Multi-arterial Coronary Grafting

Arterial conduits, especially internal thoracic arteries (ITAs), are rarely affected by intimal hyperplasia or atherosclerosis, major contributors to early and late vein graft failure. Improved survival and freedom from reintervention with multi-arterial grafting (MAG) are reported in large observational studies, particularly when more than one anatomically important coronary territory is supplied. Several grafting configurations are possible depending on conduit and target characteristics, with the left ITA to the left anterior descending (LITA-LAD) typically being the cornerstone around which the rest of the conduits are constructed. The right ITA (RITA) or radial artery (RA) is used to bypass the second most important target after the LAD. The fundamentals of MAG depend on thorough preoperative evaluation, meticulous surgical technique and intraoperative flow assessment. Pitfalls to avoid include tension in short conduits or kinks in longer ones, poor ITA inflow, competitive native and graft flow, flow imbalance between segments of a composite graft, and sequentially grafting deep intramyocardial targets. Versatility and flexibility are critical in mitigating difficulties or potential complications in MAG. Refinements in complex bilateral ITA (BITA) and RA grafting require a deliberate iterative process that ideally incorporates dedicated training and mentorship by experienced MAG surgeons.