Single or multiple arterial grafting to design a coronary bypass: a retrospective study

Aim. To compare the efficiency of single arterial grafting (SAG) and multiple arterial grafting (MAG) at coronary artery bypass graft (CABG) surgery in the long term.

Material and Methods. To assess the angiographic outcomes, we evaluated the patency of 323 bypasses at 102 angiograms obtained during coronary angiography performed > 10 years post-CABG surgery.

Results. Out of 323 analyzed bypasses, 230 (71.2%) showed physiological functioning, whereas stenosis, occlusions, and other coronary artery alterations were found in 93 (28.8%) bypasses. The most common cause for the failure of anastomoses was competitive flow (most frequently registered in the anastomoses between left internal thoracic artery and left anterior descending artery, left internal thoracic artery and diagonal branches of left anterior descending artery, right internal thoracic artery and left anterior descending artery, and between right internal thoracic artery and right coronary artery), poor distal bed (most frequently revealed in the anastomosis between left internal thoracic artery and obtuse marginal artery, saphenous vein and diagonal branches of left anterior descending artery, saphenous vein and obtuse marginal artery, and between saphenous vein and right coronary artery), progression of atherosclerosis in combination with poor distal bed (most frequently detected in the anastomosis between right internal thoracic artery and obtuse marginal artery), and combination of poor distal bed, competitive flow, and graft degeneration (most frequently found in the anastomoses between radial artery and obtuse marginal artery and between radial artery and right coronary artery). In 5 (5.4%) cases, the cause of coronary bypass dysfunction was unclear.

Conclusion. The main causes for the coronary bypass failure included competitive flow (in case with multiple arterial grafting) and poor distal bed (in case with single arterial grafting).

1. Hwang HY, Paeng JC, Kang J, Jang MJ, Kim KB. Relation between functional coronary artery stenosis and graft occlusion after coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2021;161(3):1010-1018.e1. https://doi.org/10.1016/j.jtcvs.2020.11.072

2. Limanto DH, Chang HW, Kim DJ, Kim JS, Park KH, Lim C. Coronary artery size as a predictor of Y-graft patency following coronary artery bypass surgery. Medicine (Baltimore). 2021;100(2):e24063. https://doi.org/10.1097/MD.0000000000024063

3. Frolov A.V. Morphological and functional system of graft-artery junctions. Complex Issues of Cardiovascular Diseases. 2019;8(1):112-122. (In Russ). https://doi.org/10.17802/2306-1278-2019-8-1-112-122

4. Kraler S, Libby P, Evans PC, Akhmedov A, Schmiady MO, Reinehr M, Camici GG, Luscher TF. Resilience of the Internal Mammary Artery to Atherogenesis: Shifting From Risk to Resistance to Address Unmet Needs. Arterioscler Thromb Vasc Biol. 2021;41:2237-2251. https://doi.org/10.1161/ATVBAHA.121.316256

5. Dogan P, Kuyumcu MS, Demiryapan E, Arisoy F, Ozeke J. Competitive Coronary Flow between the Native Left Anterior Descending Artery and Left Internal Mammary Artery Graft: Is It a Surrogate Angiographic Marker of Over-or-Unnecessary Revascularization Decision in Daily Practice? Int J Angiol. 2017;26:27-31. https://doi.org/10.1055/s-0036-1587695

6. Shishkova D, Markova V, Sinitsky M, Tsepokina A, Frolov A, Zagorodnikov N, Bogdanov L, Kutikhin A. Co-Culture of Primary Human Coronary Artery and Internal Thoracic Artery Endothelial Cells Results in Mutually Beneficial Paracrine Interactions. Int J Mol Sci. 2020;21(21):8032. https://doi.org/10.3390/ijms21218032

7. Doenst T, Sousa-Uva M. How to deal with nonsevere stenoses in coronary artery bypass grafting - a critical perspective on competitive flow and surgical precision. Curr Opin Cardiol. 2022;37(6):468-473. https://doi.org/10.1097/HCO.0000000000000993

