**2. Percutaneous coronary interventions**

144 Special Topics in Cardiac Surgery

SVG, coupled with increasing enthusiasm and demand for DES has lead to the emergence of "hybrid" coronary revascularization, typically consisting of LIMA-to-LAD and PCI of other

Coronary artery surgery itself has undergone several iterative changes recently. In the 1990s, great enthusiasm existed for the "mid-CAB" (minimally-invasive direct coronary artery bypass) procedure, an approach integral to "hybrid" revascularizations and primarily involving a small left anterior thoracotomy to harvest the LIMA and expose the left anterior descending [LAD] coronary artery. However, outside of the context of hybrid procedures, mid-CAB has had little widespread applicability, particularly since most patients referred for coronary surgery have multivessel disease. Introduction of mid-CAB procedures help usher in the era of off-pump CABG, which was heralded as an approach to reduce the risks associated with on-pump CABG, particularly myocardial dysfunction and cerebrovascular complications [12]. Finally, technology has introduced minimally invasive platforms for performing multi-vessel CABG, most recently the introduction of "totally endoscopic" and robotic CABG surgery [13]. However, it should be noted that these "improved techniques" continue to utilize the same conduit selection and comparative trials with objective evidence are lacking. Since minimally invasive strategies for CABG do not routinely incorporate changes to the operation known to improve short- and long-term results, there appears little reason to suspect that graft patency rates will be improved by less invasive procedures. Rather, one could argue that these alterations in approach to CABG are primarily based on industry involvement, public demands for less invasive procedures, and as marketing

*Are there alternatives to CABG, which could improve long-term outcomes for graft patency and the composite of major adverse coronary events (MACE) particularly when compared with PCI?* The answer is a resounding "yes," and it is found in arterial conduits for coronary bypass. CABG with multiple arterial grafts have been shown to have improved graft patency, reduced need for reoperation or reintervention, and prolonged survival compared with patients undergoing CABG with one IMA and SVG [14-17]. For instance, Sabik et al reviewed a 27 year experience at the Cleveland Clinic with regard to need for reintervention after primary CABG and found that the extent of arterial grafting correlated with freedom from subsequent reintervention [18]. Specifically, patients who received two IMA grafts at initial surgery had approximately 10% risk for reintervention at 10 years; those with one IMA had 20% risk; and those with no IMA had approximately 30% risk for reintervention at 10 years

However, the surgical community has not fully utilized these assets despite numerous, compelling data [19-23]. Jones succinctly summarized the decision point facing conventional, open surgery in the face of rapidly advancing technologies, particularly PCI, and the impact on referral trends for surgical intervention: " improve the long-term outcome, lessen resources used, or both." [24]. Therefore, one important philosophic principle regarding use of multiple arterial conduits is that the focus is on the *long-term*

The purpose of this chapter is to review the data available for CABG with multiple arterial grafts including bilateral IMA use, radial artery, and other conduits. Finally, we will demonstrate the advantages of multiple arterial grafting and make the argument that this strategy yields superior long-term results compared to any strategy for coronary

revascularization based on PCI or CABG with traditional conduit selection.

coronary lesions. [11].

strategies by hospital systems.

results, not the short-term.

[18].

PCI was introduced in 1977 and has undergone consistent improvements in technologies and approaches, offering a less invasive treatment modality for CAD [25]. With the introduction of DES in 2003, the percentage of CAD patients treated with PCI have increased consistently [26, 27]. However, recent studies evaluating long-term outcomes for DES have revealed increased morbidity and mortality secondary to late stent thrombosis [28-30]. While DES therapy has reduced need for target lesion reintervention [31, 32], there is a strict therapeutic requirement for dual anti-platelet therapy (DAPT). Current DAPT recommendations are for at least one year after DES therapy, but the ideal length of treatment still not yet known [33].
