SEQUENTIAL VEIN BYPASS-GRAFTING - TACTICS AND LONG-TERM RESULTS

The sequential bypass grafting technique has many advantages over coro nary artery bypass grafting with single grafts. The aim of this study was to evaluate the consequences of sequential bypass graft failure. B etween 1 January 1984 and 31 December 1996, 3846 patients underwent pr imary coronary artery bypass vein grafting. A total of 3490 patients r eceived sequential vein bypass grafts and 356 patients received single vein bypass grafts (9%). There were 6177 sequential bypass grafts (34 90 postero-lateral grafts (56%) and 2687 in the antero-lateral positio n (44%)) and 1468 single grafts (972 vein grafts and 496 internal thor acic artery grafts). Overall, there were 80 hospital deaths (2.1%). Mo rtality in relation to type of grafts used was: 13 deaths in 356 patie nts with only single graft (3.7%) and 67 deaths in 3490 patients who r eceived sequential vein grafts (1.9%). Of 3766 hospital survivors, 373 1 were followed for an average of 76 months. During follow-up, SS pati ents died (2.3%), 15 patients (0.4%) underwent cardiac transplantation and 52 (1.4%) had re-do coronary artery bypass vein grafting. Graft-p ercutaneous transluminal coronary angioplasty was performed in 56 pati ents (1.5%), 37/1390 single bypass grafts (2.7%) and 19/6023 sequentia l bypass grafts (0.3%). There were 272/6023 symptomatic sequential gra ft occlusions (4.5%) (182 were in postero-lateral position and 90 in t he antero-lateral position). There were 66/667 single vein graft occlu sions (9.9%) and 15 symptomatic internal thoracic artery graft occlusi ons (2.1%) during follow-up. In 97% of patients, presenting symptoms o f postero-lateral sequential bypass graft occlusion took the form of a renewed angina with a myocardial infarction rate of 3% and a mortalit y rate of 7%. Corresponding figures for antero-lateral sequential bypa ss grafts were 22, 78 and 68%, and anterior single vein bypass grafts were 70, 30 and 15%, respectively. The overall 10-year survival rate i n patients with sequential bypass grafts was 81.2% and the cumulative patency rate (1464 angio-controls of 2576 sequential vein grafts) was 72.2%. A symptomatic occlusion of a postero-lateral sequential vein by pass results in a low incidence of myocardial infarction with low mort ality, when the terminal anastomosis is connected to a high flow vesse l. An antero-lateral sequential vein bypass graft has better longterm patency than single vein bypass, but should occlusion occur, it would usually be associated with a higher myocardial infarction and mortalit y rates than a single vein graft. The highest risk for failure of a se quential graft in the antero-lateral position occurs when the left ant erior descending artery (LAD) is small or severely diseased. In this s ituation the single graft technique with internal thoracic artery appe ars to be safer. (C) 1998 The International Society for Cardiovascular Surgery, Published by Elsevier Science Ltd. All rights reserved.