8. Borovic MML, Lalic IM, Borovic SD, Zaletel IV, Mutavdzin SS, Bajcetic MI, Kostic JV, Trifunovicet ZZ. Structural features of arterial grafts important for surgical myocardial revascularization: Part I - Histology of the internal thoracic artery. Vojnosanit Pregl. 2015;72(10):914-921. https://doi.org/10.2298/VSP140515079L

9. Fonseca DA, Antunes PE, Antunes MJ, Cotrim MD. Histomorphometric analysis of the human internal thoracic artery and relationship with cardiovascular risk factors. PLoS ON. 2019;14(1):e0211421. https://doi.org/10.1371/journal.pone.0211421

10. Xenogiannis I, Zenati M, Bhatt DL, Rao SV, Rodes-Cabau J, Goldman S, Shunk KA, Mavromatis K, Banerjee S, Alaswad K, Nikolakopoulos I, Vemmou E, Karacsonyi J, Alexopoulos D, Burke MN, Bapat VN, Brilakis ES. Saphenous Vein Graft Failure: From Pathophysiology to Prevention and Treatment Strategies. Circulation. 2021;144(9):728-745. https://doi.org/10.1161/CIRCULATIONAHA.120.052163

11. Zhu YY, Hayward PA, Hare DL, Reid C, Stewart AG, Buxton BF. Effect of lipid exposure on graft patency and clinical outcomes: arteries and veins are different. Eur J Cardiothorac Surg. 2014;45(2):323-328. https://doi.org/10.1093/ejcts/ezt261

12. Duanmu Z, Chen W, Gao H, Yang X, Luo X, Hill NA. (2019) A One-Dimensional Hemodynamic Model of the Coronary Arterial Tree. Front Physiol. 2019;10:853. https://doi.org/10.3389/fphys.2019.00853

13. Li J, Liu R, Ji X, Xue H, Zhang G, Wang C, Chen Q, Xue F, Cui L. (2015) Insight into the Spectrum of Coronary Atherosclerosis in Asymptomatic Urban Han Chinese Population by Coronary Computed Tomography Angiography. PLoS ONE. 2015;10(7):e0132188. https://doi.org/10.1371/journal.pone.0132188

14. Giannoglou GD, Antoniadis AP, Chatzizisis YS, Louridas GE Difference in the topography of atherosclerosis in the left versus right coronary artery in patients referred for coronary angiography. BMC Cardiovascular Disorders. 2010;10:26. https://doi.org/10.1186/1471-2261-10-26

15. Chatzizisis YS, Giannoglou GD, Parcharidis GE, Louridas GE. Is left coronary system more susceptible to atherosclerosis than right? A pathophysiological insight. Intern J Cardiology. 2007;116(1):7-13. https://doi.org/10.1016/j.ijcard.2006.03.029

16. Fiddicke M, Fleissner F, Brunkhorst T, Kuhn EM, Obed D, Boethig D, Ismail I, Haverich A, Warnecke G, Sommer W. Coronary artery bypass grafts to chronic occluded right coronary arteries. JTCVS Open. 2021;7:169-179. https://doi.org/10.1016/j.xjon.2021.06.007

17. McKavanagh P, Yanagawa B, Zawadowski G, Cheema A. Management and Prevention of Saphenous Vein Graft Failure: A Review. Cardiol Ther. 2017;6(2):203-223. https://doi.org/10.1007/s40119-017-0094-6

18. Hosono M, Murakami T, Hirai H, Sasaki Y, Suehiro S, Shibata T. The Risk Factor Analysis for the Late Graft Failure of Radial Artery Graft in Coronary Artery Bypass Grafting. Ann Thorac Cardiovasc Surg. 2019;25(1):32-38. https://doi.org/10.5761/atcs.oa.18-00054

19. Gaudino M, Antoniades C, Benedetto U, Deb S, Di Franco A, Di Giammarco G, Fremes S, Glineur D, Grau J, He GW, Marinelli D, Ohmes LB, Patrono C, Puskas J, Tranbaugh R, Girardi LN, Taggart DP; ATLANTIC (Arterial Grafting International Consortium) Alliance. Mechanisms, Consequences, and Prevention of Coronary Graft Failure. Circulation. 2017;136(18):1749-1764. https://doi.org/10.1161/CIRCULATIONAHA.117.02.