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.