Complex Composite Grafting in CABG: Double Y Graft Using Bilateral BIMA and PDA Endarterectomy

Objective 

Total arterial revascularization in coronary artery bypass grafting (CABG) using bilateral internal mammary arteries (BIMA) has been associated with better long-term survival rates. Complex composite grafting can occasionally be required for total arterial revascularization in patients who need multiple grafts. Side-to-side sequential anastomosis is widely used in such cases but can be kinked. This kink can depend on configuration of grafts and target sites. Double Y grafting can be an alternative to deliver better blood flow. 

Case Video Summary 

This surgical video presents a complex composite total arterial CABG using double Y anastomosis and posterior descending artery endarterectomy. The patient is a sixty-year-old man with a triple vessel coronary disease with severe left main stenosis. His native coronary arteries were composed of two large diagonal arteries and a small distal left anterior descending artery (LAD) with a right dominant system. Because of the configuration of his two diagonals, the surgeons planned to separate his right IMA into long and short segments and connect them as the second Y anastomosis. A radial artery was also harvested for aorta to posterior descending artery (PDA) bypass.  

The anastomosis of the long RIMA and LIMA Y graft was then followed by the second Y anastomosis of two RIMA segments before the cardiopulmonary bypass. After arteriotomy of PDA, the surgeons found a long atheroma. An endarterectomy was done and was repaired by a saphenous vein patch. A distal anastomosis was performed on the patch utilizing the radial artery. Distal anastomosis of the long RIMA to the posterolateral artery and the short RIMA to the first diagonal branch were also performed. Since the patient’s distal LAD was tiny and diseased, his LIMA was anastomosed to the second diagonal, which was larger than his distal LAD.  

The post-operative transesophageal echocardiogram showed significant improvement in wall motion abnormalities. The patient was discharged uneventfully. 

Conclusion 

Double Y grafting utilizing bilateral IMAs can be a feasible option in patients who have complex configuration of the native vessels and need multiple arterial grafts. 

Reference

1. Saran N, Locker C, Said SM, et al. Current trends in bilateral internal thoracic artery use for coronary revascularization: Extending benefit to high-risk patients. The Journal of thoracic and cardiovascular surgery. 2018;155:2331-2343.

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