 approaches [124, 125]. Some studies of late mortality
favoured the skeletonized approach [126]. However, 2 recent post
hoc analyses of clinical trial data raise considerable concern
Limited length. The RITA needs to be harvested for its max- regarding graft patency and clinical outcome in the contempor-
imal length especially proximally to reach coronary targets with- ary practice of skeletonized ITA grafting. Data from the
out tension. The very distal part of the ITA however has a small COMPASS trial which assessed the role of rivaroxaban plus/minus
caliber, is very muscular and prone to spasm, and may be associ- aspirin in patients with cardiovascular disease was able to study
ated with inferior patency when used for grafting. the 1-year graft patency (by computed tomography angiography)
This limitation could potentially be mitigated by the use of the of 1002/1448 patients in the CABG arm and found graft occlu-
RITA as a Y or T graft to the lateral wall with a proximal anasto- sion in 33/344 (9.6%) of ITA grafts in the skeletonized group
mosis of the RITA to an in situ LITA to the LAD. compared with 30/764 (3.9%) in the pedicled group (adjusted OR
2.41, 95% CI 1.39–4.20; P = 0.002). Perhaps of greater concern, at
Potential injury at time of redo sternotomy. An in situ the end of the 2.5-year trial, the skeletonized graft patients had a
RITA crossing the midline either anteriorly or when the RITA is higher risk of MACE including cardiovascular death, MI, stroke or
tunnelled through the transverse sinus posteriorly is more prone revascularization (adjusted HR 3.19, 95% CI 1.53–6.67; P = 0.002),
to injury at the time of redo sternotomy [100, 101]. Such injury driven by revascularization and stroke [127]. Patients were not
could have potential devastating consequences. Specific location randomized by surgical technique and the skeletonized group
and proximity of crossing grafts to the sternum or cross-clamp had a higher incidence of hypertension, elevated cholesterol, and
must be carefully defined by preoperative gated computed tom- medication profile. Overall, RITA occlusion was 18/84 (21.4%),
ography angiography and or angiography. Even with such care- reflecting potential variability in surgical technique. Post hoc ana-
ful and detailed preoperative assessments, because of the lysis of the ART trial patients revealed similar mortality but higher
variable and unpredictable presence of adhesions, aortopathy MACE in the skeletonized versus the pedicled ITA patients at
and significant residual native coronary artery disease, such inju- 10 years of follow-up (HR 1.25, 95% CI 1.06–1.47; P = 0.01) driven
ries could have potentially very significant adverse consequences by a higher need for repeat revascularization (HR 1.42, 95% CI
[100]. 1.11–1.82; P = 0.01). Interestingly, when limiting analysis to
surgeons enrolling 51 patients or more, the difference disap- P < 0.00001), and a reduced need for outpatient wound manage-
peared [128]. ment resources.
As with any surgical procedure, ITA skeletonization is subject The Randomized Endovein Graft Prospective (REGROUP) trial
to tremendous variability in surgical technique and experience: [134] did not find a significant difference between OVH and EVH
use of unipolar versus bipolar cautery versus harmonic scalpel, in the risk of the primary outcome of a composite of MACE
mobilization of the isolated artery versus use of surrounding tis- including death from any cause, nonfatal MI, and repeat revascu-
sue, clips versus cautery for branches, speed and experience of larization (OVH 15.5% vs EVH 13.9%, HR 1.12, 95% CI 0.83–1.51;
harvest, use of sequential and Y-grafts, in situ versus free-graft, P = 0.47) over a median follow-up of 2.8 years that was confirmed
off-pump versus on-pump application, may all play a role in sur- over an extended median follow-up of 4.7 years (OVH 23.5% vs
gical results. To date, RCTs have been small and limited to assess- EVH 21.9%, HR 0.92, 95% CI 0.72–1.18; P = 0.52) [135]. However,
ment of graft flow and histology and not powered for clinical the trial did not include angiographic follow-up, and mandated
outcomes. Discrepancy in clinical results may reflect the fact that minimum harvester experience for both techniques which has
earlier studies arose from centres specializing in the technique been shown to affect quality of the conduit, particularly for EVH
which may not be uniformly translatable to a more recent broad- [136].

ly applied experience. It appears as it is generally utilized, the ske- A meta-analysis by Sastry et al. [129] that included 4 studies (2
letonized approach to ITA harvesting may be associated with a randomized, 2 non-randomized) evaluating graft patency in 4700
decreased risk of DSWI, comparable graft flow, but variable clin- patients with up to 18 months of angiographic follow-up found a
ical results that are largely operator dependent. Therefore, use is higher rate of vein graft failure with EVH (OR 1.39, 95% CI 1.11–
best reserved for patients with increased risk of DSWI, such as 1.75; P = 0.004). When only the 2 RCTs [137, 138] with angio-
diabetics or those undergoing BITA grafting, and for surgeons graphic follow-up of 3 and 6 months, respectively, were included
who have considerable experience with atraumatic harvest and in the analysis this finding no longer reached statistical signifi-
good clinical outcomes. cance (OR 1.21, 95% CI 0.76–1.90; P = 0.42). The meta-analysis by
Deppe et al. [130] of 5 studies with angiographic follow-up of
6504 grafts reported a significantly higher risk of graft failure with
EVH (OR 1.38, 95% CI, 1.01–1.88; P < 0.0001). Similarly, Kodia
Key messages et al. [132] reported superior SVG patency with OVH at a mean
follow-up of 2.6 years (OVH 82.3% vs EVH 75.1%; OR 0.61, 95%
• Patency data are mixed, and there is no clear evidence of
CI 0.43–0.87; P = 0.01). Both meta-analyses were driven by the
better patency for the RITA compared to SVG.
non-randomized post hoc analyses of the Project of Ex vivo Vein
• Observational evidence shows that patients who received Graft Engineering via Transfection (PREVENT-IV) [139] and the
RITA rather than SVG for CABG have longer survival and Randomized On/Off Bypass (ROOBY) [140] trials. The latter study
better outcomes after surgery, but the only RCT was neutral. also reported a higher 30-day mortality rate (OVH 3.4% vs EVH
• BITA harvesting may be associated with higher risk of DSWI 2.1%, OR 0.59, 95% CI 0.37–0.94; P = 0.03). Li et al. [133] also
and should be avoided in high-risk patients. reported lower patency with EVH at 1–5 years (OR 0.80, 95% CI
• The RITA should be used to graft target vessels with good 0.70–0.91, 5 studies, 5235 patients; P = 0.0005).
Thus, the current evidence for SVG patency beyond 1-year of
run-off that perfuse a large myocardial mass.
follow-up, which is mostly observational, suggests that EVH is
• The evidence on skeletonization of the ITA is limited and
associated with reduced patency in the longer term. An ad-
suggests a decrease in sternal complications, but no clear equately powered RCT of EVH vs OVH with angiographic follow-
conclusions can be drawn on the impact of skeletonization up may address this gap in the evidence. Randomized data
on graft patency and cardiovascular outcomes. pointing to equipoise for EVH and OVH in terms of MACE under-
scores the highly complex and variable association of graft pa-
tency with clinical outcomes, particularly for SVG typically
grafted to non-LAD territories.
ENDOSCOPIC VEIN HARVESTING

A systematic review of studies comparing open vein graft har- Key messages
vesting (OVH) and EVH yielded 5 relevant meta-analyses and 1 • EVH reduces the risk of leg wound complications.
RCT not included in any of the meta-analyses [129–134]. • Patency data suggest that EVH is associated with reduced
The 2016 International Society for Minimally Invasive patency in the long term, but a large RCT found no
Cardiothoracic Surgery Systematic Review and Consensus
difference between EVH and OVH in terms of MACE.
