Arterial Myocardial Revascularization Research Articles

Surgical Strategy for Sternal Closure in Patients with Surgical Myocardial Revascularization Using Mammary Arteries.

Coronary artery bypass grafting has evolved from all venous grafts to bilateral mammary artery (BIMA) grafting. This was possible due to the long-term patency of the left and right internal mammary demonstrated in angiography studies compared to venous grafts. However, despite higher survival rates when using bilateral mammary arteries, multiple studies report a higher rate of surgical site infections, most notably deep sternal wound infections, a so-called "never event". We designed a prospective study between 1 January 2022 and 31 December 2022 and included all patients proposed for total arterial myocardial revascularization in order to investigate the rate of surgical site infections (SSI). Chest closure in all patients was performed using a three-step protocol. The first step refers to sternal closure. If the patient's BMI is below 35 kg/m2, sternal closure is achieved using the "butterfly" technique with standard steel wires. If the patient's BMI exceeds 35 kg/m2, we use nitinol clips or hybrid wire cable ties according to the surgeon's preference for sternal closure. The main advantages of these systems are a larger implant-to-bone contact with a reduced risk of bone fracture. The second step refers to presternal fat closure with two resorbable monofilament sutures in a way that the edges of the skin perfectly align at the end. The third step is skin closure combined with negative pressure wound therapy. This system was applied to 217 patients. A total of 197 patients had bilateral mammary artery grafts. We report only 13 (5.9%) superficial SSI and only one (0.46%) deep SSI. The preoperative risk of major wound infection was 3.9 +/- 2.7. Bilateral mammary artery grafting was not associated with surgical site infection in a univariate analysis. We believe this strategy of sternal wound closure can reduce the incidence of deep surgical site infection when two mammary arteries are used in coronary artery bypass surgery.

Total Arterial Myocardial Revascularization - A One-Year Initial Experience and Literature Review

We presented the results of the clinical outcomes of an isolated cohort of patients in whom coronary disease was treated with total arterial revascularization of the myocardium in the period of one year. We put a special focus on the preparation and use of the gastroepiploic artery as an in situ graft for revascularization of the right and posterior descending coronary arteries considering its less frequent application in cardiac surgery practice. We have shown selected reports of individual publications that we consider to unify the aforementioned strategic approach to treatment of coronary disease. According to the general trend in cardiac surgery to use minimally invasive approaches, part of the publication is dedicated to surgical revascularization through a left mini thoracotomy, where again arterial grafts are absolutely dominant.

Surgical Myocardial Revascularization with a Composite T-graft from the Left Internal Mammary Artery-Comparison of the Great Saphenous Vein with the Radial Artery.

Composite T-grafts between left internal mammary artery (LIMA) and radial artery (RA) are a common concept in complete arterial myocardial revascularization. The aim of the present study was to investigate whether the use of the great saphenous vein (SV) instead of RA leads to comparably good results in terms of outcome in this context. Patients who underwent myocardial revascularization with a T-graft using RA or a segment of SV to the right coronary artery or circumflex artery between the beginning of 2014 and the end of 2019 at the Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Campus Kiel were included. To minimize surgical variation, only patients were observed by a single senior surgeon in the department. Exclusion criteria were previous cardiac surgery, preoperative extracorporeal circulatory support, off-pump surgery, additional aortocoronary bypasses, and cardiac combination procedures. A total of 115 patients were studied. In 55 patients, the T-graft was placed between the LIMA and SV, and in 60 patients, the T-graft was placed between the LIMA and RA. Patients in the SV group were older (70.6 ± 7.8 vs. 58.5 ± 10.0 years; p < 0.001), suffered more frequently from non-ST elevation myocardial infarction (12.7 vs. 1.7%; p = 0.027), arterial hypertension (83.6 vs. 61.7%; p = 0.009), and atrial fibrillation (18.2 vs. 1.7%; p = 0.003). They were less likely to be active smokers (16.4 vs. 38.3%; p = 0.009) and less likely to have a history of variceal surgery (0 vs. 15.0%; p = 0.003). Calcification of the ascending aorta was also found more frequently in the saphenous group (18.2 vs. 3.3%, p = 0.009). Operative times and number of distal anastomoses did not differ significantly between the two groups. Postoperative deliriums (16.7 vs. 5.0%; p = 0.043) were observed more frequently in venous patients. Wound healing disorders of the leg (11.1 vs. 0%; p = 0.011) did only occur in SV group and wound infections of the arm only in the RA group. Complete follow-up was achieved in 74.8% of cases. Median follow-up was 60.3 (39.6; 73.2) months. Serious adverse cardiac-cerebral events (19.0 vs. 22.7%; p = 0.675) and mortality (14.5 vs. 6.7%; p = 0.167) did not differ significantly between the groups at follow-up. Myocardial infarction (0 vs. 2.5%; p = 1.000) and stroke (0 vs. 7.5%; p = 0.245) were observed exclusively in RA group. Percutaneous coronary intervention was required in single patients of RA group (0 vs. 15.0%; p = 0.028). No patient from either group underwent repeat coronary artery bypass grafting (CABG). The patients of SV group had angiographically competent grafts and open anastomoses. Graft failure was noted in a single patient in RA group, in which case both grafts and native coronary vessels were stented. Kaplan-Meier analysis revealed no significant survival disadvantage for SV group compared with RA group. CABG with a composite T-graft between LIMA and a segment of SV may be comparable to bypass surgery with a composite T-graft between LIMA and RA. This might be true in terms of morbidity and mortality over an intermediate-term observation period. The results of our studies give rise to the hypothesis that the decision not to perform aortic bypass anastomosis may be more important than the choice of graft material.

