Operative Technique
Our standard operative strategy was off-pump CABG, initially attempted without cardiopulmonary bypass. If unstable hemodynamics or uncontrolled bleeding was encountered, we inserted an intra-aortic balloon pump (IABP) or switched to on-pump beating or arrest CABG.
The ITA and right gastroepiploic artery (GEA) were harvested in a skeletonized fashion using an ultrasonic scalpel (Harmonic Scalpel; Ethicon Endo-Surgery, Cincinnati, OH). ITAs were mainly harvested by 5 experienced surgeons who had harvested over 100 ITAs.
The distribution of the graft is described in Table 1. Grafts were selected according to the coronary anatomy. Bilateral ITAs were used, except in patients with uncontrolled diabetes mellitus (DM), or those with peripheral artery disease where collateral circulation to the legs was dependent on the ITAs. During BITA grafting, the in-situ right ITA (RITA) was anastomosed to the left anterior descending artery (LAD) and the in-situ left ITA (LITA) was anastomosed to the left circumflex artery (LCx) or diagonal arteries. In some cases, the in-situ LITA was anastomosed to the LAD and the RITA was anastomosed to the LCx as a Y-composite graft with proximal anastomosis of the SVG. The LAD lesions were always revascularized with ITA. LCx lesions were revascularized with ITAs or SVGs. The right coronary artery (RCA) lesions were revascularized mainly with SVGs, except in 2 cases with GEAs and 1 case with a RITA. The GEA was used in-situ only in the presence of severe stenosis (> 90%) in young patients. Radial artery grafts were not used because all patients were on hemodialysis and had upper extremity arteriovenous grafts.