Conference Statement [131] specifically examining patient-
centred outcomes and resource utilization found that the risk of • More evidence on this important topic is needed.
wound-related complications (i.e. abscess, necrosis, dehiscence,
drainage, seromas, lymphocele, oedema and haematoma) was
significantly reduced with EVH (OR 0.29, 95% CI 0.22–0.37, 29
studies, 11 919 patients, P < 0.00001), as was pain during the post- NO TOUCH SAPHENOUS VEIN GRAFT
operative period (OR 0.19, 95% CI 0.11–0.34, 7 studies, 834
patients, P < 0.00001). In addition, EVH was associated with a re- Given that the most commonly used graft continues to be the
duction in total hospital length of stay (mean difference = -0.73 - SVG and that there exist patient specific factors affecting graft pa-
days, 95% CI -1.18 to -0.28, 18 studies, 14 983 patients, tency and wound complications with the use of additional
arterial grafts, there is a compelling rationale for improving out- Two studies have reported on leg wound healing using stand-
REVASCULARIZATION
comes using SVGs. ardized questionnaires serially postoperatively. The PATENT SVG
The no touch saphenous vein graft (NT SVG) is a Class IIA, study (n = 17) used a within patient randomization [152]. Leg as-
MYOCARDIAL
LOE B recommendation in the 2018 European Revascularization sessment scores were worse in the NT legs at 3 months
Guidelines [141] based on 2 small graft patency RCTs [142, 143]. (P < 0.001) but similar and with minimal impairment at 1 year
The NT SVG harvesting method was designed to reduce vessel [153]. In the trial by Deb et al. [145], the cumulative incidence of
injury during surgical preparation. The key features are atrau- leg wound infection over 1 year was greater with NT SVG har-
matic harvesting with inclusion of a pedicle of adjacent fatty tis- vesting (25.4% vs 11.8%; P < 0.01), primarily because of differen-
sue to minimize graft spasm and avoid high-pressure dilation ces at 1 and 3 months. Adverse leg outcomes using the
during vein preparation. A longitudinal single-centre angio- standardized questionnaire were worse following NT SVG har-
graphic RCT of 104 patients by de Souza et al. comparing NT vesting at 1 and 3 months but similar and with minimal impair-
and conventional saphenous vein grafts (CON SVGs) revealed ment at 1 year. In the original trial by de Souza, leg wound
significantly better patency of the NT veins at 8.5 years (91% vs complications were 11.1% with NT harvesting versus 4.3% in the
77%; P = 0.01) which was maintained at 16 years (83% vs 64%; controls [153]. EVH compared to OVH is associated improved

P = 0.03) [142]. In an intravascular ultrasound substudy of the wound healing [129]. Given the increased incidence of adverse
same patient population, there were significant differences harvest site outcomes using NT SVGs, endoscopic approaches
which favoured the NT SVGs according to multiple graft imaging have been considered. There are reports of small case series of
endpoints 8.5 years postoperatively [144]. Two additional RCTs minimally invasive NT SVG harvesting combining both techni-
using angiographic patency have been completed—one multi- ques [135].
centre trial of 250 patients [145] and one single-centre trial of 60
patients [146]. Aggregated results from the 3 RCTs (525 SVGs)
revealed a significant reduction of graft stenosis or occlusion at Key messages
1 year in the NT SVGs (OR 0.47, 95% CI 0.26–0.84; P = 0.01) and
• Randomized data show that the patency rate of NT SVG is
a trend for complete occlusion (OR 0.57, 95% CI 0.30–1.06;
P = 0.07) with no evidence of heterogeneity between the studies significantly better than that of the traditionally harvested
[145]. De Sousa also compared the NT SVG with a RA in an SVG.
angiographic trial using a within patient randomization in 108 • There is no clear evidence of better clinical outcomes using
patients. At 8.5 years, patency was similar between the 2 con- the NT SVG compared to the CON SVG.
duits (NT SVG 86%; RA 79%, P = 0.22) but NT was superior when • The use of the NT SVG is associated with a significantly
analysed per distal anastomosis (NT SVG 91%; RA 81%, P < 0.05) higher risk of harvesting site complications.
[143]. A comprehensive NMA of 14 angiographic RCTs involving
3651 grafts at a mean follow-up of 5.1 years, confirmed that
graft occlusion was reduced in NT compared to CON SVGs (IRR
0.55, 95% CI 0.39–0.78); the RA and NT SVG ranked as the best
conduits (rank scores 0.87 and 0.85 respectively) [6]. An add-
itional NMA of 11 studies by Yokoyama et al. [147] was consist- GASTROEPIPLOIC ARTERY
ent with this result, reporting an IRR of 0.32 (95% CI 0.17–0.60)
with at least 3 years of follow-up in favour of NT SVGs over The right gastroepiploic artery (RGEA) conduit has most com-
CON SVGs. Kim et al. [148] reported better 1 year graft SVG pa- monly been used as an in situ arterial bypass graft; however, it
tency of LITA-SVG composite grafts with NT SVGs compared to can also be used as a composite graft based on the ITA, or alter-
SVGs without a pedicle (97.3% vs 92.6%; P = 0.05) in a propensity nately as a free graft if a preoperative abdominal aortogram or
score-matched study of 196 patients. computed tomography shows significant narrowing of the coel-
In a 2655-patient RCT from China graft failure was substantially iac axis or if the RGEA had low free flow [154, 155].
reduced for the NT grafts compared with CON SVG, both at
3 months (OR, 0.57, 95% CI 0.41–0.80; P < 0.001) and 12 months
(OR 0.56, 95% CI 0.41–0.76; P < 0.001) [149]. Long-term patency
SWEDEGRAFT is an ongoing 900-patient registry-based RCT
comparing NT and CON SVGs; the primary endpoint is the pro- Available data on early and long-term outcomes are mostly from
portion of patients with SVG graft failure according to study CT reports of in situ RGEA grafts anastomosed to the RCA [156–162].
angiography, SVG graft failure according to clinically driven angi- The reported early postoperative angiographic patency rate
ography, or death over 2 years of follow-up [150]. ranges as high as 97.1–99.6% [157–159, 162]. However, patency
At this point, there is no convincing data that clinical outcomes rate varies between 81.4–98.7% at 1 year [156–159, 162], 91.1–
are favourably affected using NT SVGs. The previously mentioned 96% at 3 years [156, 159, 161], 83.4–94.7% at 5 years [156, 157,
multicentre RCT by Deb and associates reported that major car- 159, 161, 162] and 66.5–90.2% [157, 159–162] at 8–10 years. This
diac and cerebrovascular events were not statistically different at is likely because the patency of RGEA graft is influenced by target
1 year (HR 1.19, 95% CI 0.64–2.19) [145]. A propensity-matched vessel stenosis and graft harvesting technique.
study of 2698 patients using the SWEDEHEART registry reported
on mortality and repeat intervention at a mean of 6.6 years Long-term clinical outcomes
follow-up [151]. There was no difference in mortality (HR 0.97,
95% CI 0.80–1.19) or repeat revascularization (HR 0.91, 95% CI Few studies have directly compared use of in situ RGEA vs SVG,
0.71–1.17) although repeat angiography was reduced in the NT and the data that exists generally tests its use as the third conduit
patients (HR 0.76, 95% CI 0.63–0.93) [151]. to supplement BITA.

Figure 1: Visual summary of key messages. Parts of the figure were drawn by using pictures from Servier Medical Art (smart.servier.com). Servier Medical Art by
Servier is licenced under a Creative Commons Attribution 3.0 Unported Licence (https://creativecommons.org/licenses/by/3.0/).
A meta-analysis by Di Mauro et al. [163] compared 2548 was harvested in skeletonized or semi-skeletonized fashion and
patients from 6 studies receiving either in situ RGEA (n = 1023) or used as in situ graft, anastomosed to distal RCA with more than
SVG (n = 1525) to supplement BITA. Overall, long-term survival 90% stenosis or minimal lumen diameter (MLD) of <1 mm. These
was not different between the 2 conduits, albeit with a high de- results were better than previously reported patency of in situ
gree of heterogeneity. When only propensity-matched studies pedicled GEA, although direct comparisons are lacking [157].
were included, in situ GEA had a long-term survival advantage
over SVG (HR 0.47, 95% CI 0.31–0.71, n = 1051; P < 0.001) and the
Patient and target vessel selection
heterogeneity was reduced.
One propensity-matched study compared long-term clinical
Contraindications for in situ GEA conduits include obese or very
outcomes of RGEA composite grafts with those of RITA compos-
elderly patients, and those in whom future abdominal surgery
ite grafts and found no statistically significant survival difference
may be needed. Although rerouting of the patent GEA graft using
at 15 years (52.9% vs 49.4%; P = 0.470) [162].