Radial artery harvesting with harmonic scalpel: fully no-touch technique

The radial artery has been used for decades as an alternative to other arterial bypass graft conduits. Positive long-term patency results and survival benefits have led to an increase in its popularity. The emerging evidence of the need for total arterial myocardial revascularization unleashes the potential of the radial artery as a versatile arterial conduit capable of reaching all coronary targets in a lot of different configurations. In addition, a radial artery graft has proven benefits in terms of graft patency compared with a saphenous venous graft. In this context, multiple randomized clinical trials have repeatedly proven the improved clinical outcomes of radial artery grafts based on 10 years of follow-up; the radial artery graft has also been shown to be a suitable arterial conduit in up to 90% of coronary artery bypass grafting cases. Despite the scientific evidence regarding the benefits of the radial artery graft, most surgeons are still reluctant to use the radial artery in coronary artery bypass graft procedures. Consequently, surgical residents risk not developing solid surgical skills for utilization of the radial artery graft. Safe, easy-to-learn techniques are needed to speed up the learning curve and at the same time lower the complications. In this context, a fully no-touch technique for harvesting the radial artery using a harmonic scalpel can be the right way to introduce young surgeons to this basic but paramount skill.

AUTOGENOUS ARTERIAL GRAFTS FOR MYOCARDIAL REVASCULARIZATION USING THE Y-COMPOSITE GRAFTS AND THE IN SITU INTERNAL THORACIC ARTERY CONDUITS. THE CURRENT STATUS OF THE PROBLEM

HighlightsThe article outlines the modern concept of arterial myocardial revascularization, presents the most promising directions for development of coronary surgery, and describes the results and prospects of the clinical application of autogenous arterial grafts using two internal thoracic arteries in various graft configuration and in situ, making it possible to assess the effectiveness of the procedure. AbstractThere are many approaches to coronary artery bypass grafting with the internal thoracic arteries: the use of I and Y configuration, in situ grafts, and composite grafts. However, there is no consensus on the most effective type of configuration of arterial grafts. This is due to the complexity of making the composite Y graft, determination of the risk factor, and the lack of sufficient evidence regarding the main approaches to bypass grafting with autogenous arterial grafts.

Arterial grafts for myocardial revascularization using the Y-composite grafts and the in situ internal thoracic artery conduits. The current status of the problem

HighlightsThe article outlines the modern concept of arterial myocardial revascularization, presents the most promising directions for development of coronary surgery, and describes the results and prospects of the clinical application of autogenous arterial grafts using two internal thoracic arteries in various graft configuration and in situ, making it possible to assess the effectiveness of the procedure. AbstractThere are many approaches to coronary artery bypass grafting with the internal thoracic arteries: the use of I and Y configuration, in situ grafts, and composite grafts. However, there is no consensus on the most effective type of configuration of arterial grafts. This is due to the complexity of making the composite Y graft, determination of the risk factor, and the lack of sufficient evidence regarding the main approaches to bypass grafting with autogenous arterial grafts.

