**3. The radial artery**

It was only a decade after the systematic use of the internal mammary artery and specifically in 1986 that a benchmark publication came from the Cleveland Clinic [9]: In an extensive retrospective study they compared the clinical outcomes and angiography findings of 2306 patients who received single internal mammary artery (IMA) graft on the left anteriordescending artery (LAD) with additional vein grafts and 3265 patients who received only vein grafts. The mean follow-up time was 8.7 years. It was found that patients on whom the internal mammary artery had been used as a graft had lower perioperative mortality rates, less re-surgery rates, smaller chances of recurrent angina or infraction and

A second study followed, by Acinapura et al [10] in which 2100 patients were followed-up for

Internal mammary artery 96% 18% 0.5% Vein graft 67% 31 6.3

Ten-year mortality rate was 10% for the IMA group and 22% for the vein grafts group.

On the same grounds, Cameron and colleagues [11] compared 479 patients with single internal mammary artery graft to 4888 patients with solely vein grafts over a period of more than 15 years. They showed that the use of a single internal mammary artery graft was an independent prognosis factor that promoted survival, especially in older patient, with a reduced LV

Conclusively, the use of the internal mammary artery on the anterior descending branch is indicated irrespectively to the age and to the ejection fraction. Moreover, the use of the IMA

Because of the ostensible biological similarity of the left and right internal mammary artery, many were those who believed that the use of the two internal mammary arteries as grafts

The patency of the 2 internal mammary (left & right) artery grafts is over 90% in 10 years. The reasonable question posed is: "Why don't we use more arterial grafts during a by-pass

**1.** Calafiore [12] from Italy showed 99% patency of the 2 internal mammary arteries as shown

**2.** Accola et al [13] showed that in young patients, BIMAS could be safely used without

putting them at higher risk of perioperative morbidity or mortality.

in patients with a low ejection fraction improves long-term survival.

Let's answer through a short review of the recent literature:

**Patency Recurrent angina Re-syrgery**

higher 10-year survival.

**Table 4.**

164 Artery Bypass

function.

surgery?"

5 years. The study showed that:

could yield additional benefits.

in angiographies, at 18 months.

The fact that radial artery grafts were patent for over 18 years after surgery [20] has been the basis to re-recruit the RA (radial artery) as a graft for CABG. There is low in situ atherosclerosis incidence for this artery, however the thickened middle lining, with the abundant cells of smooth muscle fibers (contrary to the internal mammary artery) increased intimal hyperplasia of this vessel.

Angiography studies of middle time duration showed 90% patency rate in 1 year [21], 83% in 5 years [22] and over 80% in 8 years.

Although these results are encouraging, the databases should be interpreted with caution. The majority of the studies are retrospective analyses and the rate of the grafts used for follow-up via angiography varies in these studies. The recent study by Possati [23] with 92% angiographic follow-up for over 8 years, contains the most well-documented database to this day.

Two prospective randomized control studies comparing the radial artery (RA) to other grafts by means of a full angiographic follow-up are the RAPS [24] (Radial Artery Patency Study) and RSVP (Radial artery versus Saphenous Vein Patency Study) and are still in progress.

**ARTERIAL GRAFTS PATENCY 5 year patency 10 year patency**

The Impact of Arterial Grafts in Patients Undergoing GABG

http://dx.doi.org/10.5772/54621

167

LITA →LAD 95% 90%

LITA→ other than LAD 90% 80%

RITA→RCA 90% 80%

RITA→LAD 95% "/>90%

Free ITA grafts 90%, "/>80%

Radial artery 80% 70-80%

Right gastroepiploic artery 80% 63%

Tavilla et al [30] reported on the 10 year follow-up of 201 CABGs in three-vessel disease using exclusively pedicled bilateral internal thoracic and right gastroepiploic arteries.Ten-year actuarial survival was 87%. The actuarial freedom from angina was 97% and 86% at 5 and 10 years respectively. None of the patients needed a repeat surgical revascularization after leaving the hospital, whereas 9 (5%) patients underwent a percutaneous transluminal coronary angioplasty. At 5 years 86% and at 10 years 69% of the patients remained free of any cardiac-

Nishida [31] reported on total arterial revascularization on 239 patients with the only use of BIMAs and the right gastroepiploic artery (RGEA). ITA grafts were harvested by using the skeletonization technique. Sequential grafting was performed in 64 patients; One patient (0.4%) died of mediastinitis. Graft patency was confirmed angiographically in 230 patients (96%) 2 to 3 weeks after surgery. The patency rate was 97.1% for the left ITA, 99.6% for the right ITA, and 95.5% for the RGEA. Five-year actuarial survival rate was 92.9%, and the cardiac

Finally in a prospective randomized trial on total arterial revascularization, Muneretto et al [32] conducted a TAR study with the use of LIMA in patients over 70 years old. Follow-up was performed at 15 months, and it showed higher arterial patency and freedom from ischemic

**6. Studies on total arterial revascularization (tar)**

**Table 5.** Patency of various arterial grafts over time

related event.

death-free rate was 97.8%.

attacks in the TAR group.

The RAPCO (Radial Artery Patency and Clinical Outcome) [25] is a prospective random‐ ized study that compares the radial artery (RA) to grafts from the great saphenous vein and the free grafts from the right internal mammary artery. All patients received grafts from the LIMA to the LAD and then they were randomized and received either the radial artery or the right internal mammary artery on a second target in patients less than 70 years old and either the radial artery or the great saphenous vein (again within a second target) in patients aged over 70.

The 5year angiographic patency of the radial artery and the right internal mammary artery was 95 and 100% respectively, and of the saphenous vein and the radial artery it was 87% and 94% respectively.
