The wider application of arterial conduits represents a current trend
in myocardial revascularization. More complex and demanding surgical t
echniques are being developed as alternatives to traditional grafting
procedures, in order to permit total arterial revascularization in pat
ients with diffuse coronary artery disease. The rationale behind this
strategy is the expected higher long-term patency rate of arterial con
duits as compared with vein grafts. Avoidance of proximal anastomoses
is another argument in favor of coronary revascularization with arteri
al grafts, particularly in patients with atherosclerotic changes in th
e ascending aorta. Although the reported operative results are good, t
otal arterial revascularization in multivessel disease is a complex pr
ocedure, and serious perioperative complications are possible. In plan
ning the revascularization strategy, therefore, the surgeon should tak
e into account age, clinical condition, coexisting medical problems, c
oronary anatomy, and left ventricular function. The method of myocardi
al revascularization is an important aspect of the surgical procedure
and plays a major role in the outcome of the operation in the presence
of severe left ventricular dysfunction or when the operation requires
prolonged ischemic times. To avoid the inevitable damaging effects of
cardiopulmonary bypass and aortic cross-clamping, myocardial revascul
arization is carried out without extracorporeal circulation. This tech
nique should be part of the armamentarium of the cardiac surgeon and s
hould occasionally be considered in patients who have serious coexisti
ng medical problems or severe left ventricular dysfunction.