Survival and Independent Predictors of Mortality Following Coronary Artery Bypass Graft Surgery in a Single-Unit Practice in the United Kingdom Over 20 Years

The types of graft conduits and surgical techniques may impact the long-term outcomes of patients after coronary artery bypass graft (CABG) revascularization. This study observed a long-term survival rate following CABG surgery over 20 years in the United Kingdom. A total of 2979 isolated CABG patients were studied from 1999 to 2020, and postoperative data were obtained from the hospital-recorded mortality by the data quality team of the information department. Postdischarge survival was estimated using the Kaplan-Meier method, and statistical significance was obtained with log-rank tests and the Gehan-Breslow test, and the Holm-Sidak method was used for multiple pairwise comparisons. The study observed male predominance (80%), and the median age was statistically significant (P <0.001) among the groups, 66 years (interquartile range 58-73) and 72 years (interquartile range 66-78) in survivor and non-survivor groups, respectively. In the Holm-Sidak method analysis, the best survival rate (mean 18.7 years) was observed in the total arterial group with significantly decreased survival for the mixed arterial and venous group (mean 16.12 years) and only the vein group (10.44 years). The Cox regression model observed that the New York Heart Association (NYHA) class III-IV (HR 1.57), chest re-exploration (HR 2.14), preoperative dialysis (HR 3.13), and redo surgery (HR 3.04) were potential predictors of the postoperative mortality (P ≤0.05). In our series over 20 years, albeit off-pump and on-pump CABG observed similar survival rates, the total arterial myocardial revascularization population has significantly better long-term survival benefits.

Comparative Analysis of Early Postoperative Period in Patients with Total Arterial Revascularization and Conventional Coronary Artery Bypass Grafting

The use of total arterial myocardial revascularization in patients with multivessel lesions of the coronary arteries has a number of advantages, namely the duration of functioning or patency of the grafts. The level of total arterial myocardial revascularization implementation in developed and developing countries remains quite low.&#x0D; The aim. Based on the analysis of our own experience, to determine the influence of the technique of total arterial revascularization on the frequency of complications in the early postoperative period.&#x0D; Materials and methods. From February 22, 2016 to December 24, 2020, 390 consecutive patients were operated at the Ukrainian Children’s Cardiac Center. The patients were divided into two groups: participants of the group I underwent total arterial myocardial revascularization, and those includedin the group II underwent conventional coronary artery bypass grafting (CABG). The inclusion criteria were: ischemic heart disease, stable angina or exertional angina, multivascular coronary artery disease, absence of valvular pathology.&#x0D; Results. There was zero 30-day mortality in both groups. The frequency of postoperative bleeding was higher in group II and amounted to 1.6%. Surgical wound complications (infection) were also more common in the group II: 1.2% versus 0.69% (p=0.906) in the group I. Similarly, laboratory parameters such as the level of creatine kinase-MB were almost identical.&#x0D; Conclusions. Total arterial myocardial revascularization is a safe method with good immediate results. The frequency of complications in total arterial myocardial revascularizationdoes not differ from that in conventional CABG. For a wider application of the total arterial myocardial revascularization,it is necessary to continue toconduct studies of the remote postoperative period.

Controversies in cardiac surgery: left main coronary disease, arterial myocardial revascularization, and prosthetic valves in dialysis.

Controversies in cardiac surgery: left main coronary disease, arterial myocardial revascularization, and prosthetic valves in dialysis.

Anaortic off-pump Complete Arterial Revascularization Using Composite LIMA RIMA Y grafts: 1 Year Outcome

Objective: The aim was to evaluate the early outcome of off-pump coronary artery bypass grafting (OPCABG) with a bilateral internal mammary artery (BIMA) Y configuration graft to achieve total arterial myocardial revascularization. Materials and Methods: From March 2018 to March 2020 total 30 cases of off pump CABG surgery using LIMA RIMA Y sequential grafts to achieve total arterial myocardial revascularization. Comparisons between LIMA + SVG and BIMA Y grafts were not made here. Result: The average age of the patients was 43.51±2.58 years. Most of them were male (93.34%). A total of 28 (93.34%) cases had triple-vessel disease. Double-vessel disease was found in 2 (6.66%) cases. The skeletonization skill was used to harvest the two IMAs and then the free right internal mammary artery was anastomosed end-to-side to the in situ left internal mammary artery to composite a Y configuration graft. Off-pump and sequential anastomosis methods were used to perform coronary artery bypass surgery for the patients. Graft patency was assessed by doing CT angiogram. All distal and proximal Y anastomoses were patent at 1 year follow up. There were no perioperative deaths. Conclusion: OPCABG by using LIMA RIMA Y graft is an effective option for total arterial revascularization and avoid surgical complications regarding the ascending aorta manupulation. Bangladesh Heart Journal 2022; 37(1): 27-33

Radial Artery Versus Saphenous Vein as Third Conduit in Coronary Artery Bypass Graft Surgery for Multivessel Coronary Artery Disease: a Ten-Year Literature Review.