SVG in case of abdominal surgery is possible, it requires meticu-
Suzuki et al. [164] reported better freedom from MACE at
lous surgical management [167].
7 years for in situ RGEA over SVG, although this has not been In situ RGEA flow can be compromised by native flow compe-
replicated by other matched cohort studies whether an in situ or tition when anastomosed to target coronary artery with moder-
composite graft is used [160, 162]. ate stenosis [160, 168]. MLD of native RCA seems a more reliable
indicator rather than angiographic stenosis, especially for the
Skeletonized/pedicle harvesting RCA. On the basis of systematic 3-year angiographic data,
Glineur et al. [169] recommend that in situ RGEA should be used
Although RGEA is contractile and prone to vasospasm, skeletoni- preferentially to graft the RCA system only when the MLD of tar-
zation using the harmonic scalpel can reduce spasm by removing get RCA is below 1.1 mm. Akita et al. [161] reported a 10-year pa-
the periarterial nerve plexus, as well as extend the graft length tency rate of only 39.3% for in situ RGEA when it was
and enable anastomosis with a larger diameter vessel [165, 166]. anastomosed to RCA with MLD >1 mm, but a satisfactory patency
Suzuki et al. [159] reported 8 years patency of 90.2% and Akita of 89.8% when MLD was <1 mm. A visual summary of all the key
et al. [161] reported 10 years patency of 89.8%, when in situ RGEA messages is displayed in Figure 1.
[3] Cameron A, Davis KB, Green G, Schaff HV. Coronary bypass surgery with
Key messages internal-thoracic-artery grafts effects on survival over a 15-year period.
REVASCULARIZATION
N Engl J Med 1996;334:216–9.
• There is limited data on the use of the RGEA.
MYOCARDIAL
[4] Loop F. Internal-thoracic-artery grafts—biologically better coronary
• Skeletonized harvesting and use to graft target vessels at low arteries. N Engl J Med 1996;334:263–5.
risk of chronic competitive flow have been associated with [5] Cao C, Manganas C, Horton M, Bannon P, Munkholm-Larsen S, Ang SC
et al. Angiographic outcomes of radial artery versus saphenous vein in
improved RGEA outcomes in observational series. coronary artery bypass graft surgery: a meta-analysis of randomized
controlled trials. J Thorac Cardiovasc Surg 2013;146:255–61.
[6] Gaudino M, Hameed I, Robinson NB, Ruan Y, Rahouma M, Naik A et al.
Angiographic patency of coronary artery bypass conduits: a network
Funding meta-analysis of randomized trials. J Am Heart Assoc 2021;10:e019206.
[7] Gaudino M, Benedetto U, Fremes S, Biondi-Zoccai G, Sedrakyan A,
Puskas JD et al.; RADIAL Investigators. Radial-artery or saphenous-vein
None to declare. grafts in coronary-artery bypass surgery. N Engl J Med 2018;378:
2069–77.
Conflict of interest: none declared. [8] Benedetto U, Raja SG, Albanese A, Amrani M, Biondi-Zoccai G, Frati G.

Searching for the second best graft for coronary artery bypass surgery: a
network meta-analysis of randomized controlled trials. Eur J
DATA AVAILABILITY Cardiothorac Surg 2015;47:59–65; discussion 65.
[9] Gaudino M, Rahouma M, Abouarab A, Leonard J, Kamel M, Di Franco A
et al. Radial artery versus saphenous vein as the second conduit for cor-
All relevant data are within the manuscript and its supporting in- onary artery bypass surgery: a meta-analysis. J Thorac Cardiovasc Surg
formation files. 2019;157:1819–25.e10.
[10] Gaudino M, Benedetto U, Fremes S, Ballman K, Biondi-Zoccai G,
Sedrakyan A et al.; RADIAL Investigators. Association of radial artery graft
Author contributions: vs saphenous vein graft with long-term cardiovascular outcomes among
patients undergoing coronary artery bypass grafting: a systematic review
Mario Gaudino: Conceptualization; Investigation; Methodology; and meta-analysis. JAMA 2020;324:179–87.
Validation; Writing—original draft; Writing—review & editing. [11] Goldman S, Sethi GK, Holman W, Thai H, McFalls E, Ward HB et al.
Radial artery grafts vs saphenous vein grafts in coronary artery bypass
Faisal G. Bakaeen: Conceptualization; Writing—original draft. surgery a randomized trial. JAMA 2011;305:167–74.
Sigrid Sandner: Conceptualization; Writing—original draft. [12] Goldman S, McCarren M, Sethi GK, Holman W, Bakaeen FG, Wagner TH
Gabriel S. Aldea: Conceptualization; Writing—original draft. et al.; CSP #474 Investigators. Long-term mortality follow-up of radial ar-
Hirokuni Arai: Conceptualization; Writing—original draft. tery versus saphenous vein in coronary artery bypass grafting: a multi-
Joanna Chikwe: Conceptualization; Writing—original draft. Scott center, randomized trial. Circulation 2022;146:1323–5.
[13] Buxton BF, Hayward PA, Raman J, Moten SC, Rosalion A, Gordon I et al.;
Firestone: Data curation; Project administration. Stephen E. RAPCO Investigators. Long-term results of the RAPCO trials. Circulation
Fremes: Conceptualization; Writing—original draft. Walter J. 2020;142:1330–8.
Gomes: Conceptualization; Writing—original draft. Ki Bong- [14] Jarvis MA, Jarvis CL, Jones PR, Spyt TJ. Reliability of Allen’s test in selec-
Kim: Conceptualization; Writing—original draft. Kalie Kisson: tion of patients for radial artery harvest. Ann Thorac Surg 2000;70:
Data curation; Project administration. Paul Kurlansky: 1362–5.
[15] Holman WL, Davies JE, Lin JY, Wang Y, Goldman S, Bakaeen FG et al.; VA
Conceptualization; Writing—original draft. Jennifer Lawton: CSP 474 Investigators. Consequences of radial artery harvest: results of a
Conceptualization; Writing—original draft. Daniel Navia: prospective, randomized, multicenter trial. JAMA Surg 2013;148:1020–3.
Conceptualization; Writing—original draft. John D. Puskas: [16] Moon MR, Barner HB, Bailey MS, Lawton JS, Moazami N, Pasque MK
Conceptualization; Writing—original draft. Marc Ruel: et al. Long-term neurologic hand complications after radial artery har-
Conceptualization; Writing—original draft. Joseph F. Sabik: vesting using conventional cold and harmonic scalpel techniques. Ann
Thorac Surg 2004;78:535–8; discussion 538.
Conceptualization; Writing—original draft. Thomas A. Schwann: [17] Glineur D, Grau JB, Etienne PY, Benedetto U, Fortier JH, Papadatos S
Conceptualization; Writing—original draft. David P. Taggart: et al. Impact of preoperative fractional flow reserve on arterial bypass
Conceptualization; Writing—original draft. James Tatoulis: graft anastomotic function: the IMPAG trial. Eur Heart J 2019;40:2421–8.
Conceptualization; Writing—original draft. Moritz Wyler von [18] Gatti G, Taffarello P, De Groodt J, Benussi B. A non-conventional prox-
Ballmoos: Conceptualization; Formal analysis; Investigation; imal inflow for the radial artery coronary graft. Interact CardioVasc
Thorac Surg 2020;31:179–81.
Methodology; Writing—original draft; Writing—review & editing. [19] Karagoz HY, Kurtoglu M, Bakkaloglu B, Sonmez B, Cetintas T, Bayazit K.
Coronary artery bypass grafting in the awake patient: three years’ experi-
ence in 137 patients. J Thorac Cardiovasc Surg 2003;125:1401–4.
Reviewer information [20] Yoon SK, Song H, Lim JY. Effect of the proximal anastomosis configur-
ation of the radial artery in patients undergoing coronary artery bypass
European Journal of Cardio-Thoracic Surgery thanks Piroze Davierwala, Dawn grafting. J Chest Surg 2021;54:117–26.
