Total arterial myocardial revascularization using new composite graft techniques for internal mammary and/or radial arteries conduits

Background: Total arterial myocardial revascularization (TAMR) is feasible because of the excellent long-term patency of the arterial conduits. We pre sent five new surgical configurations for TAMR. Methods: Between December 1 998 and July 1999, 34 patients with triple vessel disease underwent TAMR. A ll patients were in CCS III or IV. Sketelonized internal mammary arteries ( IMAs) were used. The surgical techniques for TAMR consisted of Y or T compo site grafts constructed between the in situ RIMA and free LIMA graft or rad ial artery (RA) conduit in three different configurations. Other techniques uses included a T graft constructed between the RA conduit and free LIMA g raft in two configurations. Twenty-six (76%) patients underwent contrast-en hanced TTE color Doppler before and a after adenosine provocative test, and seven (20%) patients had postoperative coronary angiography. Results: Over all, 144 anastomoses (average number per patient, 4.2) were completed. One (2.9%) patient undergoing an inverted T graft technique died on postoperati ve day 2. Another patient (2.9%) undergoing the right Y graft technique usi ng IMAs and RA suffered perioperative AMI due to RA conduit vasospasm. Cont rast-enhanced TTE color Doppler before and after the adenosine provocative test and at 1 week postoperation revealed a coronary flow reserve (CFR) of 2.1 +/- 0.2 in the LIMA stem, and in the RIMA stem, a CFR of 2.3 +/- 0.3 (P < 0.007). In one patient undergoing the right Y graft technique using IMAs , we found only anomalous flow dynamic parameters of RIMA, suggesting a par tial graft closure. The angiographic examination revealed a free LIMA graft closure. At 6 +/- 2.4 months after operation 33 patients were alive and fr ee of angina. The IMAs stem evaluation by TTE color Doppler at follow-up re vealed a 2.45 +/- 0.1 mm LIMA diameter and 2.6 +/- 0.2 mm RIMA diameter, wh ich was more than early postoperative data of P < 0.001 and P < 0.007, resp ectively. Conclusion: These data indicate that TAMR in young patients perha ps offers a better postoperative outcome and perhaps should be part of the surgical armamentarium. These techniques apply the "nontouch" principle and should be taken into consideration in patients with a heavily calcified ao rta. Contrast-enhanced TTE color Doppler is a safe, accurate, and noninvasi ve test, which allows assessment of IMA patency and CFR evaluation. The flo w reserve of the IMAs seems to be adequate for multiple coronary anastomose s.