Can a Single ITA Composite Graft Adequately Supply the Heart?

Very nice presentation. It was really insightfull. 1) I have no doubt about ITA upon its apptitude to meet composite grafting flow. I remember having reoperated on a CABG patient using ITA-SVG composite grafting on POD #1 for suspicion of mediastinal hemtoma . I was surprised by increasing in proximal LITA diameter up to 3 folds its previous diameter. Having said that, we have previously hypothetized that LAD has potentially a natural physiological dual source (dual LAD inflow) due to combination of systolic retrograde septal branches flow (+ in some degrees from RV branches) and antegrade systolic and diastolic LAD flows. As a degree of increasing complexity, in the setting of a left dominant coronary layout, the dual LAD source are derived from the left coronary ostium ( singly dual LAD inflow) in contrast to a right or balanced coronary layout in which the dual source is provided by both right and left coronary ostia (doubely dual LAD inflow). I have noticed that the majority of ischemia associated with AS occured in patients with left dominant anatomy (singly dual LAD inflow). Consequantlly, I consider that the perfect functional revascularisation to the patients should be restoring or creating a "doubly dual LAD inflow" layout. My policy is to resort whenever possible bilateral left and right sided composite grafting to diminish aortic manipulation (proximal-less) while achieving complete revascularisation according to doubly dual LAD inflow concept. 2) I completly share the concerns over neo-intimal hyperplasia and competitive flows compromising our composite grafting. we should set up a world-wide collective think-tank to design technical solutions or innovations to optimize the functionnal longevity of our anastomoses. Therefore, I hope readers would take this nice presentation in good advantage as to further comments or suggestions on this issues. Cordially

Very nice and important presentation! It resolves all concerns regarding the possible steal which may serve as an excuse and justification for misuse of this technique for many surgeons... I use BITA composite Y-graft technique for my young patients and I have no doubt that this technique may even become a gold standard ("conventional CABG") in the future. NO and other protective agents produced by ITA`s intima will treat and protect the distal run-off of the bypassed coronaries. Skeletonisation of ITAs, correct graft sizing and proper distal anastomoses are necessary for good long-term results. We have investigated the LITA`s stem flow using Doppler analysis postoperatively. We were surprised by increasing in proximal LITA flow up to 3 folds, which was well enough for the blood supply to all grafted branches of the left coronary artery.

Dear Vahe, I was cheered getting that my eye-ball estimation of 3 folds increasing in LITA diametere parallels your objective data drived by Duplex- ultrasonogrshy intertogation. We share the same vision on benefits afforded by more arterial grafting backed up by a myriad of recent trials. I had really enjoyed your excellent last year video of BITA Y-Composite grafting. Nevertheless, there are real concerns over all arterial grafting, and we should adopt an incentive attitude by discussing the prevailed issues and come up with collegial technical solutions. 1) arterial grafting should not only be reserved for young patients. Victor Hugo stated that forties is the aging of the youth, and the youth of the aging. The old remodeled myocardium does not less deserve attention-to-treat than the young ones. The hypertrophied, fibrotic, remodeled, scared myocardium with reduced compliance does also greatly benefit from more arterial grafting with significantly reduced attendant re-revascularisation. 2) I think that all-arterial approach is not yet for every patient, nor for every surgeon. The T or Y artetial composite grafting calls for anatomically suitable cases where the linear agencement for placement of distal anastomoses related to the side arm is possible. In the post-PCI area we are experiencing, the anatomically suitable cases becoming rare. Therefore, we should opt an intermediate solution to increase the number of arterial grafting when ever all - artetial approach would not be in our reach. Separate in-situ BITA grafting with additional SVG provide superior results than convrntional LITA and SVG grafting. The seconde way should be moving twoards new composite grafting layouts overcoming the technical issues of non-linear agencement of distal anastomoses sites, able to create large anastomosis and coronary reconstruction ( a limiting factor to kissing anastomosis) ,as well fixing pathophysiological concerns. Many excellent and experienced surgeons are reluctant to implemant arterial side-to-side anastomoses, a policy that we should respect, as the truth is shared by every one. Incentivelly, we do propose composite grafting layouts that do not require kissing anastomosis ("kissing-less" composite grafting). 3) I entierly stands with the protecting benefits of ITA produced factors on the coronary run-off and the side-arm branch ( radial artery, SVG). We should take every steps to preserve this production line as long as possible in the benefit of compsite grafting functional longevity. The last, but maybe not the least of my concerns is the adverse effect of Hyper-Flow phenomena and its chronic role in increasing shear-stress , thereby inducing accelerated endithelial degeneration, such as it is documented with coronary arteries feeding a fistula. That is maybe one of the reason I opt for a double coronary source when ever possible. Having cited these issues, one should recognize that Y and T graft should be mastered by most of the surgeons because these layouts are valid time-tested approaches that have enabled us to perform all arterial revascularisation. Therefore, I considered them as the gold standard of all artetial CABG and not gold-standard of CABG. cordially