Hui, Rafael Sadaba and the other, anonymous reviewer(s) for their contribu- [21] Tinica G, Chistol RO, Bulgaru Iliescu D, Furnica C. Long-term graft pa-
tion to the peer review process of this article. tency after coronary artery bypass grafting: effects of surgical technique.
Exp Ther Med 2019;17:359–67.
[22] Hosono M, Murakami T, Hirai H, Sasaki Y, Suehiro S, Shibata T. The risk
REFERENCES factor analysis for the late graft failure of radial artery graft in coronary
artery bypass grafting. Ann Thorac Cardiovasc Surg 2019;25:32–8.
[1] ElBardissi AW, Aranki SF, Sheng S, O’Brien SM, Greenberg CC, Gammie [23] Kim DJ, Lee SH, Joo HC, Yoo KJ, Youn YN. Effect of the proximal anasto-
JS. Trends in isolated coronary artery bypass grafting: an analysis of the mosis site on mid-term radial artery patency in off-pump coronary ar-
Society of Thoracic Surgeons adult cardiac surgery database. J Thorac tery bypass. Eur J Cardiothorac Surg 2018;54:475–82.
Cardiovasc Surg 2012;143:273–81. [24] Watson RA, Hamza M, Tsakok TM, Tsakok MT. Radial artery for coronary
[2] Loop FD, Lytle BW, Cosgrove DM, Stewart RW, Goormastic M, Williams artery bypass grafting: does proximal anastomosis to the aorta or left in-
GW et al. Influence of the internal-mammary-artery graft on 10-year ternal mammary artery achieve better patency? Interact CardioVasc
survival and other cardiac events. N Engl J Med 1986;314:1–6. Thorac Surg 2013;17:1020–4.
[25] Nakajima H, Kobayashi J, Toda K, Fujita T, Shimahara Y, Kasahara Y et al. [46] Buturak A, Tekturk BM, Degirmencioglu A, Ulus S, Surgit O, Ariturk C et
Angiographic evaluation of flow distribution in sequential and compos- al. Transradial catheterization may decrease the radial artery luminal
ite arterial grafts for three vessel disease. Eur J Cardiothorac Surg 2012; diameter and impair the vasodilatation response in the access site at late
41:763–9. term: an observational study. Heart Vessels 2016;31:482–9.
[26] Gaudino M, Alessandrini F, Pragliola C, Cellini C, Glieca F, Luciani N et [47] Madssen E, Haere P, Wiseth R. Radial artery diameter and vasodilatory
al. Effect of target artery location and severity of stenosis on mid-term properties after transradial coronary angiography. Ann Thorac Surg
patency of aorta-anastomosed vs. internal thoracic artery-anastomosed 2006;82:1698–702.
radial artery grafts. Eur J Cardiothorac Surg 2004;25:424–8. [48] Yan Z, Zhou Y, Zhao Y, Zhou Z, Yang S, Wang Z. Impact of transradial
[27] Deb S, Cohen EA, Singh SK, Une D, Laupacis A, Fremes SE; RAPS coronary procedures on radial artery function. Angiology 2014;65:
Investigators. Radial artery and saphenous vein patency more than 5 104–7.
years after coronary artery bypass surgery: results from RAPS (Radial [49] Dawson EA, Rathore S, Cable NT, Wright DJ, Morris JL, Green DJ. Impact
Artery Patency Study). J Am Coll Cardiol 2012;60:28–35. of introducer sheath coating on endothelial function in humans after
[28] Qiao E, Wang Y, Yu J, Wang X, Luo X, Wang W. Short-term assessment transradial coronary procedures. Circ Cardiovasc Interv 2010;3:148–56.
of radial artery grafts with multidetector computed tomography. J [50] Burstein JM, Gidrewicz D, Hutchison SJ, Holmes K, Jolly S, Cantor WJ.
Cardiothorac Surg 2021;16:93. Impact of radial artery cannulation for coronary angiography and angio-
[29] Royse AG, Brennan AP, Pawanis Z, Canty D, Royse CF. Patency when plasty on radial artery function. Am J Cardiol 2007;99:457–9.
grafted to coronary stenosis more than 50% in LIMA-RA-Y grafts. Heart [51] Lim LM, Galvin SD, Javid M, Matalanis G. Should the radial artery be

Lung Circ 2020;29:1101–7. used as a bypass graft following radial access coronary angiography.
[30] Jawitz OK, Cox ML, Ranney D, Williams JB, Mulder H, Gaudino MFL et al. Interact CardioVasc Thorac Surg 2014;18:219–24.
Outcomes following revascularization with radial artery bypass grafts: [52] Ruzieh M, Moza A, Siddegowda Bangalore B, Schwann T, Tinkel JL. Effect
insights from the PREVENT-IV trial. Am Heart J 2020;228:91–7. of transradial catheterisation on patency rates of radial arteries used as a
[31] Tamim M, Alexiou C, Al-Hassan D, Al-Faraidy K. Prospective randomized conduit for coronary bypass. Heart Lung Circ 2017;26:296–300.
trial of endoscopic vs open radial artery harvest for CABG: clinical out- [53] Gaudino M, Fremes S, Schwann TA, Tatoulis J, Wingo M, Tranbaugh RF.
come, patient satisfaction, and midterm RA graft patency. J Card Surg Technical aspects of the use of the radial artery in coronary artery by-
2020;35:2147–54. pass surgery. Ann Thorac Surg 2019;108:613–22.
[32] Gaudino MF, Lorusso R, Ohmes LB, Narula N, McIntire P, Gargiulo A et [54] Moscarelli M, Gaudino M. Calcium-channel blockers in patients with ra-
al. Open radial artery harvesting better preserves endothelial function dial artery grafts. When enough is enough. J Card Surg 2021;36:1827–31.
compared to the endoscopic approach. Interact CardioVasc Thorac Surg [55] Cable DG, Caccitolo JA, Pearson PJ, O’Brien T, Mullany CJ, Daly RC et al.
2019;29:561–7. New approaches to prevention and treatment of radial artery graft vaso-
[33] Kiaii BB, Swinamer SA, Fox SA, Stitt L, Quantz MA, Novick RJ. A prospect- spasm. Circulation 1998;98:II15-21; discussion II21-2.
ive randomized study of endoscopic versus conventional harvesting of [56] He GW, Yang CQ. Comparative study on calcium channel antagonists in
the radial artery. Innovations (Phila) 2017;12:231–8. the human radial artery: clinical implications. J Thorac Cardiovasc Surg
[34] Lei JJH, Ravendren A, Snosi M, Harky A. In patients undergoing coronary 2000;119:94–100.
artery bypass grafting, is endoscopic harvesting superior to open radial [57] Tatoulis J, Buxton BF, Fuller JA, Meswani M, Theodore S, Powar N et al.
artery harvesting? Interact CardioVasc Thorac Surg 2021;32:447–51. Long-term patency of 1108 radial arterial-coronary angiograms over 10
[35] Huang TY, Huang TS, Cheng YT, Wang YC, Chen TP, Yin SY et al. Radial years. Ann Thorac Surg 2009;88:23–9; discussion 29–30.
artery harvesting in coronary artery bypass grafting surgery-endoscopic [58] Gaudino M, Benedetto U, Fremes SE, Hare DL, Hayward P, Moat N et al.;
or open method? A meta-analysis. PLoS One 2020;15:e0236499. RADIAL Investigators. Effect of calcium-channel blocker therapy on ra-
[36] Kamiya H, Ushijima T, Kanamori T, Ikeda C, Nakagaki C, Ueyama K et al. dial artery grafts after coronary bypass surgery. J Am Coll Cardiol 2019;
Use of the radial artery graft after transradial catheterization: is it suitable 73:2299–306.
as a bypass conduit? Ann Thorac Surg 2003;76:1505–9. [59] Gaudino M, Burzotta F, Bakaeen F, Bertrand O, Crea F, Di Franco A et al.;
[37] Antonopoulos AS, Latsios G, Oikonomou E, Aznaouridis K, Papanikolaou Arterial Grafting International Consortium Alliance. The radial artery for
A, Syrseloudis D et al. Long-term endothelial dysfunction after trans- percutaneous coronary procedures or surgery? J Am Coll Cardiol 2018;
radial catheterization: a meta-analytic approach. J Card Surg 2017;32: 71:1167–75.
