Coronary artery bypass surgery conduits used for bypass

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Coronary Artery Bypass Surgery Microchapters


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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-in-Chief: Cafer Zorkun, M.D., Ph.D. [2], Mohammed A. Sbeih, M.D. Anahita Deylamsalehi, M.D.[3]


The choice of conduits (arteries and/or veins from elsewhere in the body) to bypass the blockages is highly surgeon and institution dependent. To choose the proper conduits for CABG both clinical and technical factors such as life expectancy, presence of diabetes, chronic renal failure, and degree of the target stenosis must be considered. Saphenous vein, internal thoracic artery, and radial artery are the most used vessels to harvest for grafting. The saphenous vein can be harvested by either direct visualization or via an endoscopic approach. Among these two methods the endoscopic approach has been associated with lower rates of wound infection, greater patient satisfaction, and earlier mobilization. However, non-randomized data from a much larger multicenter study does suggest that endoscopyendoscopic harvesting may be associated with a higher rate of failure and adverse events such as death and MI. Veins that are used either have their valves removed or are turned around so that the valves in them do not occlude blood flow in the graft. On the other hand, numerous studies support the use of the left internal thoracic artery (LITA) (also known as the left internal mammary artery (LIMA)) to graft the LAD in order to improve survival unless contraindicated. Evidence shows that the right IMA can be used to graft the LAD if the LIMA is impractical and unusable. Furthermore, the right IMA can be used in conjunction with the LIMA which is called bilateral internal mammary artery (BIMA) grafting. The latter method showed a better outcome based on multiple studies. In multiple arterial revascularization during Coronary artery bypass surgery, the right internal thoracic artery (RITA) has been proofed to be a better choice as a conduit than the radial artery. On the other hand, numerous clinical trials have demonstrated better patency rates (in mid- and long-term) when the radial artery is used in comparison with the saphenous vein.

Conduits used for bypass

  • The choice of conduits (arteries and/or veins from elsewhere in the body) to bypass the blockages is highly surgeon and institution dependent.
  • To choose the proper conduits for CABG both clinical and technical factors such as life expectancy, presence of diabetes, chronic renal failure, and degree of the target stenosis must be considered.[1]
  • The following table published by 2021 ACA Revascularization Guideline presents the best practices for the Use of bypass conduits in CABG:[1]
Assessing palmar arch completeness and ulnar compensation before harvesting the radial artery. If radial artery harvesting is considered it is recommended to use the arm with the best ulnar compensation.
It is recommended to use radial artery grafts to target vessels with subocclusive stenosis.
It is recommended to avoid radial artery use after transradial catheterization.
It is recommended to avoid radial artery use in chronic kidney disease patients and in those with a high likelihood of rapid progression to hemodialysis.
It is recommended to avoid oral calcium channel blockers for the first postoperative year after radial artery grafting.
It is recommended to avoid bilateral percutaneous or surgical radial artery procedures in patients with coronary artery disease with a goal to preserve the artery for future use.
It is recommended to use the internal mammary artery (using the skeletonization technique) to reduce the risk of sternal wound complications.
It is recommended to use an endoscopic saphenous vein harvest technique in patients at risk of wound complications.
For patients at low risk of wound complications, it is recommended to use a no-touch saphenous vein harvest technique.
It is recommended to use the skeletonized right gastroepiploic artery to graft right coronary artery target vessels with subocclusive stenosis if the operator is experienced with the use of the artery.

Saphenous vein

Saphenous vein anatomy

Saphenous vein harvesting

The Internal Thoracic Artery

Radial Artery

Conduit Nomenclature

Assessment of Target Vessels for Bypass Grafting

A coronary artery may be unsuitable for bypass grafting for the following reasons:

  • Size: If the native target artery it is small (< 1 mm or < 1.5 mm depending on surgeon preference)
  • Location: Some distal locations of the native target artery may not be accessible, or a conduit may not reach far down the native artery.
  • Native artery calcification: Heavily calcified native arteries are sometimes technically not amenable to anastomosis of a conduit.
  • Diffuse disease: The native artery may not have a section of the vessel that has a minimal disease where a conduit can be grafted to.
  • The native artery lies in the heart muscle or is intramyocardial: In this scenario, the native coronary artery is located within the heart muscle rather than on the surface of the heart and a graft cannot be attached to it.

Although the cardiothoracic surgeon reviews the coronary angiogram prior to surgery and identifies the lesions (or "blockages") in the coronary arteries and will estimate the number of bypass grafts prior to surgery, the final decision is made in the operating room based upon the direct examination of the heart and the suitability of the native target vessel for bypassing.

2021 ACA Revascularization Guideline

Class 1 Recommendation, Level of Evidence: B-R[1][24][22][12]
To improve long-term cardiac outcomes, using a radial artery is recommended in preference to a saphenous vein conduit to graft the second most important, significantly stenosed non–LAD vessel.
Class 1 Recommendation, Level of Evidence: B-NR [1][9][11][10][8][27]
When bypass of the LAD is indicated to improve survival and reduce recurrent ischemic events, an internal thoracic artery (IMA), preferably the left, should be used to bypass the LAD.
Class 2a Recommendation, Level of Evidence: B-NR [1]
Among patients undergoing CABG, grafting the bilateral IMA (BIMA) by experienced operators is beneficial in improving long-term cardiac outcomes (only if patients are selected appropriately).

2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery (DO NOT EDIT)[28]

Class I
"1. If possible, the left internal mammary artery (LIMA) should be used to bypass the left anterior descending (LAD) artery when bypass of the LAD artery is indicated.[10][8][11][29] (Level of Evidence: B)"
"1. An arterial graft should not be used to bypass the right coronary artery with less than a critical stenosis (<90%).[29] (Level of Evidence: C)"
Class IIa
"1. The right internal mammary artery is probably indicated to bypass the LAD artery when the LIMA is unavailable or unsuitable as a bypass conduit. (Level of Evidence: C)"
"2. When anatomically and clinically suitable, use of a second internal mammary artery to graft the left circumflex or right coronary artery (when critically stenosed and perfusing LV myocardium) is reasonable to improve the likelihood of survival and to decrease reintervention.[30][20][31][32][33] (Level of Evidence: B)"
Class IIb
"1. Complete arterial revascularization may be reasonable in patients less than or equal to 60 years of age with few or no comorbidities. (Level of Evidence: C)"
"2. Arterial grafting of the right coronary artery may be reasonable when a critical (≥90%) stenosis is present.[29][32][34] (Level of Evidence: B)"
"3. Use of a radial artery graft may be reasonable when grafting left-sided coronary arteries with severe stenoses (>70%) and right-sided arteries with critical stenoses (≥90%) that perfuse LV myocardium.[35][36][37][38][39][40] (Level of Evidence: B)"


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