title: Multiple composite grafts (k, π or double-Y) in coronary artery surgery: a choice or a necessity?
abstract: OBJECTIVE
  Composite grafts allow complete arterial revascularization with minimal aortic manipulations. The Y-T configuration supplies all distal branches adequately, whereas it is unclear whether complex composite configurations (K, Π or double-Y) are equally at rest or when challenged by maximal requirements.
  
  
  METHODS
  Forty-seven patients who underwent off-pump coronary artery revascularization by multiple arterial composite grafts (K, Π or double-Y) were retrospectively evaluated. Indication for this surgical option was porcelain aorta or conduit unavailability. Composite systems were evaluated by intraoperative flow measurements and perioperative transthoracic Doppler ultrasonography, 12 months later also by exercise test, sestamibi scintigraphy at rest and during induced hyperaemia and by 64-slice multidetector CT angiography.
  
  
  RESULTS
  A total of 141 distal anastomoses were implanted as composite grafts. Perioperative flow measurements and 12-month Doppler ultrasonography were adequate at rest. At stress test, chest pain and/or induced ECG evidence of ischaemia are found in 16 patients (39%). During dipyridamole-induced hyperaemia, single-photon emission computed tomography image revealed that mean summed stress score was 7.2 ± 5.7, summed difference score 5.3 ± 4.2 and coronary flow reserve 1.7 ± 0.2.
  
  
  CONCLUSIONS
  Multiple composite grafts, albeit adequate at rest, were unable to meet flow requirements during maximal hyperaemia. In daily practice, their use must be not a choice but rather a necessity in those patients without alternative options.
authors.affiliation: Department of Cardiac Surgery, University Federico II, School of Medicine, Naples, Italy vitomannacio2@libero.it.
authors.forename: Vito
authors.initials: V
authors.lastname: Mannacio
authors.affiliation: Department of Advanced Biomedical Sciences, University Federico II, School of Medicine, Naples, Italy.
authors.forename: Plinio
authors.initials: P
authors.lastname: Cirillo
authors.affiliation: Department of Cardiac Surgery, University Federico II, School of Medicine, Naples, Italy.
authors.forename: Luigi
authors.initials: L
authors.lastname: Mannacio
authors.affiliation: Department of Cardiology, Azienda Ospedaliera Santobono-Pausillipon, Naples, Italy.
authors.forename: Anita
authors.initials: A
authors.lastname: Antignano
authors.affiliation: Department of Cardiac Surgery, University Federico II, School of Medicine, Naples, Italy.
authors.forename: Michele
authors.initials: M
authors.lastname: Mottola
authors.affiliation: Department of Cardiac Surgery, University Federico II, School of Medicine, Naples, Italy.
authors.forename: Carlo
authors.initials: C
authors.lastname: Vosa
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001783:Blood Flow Velocity; D017023:Coronary Angiography / Q000379:methods; D047549:Coronary Artery Bypass, Off-Pump / Q000009:adverse effects / Q000379:methods*; D003324:Coronary Artery Disease / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D003326:Coronary Circulation; D003331:Coronary Vessels / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D015150:Echocardiography, Doppler; D004562:Electrocardiography; D005080:Exercise Test; D005260:Female; D006439:Hemodynamics; D006801:Humans; D008297:Male; D008875:Middle Aged; D061330:Multidetector Computed Tomography; D011183:Postoperative Complications / Q000175:diagnosis / Q000503:physiopathology; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D015899:Tomography, Emission-Computed, Single-Photon; D016896:Treatment Outcome
keywords: Arterial grafts; Composite grafts; Coronary artery bypass graft; Follow-up