464–73. [60] Taggart DP, Benedetto U, Gerry S, Altman DG, Gray AM, Lees B et al.;
[38] Dharma S, Kedev S, Patel T, Kiemeneij F, Gilchrist IC. A novel approach Arterial Revascularization Trial Investigators. Bilateral versus single
to reduce radial artery occlusion after transradial catheterization: post- internal-thoracic-artery grafts at 10 years. N Engl J Med 2019;380:
procedural/prehemostasis intra-arterial nitroglycerin. Catheter 437–46.
Cardiovasc Interv 2015;85:818–25. [61] Benedetto U, Caputo M, Gaudino M, Mariscalco G, Bryan A, Angelini
[39] Mounsey CA, Mawhinney JA, Werner RS, Taggart DP. Does previous GD. Is the right internal thoracic artery superior to saphenous vein for
transradial catheterization preclude use of the radial artery as a conduit grafting the right coronary artery? A propensity score-based analysis. J
in coronary artery bypass surgery? Circulation 2016;134:681–8. Thorac Cardiovasc Surg 2017;154:1269–75.e5.
[40] Rashid M, Kwok CS, Pancholy S, Chugh S, Kedev SA, Bernat I et al. Radial [62] Gaudino M, Lorusso R, Rahouma M, Abouarab A, Tam DY, Spadaccio C
artery occlusion after transradial interventions: a systematic review and et al. Radial artery versus right internal thoracic artery versus saphenous
meta-analysis. J Am Heart Assoc 2016;5:e002686. vein as the second conduit for coronary artery bypass surgery: a network
[41] Wakeyama T, Ogawa H, Iida H, Takaki A, Iwami T, Mochizuki M et al. meta-analysis of clinical outcomes. J Am Heart Assoc 2019;8:e010839.
Intima-media thickening of the radial artery after transradial interven- [63] Gaudino M, Bf U, Benedetto M, Rahouma D, Franco A, Tam DY et al.
tion. An intravascular ultrasound study. J Am Coll Cardiol 2003;41: Use rate and outcome in bilateral internal thoracic artery grafting:
1109–14. insights from a systematic review and meta-analysis. J Am Heart Assoc
[42] Yonetsu T, Kakuta T, Lee T, Takayama K, Kakita K, Iwamoto T et al. 2018;7:e009361.
Assessment of acute injuries and chronic intimal thickening of the radial [64] Chikwe J, Sun E, Hannan EL, Itagaki S, Lee T, Adams DH et al.
artery after transradial coronary intervention by optical coherence tom- Outcomes of second arterial conduits in patients undergoing multi-
ography. Eur Heart J 2010;31:1608–15. vessel coronary artery bypass graft surgery. J Am Coll Cardiol 2019;
[43] Di Vito L, Burzotta F, Trani C, Pirozzolo G, Porto I, Niccoli G et al. Radial 74:2238–48.
artery complications occurring after transradial coronary procedures [65] Samadashvili Z, Sundt TM 3rd, Wechsler A, Chikwe J, Adams DH, Smith
using long hydrophilic-coated introducer sheath: a frequency domain- CR et al. Multiple versus single arterial coronary bypass graft surgery for
optical coherence tomography study. Int J Cardiovasc Imaging 2014;30: multivessel disease. J Am Coll Cardiol 2019;74:1275–85.
21–9. [66] Deo SV, Shah IK, Dunlay SM, Erwin PJ, Locker C, Altarabsheh SE et al.
[44] Gaudino M, Leone A, Lupascu A, Toesca A, Mazza A, Ponziani FR et al. Bilateral internal thoracic artery harvest and deep sternal wound infec-
Morphological and functional consequences of transradial coronary tion in diabetic patients. Ann Thorac Surg 2013;95:862–9.
angiography on the radial artery: implications for its use as a bypass [67] Dai C, Lu Z, Zhu H, Xue S, Lian F. Bilateral internal mammary artery
conduit. Eur J Cardiothorac Surg 2015;48:370–4. grafting and risk of sternal wound infection: evidence from observational
[45] Staniloae CS, Mody KP, Sanghvi K, Mindrescu C, Coppola JT, Antonescu studies. Ann Thorac Surg 2013;95:1938–45.
CR et al. Histopathologic changes of the radial artery wall secondary to [68] Urso S, Nogales E, González JM, Sadaba R, Tena MÁ, Bellot R et al.
transradial catheterization. Vasc Health Risk Manag 2009;5:527–32. Bilateral internal thoracic artery versus single internal thoracic artery: a
meta-analysis of propensity score-matched observational studies. [88] Raza S, Blackstone EH, Houghtaling PL, Olivares G, Ravichandren K,
Interact CardioVasc Thorac Surg 2019;29:163–72. Koprivanac M et al. Natural history of moderate coronary artery stenosis
REVASCULARIZATION
[69] Dorman MJ, Kurlansky PA, Traad EA, Galbut DL, Zucker M, Ebra G. after surgical revascularization. Ann Thorac Surg 2018;105:815–21.
MYOCARDIAL
Bilateral internal mammary artery grafting enhances survival in diabetic [89] Manabe S, Fukui T, Shimokawa T, Tabata M, Katayama Y, Morita S et al.
patients: a 30-year follow-up of propensity score-matched cohorts. Increased graft occlusion or string sign in composite arterial grafting for
Circulation 2012;126:2935–42. mildly stenosed target vessels. Ann Thorac Surg 2010;89:683–7.
[70] Puskas JD, Sadiq A, Vassiliades TA, Kilgo PD, Lattouf OM. Bilateral intern- [90] Bakaeen FG, Ghandour H, Ravichandren K, Zhen-Yu Tong M, Soltesz EG,
al thoracic artery grafting is associated with significantly improved long- Johnston DR et al. Right internal thoracic artery patency is affected more
term survival, even among diabetic patients. Ann Thorac Surg 2012;94: by target choice than conduit configuration. Ann Thorac Surg 2022;114:
710–5; discussion 715–6. 458–66.
[71] Pevni D, Medalion B, Mohr R, Ben-Gal Y, Laub A, Nevo A et al. Should [91] Yanagawa B, Verma S, Jüni P, Tam DY, Mazine A, Puskas JD et al. A sys-
bilateral internal thoracic artery grafting be used in patients with dia- tematic review and meta-analysis of in situ versus composite bilateral in-
betes mellitus? Ann Thorac Surg 2017;103:551–8. ternal thoracic artery grafting. J Thorac Cardiovasc Surg 2017;153:
[72] Raza S, Blackstone EH, Houghtaling PL, Koprivanac M, Ravichandren K, 1108–16.e16.
Javadikasgari H et al. Similar outcomes in diabetes patients after coron- [92] Deininger MO, Moreira LFP, Dallan LAO, Oliveira O, Magalhaes DMS,
ary artery bypass grafting with single internal thoracic artery plus radial Coelho J et al. Comparative analysis of the patency of the internal thor-
artery grafting and bilateral internal thoracic artery grafting. Ann Thorac acic artery in the CABG of left anterior descending artery: 6-month post-

Surg 2017;104:1923–32. operative coronary CT angiography evaluation. Rev Bras Cir Cardiovasc
[73] Shahian DM, O’Brien SM, Filardo G, Ferraris VA, Haan CK, Rich JB et al.; 2014;29:192–201.
Society of Thoracic Surgeons Quality Measurement Task Force. The [93] Tatoulis J, Buxton BF, Fuller JA. The right internal thoracic artery: the for-
Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 1– gotten conduit–5,766 patients and 991 angiograms. Ann Thorac Surg
coronary artery bypass grafting surgery. Ann Thorac Surg 2009;88:S2–22. 2011;92:9–7.
[74] Bakaeen FG, Gaudino M, Whitman G, Doenst T, Ruel M, Taggart DP et [94] Ji Q, Xia L, Shi Y, Ma R, Shen J, Lai H et al. Mid-term graft patency of
al.; Invited Experts. 2021: the American Association for Thoracic Surgery right versus left internal mammary artery as arterial conduit usage for
Expert Consensus Document: coronary artery bypass grafting in patients left anterior descending artery revascularisation: insights from a single-
with ischemic cardiomyopathy and heart failure. J Thorac Cardiovasc centre study of propensity-matched data. Int J Surg 2017;48:99–104.
