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Total and Multiple Arterial Revascularization

  • James TatoulisEmail author
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Abstract

Total arterial revascularization (TAR) or multiple arterial bypass grafting (MABG) maximizes long term survival, whilst minimizing interval events—recurrent angina, myocardial infarction, re-intervention, and mortality. Saphenous vein grafts (SVGs) have failure rates of 25% at 1 year, and 50% at 10 years, in the modern era, despite statins. Conversely arterial grafts always have better patency whether left or right internal thoracic arteries (ITAs), radial artery (RA) or right gastroepiploic (RGEA)—especially if there is spasm prophylaxis, and competitive flow is avoided. This has been documented in numerous reports, meta-analyses, and randomized studies over 30 years. TAR and/or MABG can be performed with identical low perioperative mortality (1%) and morbidity as for LITA + SVG. Arterial grafts have patency rates of 90–95% at 10 years and 85–90% at 20 years. Arterial graft patency determines long term outcomes. For every 100 patients having CABG, 10 more will be alive at 10 years if they had TAR or MABG (80–88% versus 70–78%). This holds true for patient subsets including women, older patients, and those with diabetes, or preoperative renal dysfunction. Strategies for arterial graft deployment can vary—one or two ITAs, one or two RAs, RGEA—in various combinations, on-pump or off-pump, single, sequential, or Y-grafts. Important principles are to target the most important coronaries (usually the left anterior descending and circumflex) minimizing aortic manipulation, spasm prophylaxis and avoidance of competitive flow, especially for RA and RGEA. TAR and MABG should be in every cardiac surgeon’s repertoire. This chapter provides an overview of rationale, technical aspects and outcomes of TAR.

Keywords

Bilateral internal thoracic arteries Hypoperfusion Multiple arterial bypass grafting Total arterial grafting Total arterial revascularization 

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Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Department of Cardiothoracic SurgeryThe Royal Melbourne HospitalMelbourneAustralia
  2. 2.Department of SurgeryUniversity of MelbourneMelbourneAustralia

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