1. Configurations of Arterial Grafts:
Advanced Techniques for State of the Art CABG Session
AATS 2015
Configurations of Arterial Grafts:
In situ vs. composite arterial conduits
David P Taggart MD PhD FRCS FESC
Professor of Cardiovascular Surgery, University of Oxford
Conflicts of Interest:None 1

2. In Situ or Composite (‘Y’): BIMA
Advantages
Technically easy
More Distal Anastomoses
No Midline Cross
Do not need Distal RIMA
Disadvantages
Cross Midline
20% too short
Uses distal RIMA (spasm) and devascularizes xiphisternum
Technically more complex
‘All eggs in one basket’
4 Questions re In Situ or Composite
Patency ?
Adequate flow to supply whole heart ?
Functionality of free IMA (denervation) ?
Clinical Outcomes ?

3. [CIRC 2008]
304 patients
Anastomoses
In situ (2.4) vs Composite (3.2): p<0.001
6 month patency
97% of 295 In situ
97% of 464 composite

4. [JTCVS 2010]
17 composite Y grafts studied at 6 months (RITA 10; SVG 7)

5. [EJCTS 2011]
11 patients 3 years after CABG
CONCLUSION: RIMA used as free graft does not affect basal vasomotor tone, endothelial function or vasomotor reserve

6. [JTCVS 2014]

7. BIMA CONFIGURATIONS RIMA Intd LIMA LlIMA RIMA OM LAD OM LlIMA Intd OM
Diag
RIMA OM
LAD

8. In situ vs. composite arterial conduits
No difference in patency, endothelial function or vasomotor reserve when BIMA used In situ or as Composite Grafts
Composite grafts allow more distal anastomoses, avoid the need to use distal RIMA and avoid crossing midline

9. 43 patients (mortality 5%)
6 BIMA (mortality 0%)
Graft Flow Measurements (45ml/min (range 30-60ml/min)
Repeat Angiography at 2-3 weeks 97% patency

10. BIMA SKELETONIZATION Preparation: Harvest, divide distally and clip
Wrap in papaverine swab + increase BP to 150 for 5 mins
No need to heparinize !!!!
No need to inject
ARTERY
Longer
Wider
See Full Length
Easier composites
Easier sequentials
CHEST WALL
Not denuded
Less Bleeding
Better Healing

11. [JTCVS 2014]
224 patients
1 year angio patency 98% SVG and 97% RITA