Surg 2021;162:829–50.e1. [95] Ogawa S, Tsunekawa T, Hosoba S, Goto Y, Kato T, Kitamura H et al.
[75] Jones EL, Lattouf OM, Weintraub WS. Catastrophic consequences of in- Bilateral internal thoracic artery grafting: propensity analysis of the left
ternal mammary artery hypoperfusion. J Thorac Cardiovasc Surg 1989; internal thoracic artery versus the right internal thoracic artery as a by-
98:902–7. pass graft to the left anterior descending artery. Eur J Cardiothorac Surg
[76] Navia D, Cosgrove DM 3rd, Lytle BW, Taylor PC, McCarthy PM, Stewart 2020;57:701–8.
RW et al. Is the internal thoracic artery the conduit of choice to replace [96] Jabagi H, Tran D, Glineur D, Rubens FD. Optimal configuration for by-
a stenotic vein graft? Ann Thorac Surg 1994;57:40–4. pass of the left anterior descending artery during bilateral internal thor-
[77] Lytle BW, Blackstone EH, Sabik JF, Houghtaling P, Loop FD, Cosgrove acic artery grafting. Ann Thorac Surg 2020;110:1917–25.
DM. The effect of bilateral internal thoracic artery grafting on survival [97] Ben-Gal Y, Gordon A, Ziv-Baran T, Farkash A, Mohr R, Kramer A et al.
during 20 postoperative years. Ann Thorac Surg 2004;78:2005–12; dis- Late outcomes of in situ versus composite bilateral internal thoracic ar-
cussion 2012–4. tery revascularization. Ann Thorac Surg 2021;112:1441–6.
[78] Galbut DL, Kurlansky PA, Traad EA, Dorman MJ, Zucker M, Ebra G. [98] Raja SG, Benedetto U, Husain M, Soliman R, De Robertis F, Amrani M;
Bilateral internal thoracic artery grafting improves long-term survival in Harefield Cardiac Outcomes Research Group. Does grafting of the left
patients with reduced ejection fraction: a propensity-matched study anterior descending artery with the in situ right internal thoracic artery
with 30-year follow-up. J Thorac Cardiovasc Surg 2012;143:844–53.e4. have an impact on late outcomes in the context of bilateral internal
[79] Farkash A, Pevni D, Mohr R, Kramer A, Ziv-Baran T, Paz Y et al. Single thoracic artery usage? J Thorac Cardiovasc Surg 2014;148:1275–81.
versus bilateral internal thoracic artery grafting in patients with low ejec- [99] Mohammadi S, Dagenais F, Voisine P, Dumont E, Baillot R, Doyle D et al.
tion fraction. Medicine (Baltimore) 2020;99:e22842. Lessons learned from the use of 1,977 in-situ bilateral internal mammary
[80] Mohammadi S, Kalavrouziotis D, Cresce G, Dagenais F, Dumont E, arteries: a retrospective study. J Cardiothorac Surg 2014;9:158.
Charbonneau E et al. Bilateral internal thoracic artery use in patients [100] Joyce FS, McCarthy PM, Taylor PC, Cosgrove DM 3rd, Lytle BW. Cardiac
with low ejection fraction: is there any additional long-term benefit? Eur reoperation in patients with bilateral internal thoracic artery grafts. Ann
J Cardiothorac Surg 2014;46:425–31; discussion 431. Thorac Surg 1994;58:80–5.
[81] Gaudino M, Di Franco A, Flather M, Gerry S, Bagiella E, Gray A et [101] Bakaeen FG, Ghandour H, Ravichandren K, Pettersson GSB, Weiss AJ,
al. Association of age with 10-year outcomes after coronary surgery Tong MZ et al. Risks and outcomes of reoperative cardiac surgery in
in the arterial revascularization trial. J Am Coll Cardiol 2021;77: patients with patent bilateral internal thoracic artery grafts. Ann Thorac
18–26. Surg 2022;114:736–43.
[82] Deo SV, Altarabsheh SE, Shah IK, Cho YH, McGraw M, Sarayyepoglu B et [102] Gaudino M, Toesca A, Nori SL, Glieca F, Possati G. Effect of skeletoniza-
al. Are two really always better than one? Results, concerns and contro- tion of the internal thoracic artery on vessel wall integrity. Ann Thorac
versies in the use of bilateral internal thoracic arteries for coronary artery Surg 1999;68:1623–7.
bypass grafting in the elderly: a systematic review and meta-analysis. Int [103] Yoshikai M, Ito T, Kamohara K, Yunoki J. Endothelial integrity of ultra-
J Surg 2015;16:163–70. sonically skeletonized internal thoracic artery: morphological analysis
[83] Pevni D, Ziv-Baran T, Kramer A, Farkash A, Ben-Gal Y. Is the use of BITA with scanning electron microscopy. Eur J Cardiothorac Surg 2004;25:
vs SITA grafting safe and beneficial in octogenarians? Ann Thorac Surg 208–11.
2021;111:1998–2003. [104] Gaudino M, Toesca A, Glieca F, Girola F, Luciani N, Possati G.
[84] Bakaeen FG, Ravichandren K, Blackstone EH, Houghtaling PL, Soltesz EG, Skeletonization does not influence internal thoracic artery innervation.
Johnston DR et al. Coronary artery target selection and survival after bi- Ann Thorac Surg 2004;77:1257–61.
lateral internal thoracic artery grafting. J Am Coll Cardiol 2020;75: [105] Deja MA, Wos S, Gołba KS, Zurek P, Domaradzki W, Bachowski R et al.
258–68. Intraoperative and laboratory evaluation of skeletonized versus pedicled
[85] Limanto DH, Chang HW, Kim DJ, Kim JS, Park KH, Lim C. Coronary ar- internal thoracic artery. Ann Thorac Surg 1999;68:2164–8.
tery size as a predictor of Y-graft patency following coronary artery by- [106] Sá MP, Cavalcanti PE, Santos HJ, Soares AF, Miranda RG, Araújo ML et al.
pass surgery. Medicine (Baltimore) 2021;100:e24063. Flow capacity of skeletonized versus pedicled internal thoracic artery in
[86] Glineur D, Hanet C, D’Hoore W, Poncelet A, De Kerchove L, Etienne PY coronary artery bypass graft surgery: systematic review, meta-analysis
et al. Causes of non-functioning right internal mammary used in a Y- and meta-regression. Eur J Cardiothorac Surg 2015;48:25–31.
graft configuration: insight from a 6-month systematic angiographic trial. [107] Chaudhri MS, Shah MU, Asghar MI, Siddiqi R, Janjua AM, Iqbal A.
Eur J Cardiothorac Surg 2009;36:129–35; discussion 135–6. Skeletonization of left internal mammary artery in coronary artery by-
[87] Sabik JF 3rd, Lytle BW, Blackstone EH, Khan M, Houghtaling PL, pass grafting. J Coll Physicians Surg Pak 2016;26:736–9.
Cosgrove DM. Does competitive flow reduce internal thoracic artery [108] Satdhabudha O, Noppawinyoowong N. A randomized comparison of
graft patency? Ann Thorac Surg 2003;76:1490–6; discussion 1497. flow characteristics of semiskeletonized and pedicled internal thoracic
artery preparations in coronary artery bypass. J Cardiothorac Surg 2017; outcomes of skeletonized vs pedicled internal thoracic artery har-
12:28. vesting techniques in the arterial revascularization trial. JAMA
[109] Silva M, Rong LQ, Naik A, Rahouma M, Hameed I, Robinson B et al. Cardiol 2021;6:1380–6.
