title: Giant leaps in surgical myocardial revascularisation.
abstract: There have been dramatic advances in Coronary Artery Bypass graft surgery over the past 45 years. Coronary artery bypass grafting with saphenous vein grafts, was a highly reproducible procedure effective in alleviating angina. Its usefulness was compromised by myo proliferative change and atheromatous changes in the saphenous vein grafts resulting in reduced graft patency (50-60%) and survival (60-70%) at 10 years. Introduction of the left internal thoracic artery to the left anterior ascending artery was a significant advance resulting in less recurrent angina, fewer cardiac events improved patency (> 90%) and survival (80-90%) 10 years postoperatively. The left internal thoracic artery to the left anterior descending artery and saphenous vein graft to other vessels remains the standard operation today. Off-pump coronary artery bypass grafting provides equivalent results in routine patients but is of particular value in those with a calcified or atheromatous ascending aorta. Bilateral internal thoracic arteries are better than one internal thoracic artery, especially in the 10-20 year time frame. Multiple arterial grafting and total arterial grafting, facilitated by the use of bilateral internal thoracic arteries, T or Y-Grafts, use of the radial artery, right gastroepiploic artery and sequential anastomosis are consistently associated with even further improvements in symptoms and prognosis with survival greater than 90% at 10 years despite increase in patient age and co morbidities in recent series. Overall patencies for other arterial grafts at 10 years are - the right internal thoracic artery 90%, the radial artery 89%, and the right gastroepiploic artery 70%. Contemporary randomised studies consistently show superior patencies for arterial grafts over saphenous vein grafting. In summary, the left internal thoracic artery to the left anterior descending artery is essential; two or more arterial grafts are preferable, especially to the left anterior descending and the circumflex, and total arterial vascularisation is ideal.
authors.affiliation: Department of Cardiac Surgery, Royal Melbourne Hospital, Parkville, Melbourne, Victoria, Australia. james.tatoulis@mh.org.au
authors.forename: James
authors.initials: J
authors.lastname: Tatoulis
mesh_terms: D000787:Angina Pectoris / Q000401:mortality / Q000601:surgery*; D047549:Coronary Artery Bypass, Off-Pump / Q000266:history* / Q000379:methods*; D018572:Disease-Free Survival; D005260:Female; D049673:History, 20th Century; D049674:History, 21st Century; D006801:Humans; D008297:Male; D015996:Survival Rate