**11. Conclusion**

TAR. The presence of diabetes and hyperlipidemia had a negative impact on clinical out‐ come, especially in patients receiving saphenous vein grafts in the conventional CABG group. Conventional CABG surgery was also found to be significantly associated with coronary graft occlusion. Overall, at follow-up, TAR resulted in improved clinical out‐ comes in patients undergoing CABG procedures when compared to conventional CABG

In a more recent, long-term study with a mean follow-up of 6 years, Chung *et al.* exam‐ ined 503 patients undergoing isolated CABG procedures for three-vessel coronary dis‐ ease. Patients in the study either received TAR (117 patients) or conventional revascularization (386 patients). In both the crude analysis and propensity-score matched analysis, there was no significant difference in the rates of death, reintervention, MI, or stroke between the patients receiving TAR or conventional CABG. However, the study did not examine graft patency. The authors conclude that, since the outcomes were simi‐

lar between the two groups, "the selection of conduit should be more liberal" [35].

Zacharias *et al.* conducted a long-term study of 4,743 patients undergoing multivessel CABG procedures receiving either TAR (612 patients) or conventional CABG (4,131 pa‐ tients). Early, 30-day mortality was similar for both patient groups, with a 1.30% mortali‐ ty rate in the TAR group and a 1.67% mortality rate in the conventional group. Due to significant differences in the patient cohort for the two groups, propensity-matched anal‐ yses were performed for the 12-year follow up. Late survival was found to be significant‐ ly better in total arterial patients with three-vessel disease compared to conventional CABG patients with three-vessel disease (p < 0.001). However, there was not a significant difference in late survival between the two groups for patients with two-vessel disease (p = 0.89). The authors also noted that the completeness of myocardial revascularization was "critical for maximizing the achievable long-term benefits of total arterial grafting" [36].

Poor long-term patencies of saphenous vein grafts coupled with the greater long term patency results of the LIMA as the gold standard conduit for CABG has prompted sur‐ geons to seek out additional arterial conduits [1,2]. Achieving total arterial revasculariza‐

Since it is anatomically identical to the LIMA, the RIMA would be the next logical choice in arterial conduits, yet is rarely used in CABG operations due to the perceived technical difficulty of harvest and increased operating times, a higher risk of developing SWIs, and previous lack of long-term studies of clinical outcomes [7,8]. However, several studies have demonstrated significantly increased long-term survival rates for patients receiving BIMA grafting compared to SIMA grafting [9-12]. BIMA patients also have significantly improved cardiac event-free survival than SIMA patients [4, 6, 9]. Patency rates for RI‐

tion of the myocardium would then be a natural progression for the procedure.

[34].

128 Artery Bypass

**10. Summary**

With favorable results for the use of arterial conduits and results that are at least as good as those seen in conventional CABG, these results should allow surgeons flexibility in their choice of conduits. Due to the significantly increased long-term survival advantages over saphenous vein grafts, BIMA use should be particularly indicated for younger patients, with special attempts to achieve TAR in patients with three vessel disease. Especially with skeletonized harvesting, BIMA may be safe to use in high-risk patients for SWI, such as insulin-dependent diabetics. BIMA use may also decrease the incidence of postoperative cerebrovascular events due to the decreased manipulation of the ascending aorta if both IMAs are used *in situ.* The radial artery is also a suitable conduit to use in conjunction with BIMA or as a second arterial conduit if either the LIMA or RIMA is not suitable for use. This ultimate flexibility provided by TAR should allow surgeons to determine their revascularization strategies not based on the availability of conduits, but by the possible co-morbidities and post-operative complica‐ tions that may arise based on the patient in question.