Intraoperative graft flow profiles in coronary artery bypass surgery: a [129] Sastry P, Rivinius R, Harvey R, Parker RA, Rahm AK, Thomas D et al. The
meta-analysis. J Card Surg 2020;35:279–85. influence of endoscopic vein harvesting on outcomes after coronary by-
[110] Kusu-Orkar TE, Kermali M, Masharani K, Noshirwani A, MacCarthy- pass grafting: a meta-analysis of 267,525 patients. Eur J Cardiothorac
Ofosu B, Oguamanam N et al. Skeletonized or pedicled harvesting of left Surg 2013;44:980–9.
internal mammary artery: a systematic review and meta-analysis. Semin [130] Deppe AC, Liakopoulos OJ, Choi YH, Slottosch I, Kuhn EW, Scherner M
Thorac Cardiovasc Surg 2021;33:10–8. et al. Endoscopic vein harvesting for coronary artery bypass grafting: a
[111] Kamiya H, Akhyari P, Martens A, Karck M, Haverich A, Lichtenberg A. systematic review with meta-analysis of 27,789 patients. J Surg Res 2013;
Sternal microcirculation after skeletonized versus pedicled harvesting of 180:114–24.
the internal thoracic artery: a randomized study. J Thorac Cardiovasc [131] Ferdinand FD, MacDonald JK, Balkhy HH, Bisleri G, Hwang HY,
Surg 2008;135:32–7. Northrup P et al. Endoscopic conduit harvest in coronary artery bypass
[112] Nishi H, Mitsuno M, Tanaka H, Ryomoto M, Fukui S, Miyamoto Y. grafting surgery: an ISMICS systematic review and consensus conference
Decreasing sternum microcirculation after harvesting the internal thor- statements. Innovations (Phila) 2017;12:301–19.
acic artery. Eur J Cardiothorac Surg 2011;40:240–4. [132] Kodia K, Patel S, Weber MP, Luc JGY, Choi JH, Maynes EJ et al. Graft pa-
[113] Lorberboym M, Medalion B, Bder O, Lockman J, Cohen N, Schachner A tency after open versus endoscopic saphenous vein harvest in coronary

et al. 99mTc-MDP bone SPECT for the evaluation of sternal ischaemia artery bypass grafting surgery: a systematic review and meta-analysis.
following internal mammary artery dissection. Nucl Med Commun Ann Cardiothorac Surg 2018;7:586–97.
2002;23:47–52. [133] Li G, Zhang Y, Wu Z, Liu Z, Zheng J. Mid-term and long-term outcomes
[114] Cohen AJ, Lockman J, Lorberboym M, Bder O, Cohen N, Medalion B et of endoscopic versus open vein harvesting for coronary artery bypass: a
al. Assessment of sternal vascularity with single photon emission com- systematic review and meta-analysis. Int J Surg 2019;72:167–73.
puted tomography after harvesting of the internal thoracic artery. J [134] Zenati MA, Bhatt DL, Bakaeen FG, Stock EM, Biswas K, Gaziano JM et
Thorac Cardiovasc Surg 1999;118:496–502. al.; REGROUP Trial Investigators. Randomized trial of endoscopic or
[115] Boodhwani M, Lam BK, Nathan HJ, Mesana TG, Ruel M, Zeng W et al. open vein-graft harvesting for coronary-artery bypass. N Engl J Med
Skeletonized internal thoracic artery harvest reduces pain and dysesthe- 2019;380:132–41.
sia and improves sternal perfusion after coronary artery bypass surgery: [135] Zenati MA, Bhatt DL, Stock EM, Hattler B, Wagner TH, Bakaeen FG et al.
a randomized, double-blind, within-patient comparison. Circulation Intermediate-term outcomes of endoscopic or open vein harvesting for
2006;114:766–73. coronary artery bypass grafting: the REGROUP randomized clinical trial.
[116] Toumpoulis IK, Theakos N, Dunning J. Does bilateral internal thoracic ar- JAMA Netw Open 2021;4:e211439.
tery harvest increase the risk of mediastinitis? Interact CardioVasc [136] Desai P, Kiani S, Thiruvanthan N, Henkin S, Kurian D, Ziu P et al. Impact
Thorac Surg 2007;6:787–91. of the learning curve for endoscopic vein harvest on conduit quality and
[117] Saso S, James D, Vecht JA, Kidher E, Kokotsakis J, Malinovski V et al. early graft patency. Ann Thorac Surg 2011;91:1385–91; discussion
Effect of skeletonization of the internal thoracic artery for coronary 1391–2.
revascularization on the incidence of sternal wound infection. Ann [137] Perrault LP, Jeanmart H, Bilodeau L, Lesperance J, Tanguay JF, Bouchard
Thorac Surg 2010;89:661–70. D et al. Early quantitative coronary angiography of saphenous vein grafts
[118] Sá MP, Cavalcanti PE, de Andrade Costa Santos HJ, Soares AF, for coronary artery bypass grafting harvested by means of open versus
Albuquerque Miranda RG, Araújo ML et al. Skeletonized versus pedicled endoscopic saphenectomy: a prospective randomized trial. J Thorac
bilateral internal mammary artery grafting: outcomes and concerns ana- Cardiovasc Surg 2004;127:1402–7.
lyzed through a meta-analytical approach. Int J Surg 2015;16:146–52. [138] Yun KL, Wu Y, Aharonian V, Mansukhani P, Pfeffer TA, Sintek CF et al.
[119] Fouquet O, Tariel F, Desulauze P, Mével G. Does a skeletonized internal Randomized trial of endoscopic versus open vein harvest for coronary
thoracic artery give fewer postoperative complications than a pedicled artery bypass grafting: six-month patency rates. J Thorac Cardiovasc
artery for patients undergoing coronary artery bypass grafting? Interact Surg 2005;129:496–503.
CardioVasc Thorac Surg 2015;20:663–8. [139] Lopes RD, Hafley GE, Allen KB, Ferguson TB, Peterson ED, Harrington RA
[120] Benedetto U, Altman DG, Gerry S, Gray A, Lees B, Pawlaczyk R et al.; et al. Endoscopic versus open vein-graft harvesting in coronary-artery
Arterial Revascularization Trial investigators. Pedicled and skeletonized bypass surgery. N Engl J Med 2009;361:235–44.
single and bilateral internal thoracic artery grafts and the incidence of [140] Zenati MA, Shroyer AL, Collins JF, Hattler B, Ota T, Almassi GH et al.
sternal wound complications: insights from the Arterial Impact of endoscopic versus open saphenous vein harvest technique on
Revascularization Trial. J Thorac Cardiovasc Surg 2016;152:270–6. late coronary artery bypass grafting patient outcomes in the ROOBY
[121] Jacobs JP, Shahian DM, Grau-Sepulveda M, O’Brien SM, Pruitt EY, Bloom (Randomized On/Off Bypass) trial. J Thorac Cardiovasc Surg 2011;141:
JP et al. Current penetration, completeness, and representativeness of 338–44.
the Society of Thoracic Surgeons Adult Cardiac Surgery Database. Ann [141] Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto
Thorac Surg 2022;113:1461–8. U et al.; ESC Scientific Document Group. 2018 ESC/EACTS Guidelines on
[122] Schwann TA, Gaudino MFL, Engelman DT, Sedrakyan A, Li D, Tranbaugh myocardial revascularization. Eur Heart J 2019;40:87–165.
RF et al. Effect of skeletonization of bilateral internal thoracic arteries on [142] Samano N, Geijer H, Liden M, Fremes S, Bodin L, Souza D. The no-touch
deep sternal wound infections. Ann Thorac Surg 2021;111:600–6. saphenous vein for coronary artery bypass grafting maintains a patency,
[123] Oswald I, Boening A, Pons-Kuehnemann J, Grieshaber P. Wound infec- after 16 years, comparable to the left internal thoracic artery: a random-
tion after CABG using internal mammary artery grafts: a meta-analysis. ized trial. J Thorac Cardiovasc Surg 2015;150:880–8.
Thorac Cardiovasc Surg 2021;69:639–48. [143] Dreifaldt M, Mannion JD, Geijer H, Liden M, Bodin L, Souza D. The no-
[124] Sá MP, Ferraz PE, Escobar RR, Nunes EO, Lustosa P, Vasconcelos FP et al. touch saphenous vein is an excellent alternative conduit to the radial ar-
Patency of skeletonized versus pedicled internal thoracic artery in cor- tery 8 years after coronary artery bypass grafting: a randomized trial. J
onary bypass graft surgery: a systematic review, meta-analysis and meta- Thorac Cardiovasc Surg 2021;161:624–30.
regression. Int J Surg 2014;12:666–72. [144] Johansson BL, Souza DSR, Bodin L, Filbey D, Loesch A, Geijer H et al.
