Choice of Conduits for Optimal

Coronary Revascularization
Nora Albogami
PGY2
Table of contents:
• Introduction
• IMA
• Radial artery conduit
• SVG
• Other choices
• Coronary artery bypass graft is the gold standard for coronary surgical
revascularization.

Most commonly used conduits in CABG:

o Arterial: internal mammary artery, radial artery
o Venous: greater saphenous vein, short saphenous vein
Factors that influence your conduit choice:

• Life expectancy
• Age
• Comorbidities
• Elective vs emergency surgery
• Target vessel
The decision regarding the optimal strategy for coronary
revascularization has been one of continuous change over the last 50
years during which CABG has evolved.

• The initial strategy of venous grafts was eventually supplanted by the

predominant use of the LIMA to the LAD after the seminal study
published by the Cleveland Clinic in 1984 [1].
Internal Mammary Artery:
1. Anatomy and Histology
2. Advantages vs disadvantages
 Advantages:
1. The conduit of first choice for anastomosis to LAD
2. A proven superior long-term patency (between
90%-98%) at 1 year.
3. Reduced risk of reoperation, length of
hospitalization.
4. Most important determinant of long-term survival
after revascularization, even with occluded vein
grafts.
5. Histological advantage
6. In situ use, avoid proximal anastomosis
7. Excellent size match for coronary arteries
Disadvatage:
1. Small competance vessel: low flow rate
than vein grafts
2. Unable to perfuse large territories
immediately
3. Suseptiable to competetive flow
4. Dependant on patancy of left
subclavian artery- risk of steel
syndrome
5. Proximal harvesting risk
BIMA:
• Slightly longer operative time,
as it requires more dissection,
• Theoretically can impair sternal
bone healing.
• Between 5% and 11% in US.
BIMA
• Concern for complications: obese, diabetes, copd
• Most studies suggest survival benefits of bilateral internal mammary
arteries (BIMA) grafting
• Women vs men?
• Other studies have not shown conclusive superiority of the technique.
 BIMA
• The optimal strategy regarding
which IMA should be
anastomosed to which vessel
remains unresolved.
• Frequently, the LIMA is joined
to the LAD, and the RIMA is
used either for the RCA or
circumflex (obtuse marginal
branch) brought through the
transverse sinus for posterior
access.
skeletonization vs pedicled harvest technique:

a longer graft capable of reaching:

• the distal right coronary artery (RCA),
• the posterior descending artery (PDA),
• Circumflex and LAD vessels

With a potentially lower risk of sternal complications.

• The utilization of T-grafts using
the LIMA as a donor begun to be
more common and serves as a
basis for studies regarding
patency and survival.

• Technically demanding
• Provides competitive flow
Radial Artery:
Advantages vs disadvantages
Radial artery conduit:
Advantages:
• Ease of handling
• Ability to reach all coronary targets
• 10-year patency rates of 85% to 90%
• Recent studies advocating all-arterial
grafting, especially in patients with
diabetes. With or without aortic
anastomoses.
Radial artery conduit:
Disadvantages:
• More prone to spasm, due thicker smooth muscle media
• Prone to competitive flow
• CI in vasculitis or Raynaud’s syndrome, incomplete palmar arch
• 5% incidence of median nerve injury
• Risk of String sign
SVG:
1. Anatomy and Histology
2. Advantages vs disadvantages
Anatomy and histology:
• SVG has a larger diameter (3.1 to 8.5 mm)
• wall thickness ranges from 180 to 650
microns.
• its course
SVG:
Advantages:
• 85% patency rate after 1 year
• 70% after 10 years
• 25% after 20 years
• Available length of conduit
• Large competance vessle
• No risk of competitive flow
Disadvantages:
• 10% early occlusion and approximately
• 5% per year stenosis and/or occlusion
• Intimal thickening

Thus, limiting the long term benefits of coronary artery bypass graft
(CABG) surgery with SVGs
Enhancing techniques of SVG:
• Avoid tension/ traction, over distention (no touch technique)
• Size mismatch
• Quality check (varicosites, atherosclerotic changes, calcifications,
valves)
For patients in whom no other conduit is
available:
o Right gastroepiploic
o Inferior epigastric artery
o Ulnar artery
o Left gastric artery
o Splenic artery
o Thoracodorsal artery

However, little substantial data exist regarding long-term outcomes.

Refrences:
1. STS E-book
2. Cardiac surgery in the adults by Lawrence