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

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 cardiacrelated event.

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 death-free rate was 97.8%.

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 attacks in the TAR group.

#### **Recommendation for the use of BIMA**

In young patients (less than 65 years old)



Bilateral ΙΜΑs shall go to he left system

#### **Contraindications**



**Table 6.** Indications and Contraindications for the use of BIMA