[125] Sun X, Huang J, Wang W, Lu S, Zhu K, Li J et al. Off-pump skeletonized Slower progression of atherosclerosis in vein grafts harvested with ‘no
versus pedicled left internal mammary artery grafting: mid-term results. J touch’ technique compared with conventional harvesting technique in
Card Surg 2015;30:494–9. coronary artery bypass grafting: an angiographic and intravascular ultra-
[126] Hu X, Zhao Q. Skeletonized internal thoracic artery harvest improves sound study. Eur J Cardiothorac Surg 2010;38:414–9.
prognosis in high-risk population after coronary artery bypass surgery [145] Deb S, Singh SK, de Souza D, Chu MWA, Whitlock R, Meyer SR et al.;
for good quality grafts. Ann Thorac Surg 2011;92:48–58. SUPERIOR SVG Study Investigators. SUPERIOR SVG: no touch saphenous
[127] Lamy A, Browne A, Sheth T, Zheng Z, Dagenais F, Noiseux N et al.; harvesting to improve patency following coronary bypass grafting (a
COMPASS Investigators. Skeletonized vs pedicled internal mammary ar- multi-Centre randomized control trial, NCT01047449). J Cardiothorac
tery graft harvesting in coronary artery bypass surgery: a post hoc ana- Surg 2019;14:85.
lysis from the COMPASS trial. JAMA Cardiol 2021;6:1042–8. [146] Pettersen Ø, Haram PM, Winnerkvist A, Karevold A, Wahba A, Stenvik M
[128] Gaudino M, Audisio K, Rahouma M, Chadow D, Cancelli G, Soletti et al. Pedicled vein grafts in coronary surgery: perioperative data from a
GJ et al.; ART Investigators. Comparison of long-term clinical randomized trial. Ann Thorac Surg 2017;104:1313–7.
[147] Yokoyama Y, Takagi H, Kuno T. Graft patency of a second conduit for [158] Fukui T, Tabata M, Manabe S, Shimokawa T, Takanashi S. Graft selection
coronary artery bypass surgery: a network meta-analysis of randomized and one-year patency rates in patients undergoing coronary artery by-
REVASCULARIZATION
controlled trials. Semin Thorac Cardiovasc Surg 2022;34:102–9. pass grafting. Ann Thorac Surg 2010;89:1901–5.
MYOCARDIAL
[148] Kim YH, Oh HC, Choi JW, Hwang HY, Kim K-B. No-touch saphenous [159] Suzuki T, Asai T, Nota H, Kuroyanagi S, Kinoshita T, Takashima N et al. Early
vein harvesting may improve further the patency of saphenous vein and long-term patency of in situ skeletonized gastroepiploic artery after off-
composite grafts: early outcomes and 1-year angiographic results. Ann pump coronary artery bypass graft surgery. Ann Thorac Surg 2013;96:90–5.
Thorac Surg 2017;103:1489–97. [160] Jeong DS, Kim YH, Lee YT, Chung SR, Sung K, Kim WS et al.
[149] Wang X, Tian M, Zheng Z, Gao H, Wang Y, Wang L et al. Rationale and Revascularization for the right coronary artery territory in off-pump coron-
design of a multicenter randomized trial to compare the graft patency ary artery bypass surgery. Ann Thorac Surg 2013;96:778–85; discussion 785.
between no-touch vein harvesting technique and conventional ap- [161] Akita S, Tajima K, Kato W, Tanaka K, Goto Y, Yamamoto R et al. The
proach in coronary artery bypass graft surgery. Am Heart J 2019;210: long-term patency of a gastroepiploic artery bypass graft deployed in a
75–80. semiskeletonized fashion: predictors of patency. Interact CardioVasc
[150] Ragnarsson S, Janiec M, Modrau IS, Dreifaldt M, Ericsson A, Holmgren A Thorac Surg 2019;28:868–75.
et al. No-touch saphenous vein grafts in coronary artery surgery [162] Kim MS, Hwang HY, Cho KR, Kim KB. Right gastroepiploic artery versus
(SWEDEGRAFT): rationale and design of a multicenter, prospective, right internal thoracic artery composite grafts: 10-year patency and
registry-based randomized clinical trial. Am Heart J 2020;224:17–24. long-term outcomes. J Thorac Cardiovasc Surg 2022;163:1333–43.
[151] Janiec M, Friberg O, Thelin S. Long-term clinical outcomes after coron- [163] Di Mauro M, Lorusso R, Di Franco A, Foschi M, Rahouma M, Soletti G et

ary artery bypass grafting with pedicled saphenous vein grafts. J al. What is the best graft to supplement the bilateral internal thoracic ar-
Cardiothorac Surg 2018;13:122. tery to the left coronary system? A meta-analysis. Eur J Cardiothorac
[152] Verma S, Lovren F, Pan Y, Yanagawa B, Deb S, Karkhanis R et al. Pedicled Surg 2019;56:21–9.
no-touch saphenous vein graft harvest limits vascular smooth muscle [164] Suzuki T, Asai T, Matsubayashi K, Kambara A, Kinoshita T, Takashima N
cell activation: the PATENT saphenous vein graft study. Eur J et al. In off-pump surgery, skeletonized gastroepiploic artery is superior
Cardiothorac Surg 2014;45:717–25. to saphenous vein in patients with bilateral internal thoracic arterial
[153] Souza DSR, Dashwood MR, Tsui JCS, Filbey D, Bodin L, Johansson B et al. grafts. Ann Thorac Surg 2011;91:1159–64.
Improved patency in vein grafts harvested with surrounding tissue: [165] Yokoyama Y, Matsushita S, Iesaki T, Yamamoto T, Inaba H, Okada T et al.
results of a randomized study using three harvesting techniques. Ann Denervation of gastroepiploic artery graft can reduce vasospasm. J
Thorac Surg 2002;73:1189–95. Thorac Cardiovasc Surg 2014;147:951–5.
[154] Mills NL, Hockmuth DR, Everson CT, Robart CC. Right gastroepiploic ar- [166] Asai T, Tabata S. Skeletonization of the right gastroepiploic artery using
tery used for coronary artery bypass grafting. Evaluation of flow charac- an ultrasonic scalpel. Ann Thorac Surg 2002;74:1715–7.
teristics and size. J Thorac Cardiovasc Surg 1993;106:579–86. [167] Sakai K, Mizuno T, Watanabe T, Nagaoka E, Oi K, Yashima M et al.
[155] Kim KB, Cho KR, Choi JS, Lee HJ. Right gastroepiploic artery for revascu- Management of right gastroepiploic arterial coronary grafts in subse-
larization of the right coronary territory in off-pump total arterial revas- quent abdominal surgeries. Ann Thorac Surg 2018;106:52–7.
cularization: strategies to improve patency. Ann Thorac Surg 2006;81: [168] Shimizu T, Suesada H, Cho M, Ito S, Ikeda K, Ishimaru S. Flow capacity of
2135–41. gastroepiploic artery versus vein grafts for intermediate coronary artery
[156] Hirose H, Amano A, Takanashi S, Takahashi A. Coronary artery bypass stenosis. Ann Thorac Surg 2005;80:124–30.
grafting using the gastroepiploic artery in 1,000 patients. Ann Thorac [169] Glineur D, D’Hoore W, de Kerchove L, Noirhomme P, Price J, Hanet C et
Surg 2002;73:1371–9. al. Angiographic predictors of 3-year patency of bypass grafts implanted
[157] Suma H, Tanabe H, Takahashi A, Horii T, Isomura T, Hirose H et al. on the right coronary artery system: a prospective randomized compari-
Twenty years experience with the gastroepiploic artery graft for CABG. son of gastroepiploic artery, saphenous vein, and right internal thoracic
Circulation 2007;116:I188–91. artery grafts. J Thorac Cardiovasc Surg 2011;142:980–8.

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European Journal of Cardio-Thoracic Surgery 2023, 64(2), ezad163 REVIEW

Expert systematic review on the choice of conduits for coronary

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Patient selection Target vessel selection

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ENDOSCOPIC VEIN HARVESTING

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