**10. Summary**

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

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‐ MA grafts have also been shown to be similar to those of the LIMA, even when consid‐ ering the sites of distal anastomoses and the proximal anastomosing techniques [16, 17, 18, 19, 20]. Further studies are needed to determine if there is any significant effect on operative length in BIMA grafting versus conventional CABG.

The incidence of SWI has been a significant concern for surgeons, especially among high-risk patients such as the morbidly obese, insulin-dependent diabetics, and those with COPD. BIMA harvesting is generally avoided in these patients [7, 8], however studies have shown that BIMA harvesting in general does not significantly affect the incidence of SWIs [12, 23]. The risk of SWI can be even further reduced with the use of skeletonized BIMA harvesting rather than pedicled harvesting [22, 23].

Studies have shown that the radial artery is also a good choice for an arterial conduit after the LIMA. Studies examining clinical outcomes and patency rates of the radial artery have been mixed, with some studies showing better short-term patency rates than saphenous vein grafts [25-28], while other studies have shown that radial artery outcomes are at least similar to those for the RIMA and saphenous vein [11, 32, 33].

While not all studies have been favorable with regards to BIMA and radial artery use [11, 15, 32, 33], studies generally find patency rates and clinical outcomes of these two arterial conduits are at least as good as the currently accepted standards of care, which should give surgeons flexibility in their choice of conduits, ultimately leading to total arterial revascularization.

Studies in general have provided favorable results for TAR, with TAR at least being similar in outcomes to conventional CABG [35]. Several studies have demonstrated that TAR, and the use of arterial conduits in general, provides significantly better late survival (especially in patients with three vessel coronary disease), cardiac event-free survival, and improved healthrelated quality of life when compared to conventional CABG [11, 21, 36].