Coronary artery bypass grafting is the gold standard strategy for obtaining complete coronary revascularization in patients with multivessel coronary artery disease. The recent AHA and EACTS guidelines on myocardial revascularization recommend total arterial revascularization, especially in younger patients, whenever possible. However, the use of saphenous vein grafts in association with single or bilateral internal thoracic artery (SITA, BITA) instead of arterial grafts (radial arteries, right gastroepiploic artery and inferior epigastric artery) is widespread. We analyzed literature from the last ten years (January 2010 to December 2020) looking for evidence in favour of the use of a radial artery compared to a saphenous vein in association with BITA. We identified nine studies (4 Systematic Reviews and Meta-analyses and 6 large cohort observational studies with propensity score-matching) that compared arterial with saphenous grafts as third conduit. The main finding of the review is the higher rate of freedom from any cardiac adverse event in the population which reached Total Arterial myocardial Revascularization (TAR). A probable reason for the limited application of TAR as a strategy is the shortage of Randomized Controlled Trials (RCTs). (www.actabiomedica.it)

Remodeling of ipsilateral ulnar artery after radial artery harvesting for coronary artery bypass graft.

There are controversies in the literature on the blood supply to the forearm after surgical removal of the radial artery in coronary artery bypass grafting (CABG). The objective was to investigate the arterial remodeling of the ulnar artery after the removal of the radial artery in myocardial revascularization by means of ultrasound examination with color Doppler in the pre- and post-operative periods. This paper describes an observational prospective study of the remodeling of the left brachial and ulnar arteries (donor arm) in 103 right-handed non-consecutive adult patients undergoing CABG with removal of the ipsilateral radial artery using the color Doppler ultrasound examination. In the ulnar artery, a significant increase (P < 0.05) was seen in the following measurements: lumen diameter by 13%, lumen area by 26%, peak systolic flow by 40%, and average flow by 46%. Intima-media thickness measured in the ulnar artery did not show a statistically significant difference (P= 0.22), except in diabetic patients (P = 0.007). We conclude that the ulnar artery undergoes positive physiological remodeling, adapting to the new requirements of chronic increase in flow after the ipsilateral removal of the radial artery to serve as a graft in CABG. There was no evidence of increased intima-media thickness, except in diabetic patients.

Total Arterial Myocardial Revascularization on a Beating Heart in Patients with Atherosclerotic Damage of Coronary Vessels

&#x0D; Introduction. One of the main unresolved problems in coronary surgery has been the search for an “ideal” graft for coronary artery bypass surgery. Surgical procedures with the use of artificial circulation can lead to high incidence of postoperative complications compared to operations on a beating heart.&#x0D; The aim. To study the results of total arterial myocardial revascularization on a beating heart and to evaluate the medium-term outcomes in patients with coronary heart disease.&#x0D; Materials and methods. Ninety eight patients with coronary heart disease were treated from 2009 to 2013. The patients underwent total arterial myocardial revascularization on a beating heart using only arterial grafts: those obtained from internal thoracic artery, radial artery, and right gastroepiploic artery.&#x0D; Results and discussion. No deaths were observed in the postoperative period. In 91 (92.8%) patients, the postoperative period was uneventful. After 5 years of follow-up, clinical and non-invasive methods of examination revealed no coronary circulation disorders.&#x0D; Conclusions. Our clinical experience showed promising short- and medium-term results. The technique of total arterial myocardial revascularization on a beating heart is a good alternative to operations performed under the condition of artificial circulation.

A non-conventional proximal inflow for the radial artery coronary graft.

Despite good outcomes, the use of the radial artery as a coronary graft is not widespread. Concerns regarding its low versatility and the risk of hand ischaemia, as well as the lack of reliable information regarding the best storage solution of the graft, and regarding the treatment for preventing spasms have limited its use. In this manuscript, the (numerous) benefits and (few) drawbacks of the proximal inflow for the radial artery from the in situ right internal thoracic artery proximal stump are discussed. Outcomes are reported from a limited series of patients undergoing totally arterial myocardial revascularization using this composite graft and both internal thoracic arteries.

Intimal hyperplasia of internal mammary artery in myocardial revascularization

Intimal hyperplasia of internal mammary artery in myocardial revascularization

Long-Term Outcome of Total Arterial Myocardial Revascularization Versus Conventional Coronary Artery Bypass in Diabetic and Non-Diabetic Patients: A Propensity-Match Analysis

ObjectiveDespite the improved survival in patients with multi-vessel coronary disease compared to conventional myocardial revascularization associated with the use of multiple arterial grafting for myocardial revascularization, it has been adopted in the minority of centers. We sought to evaluate the long-term outcome of patients with and without diabetes undergoing total arterial versus conventional myocardial revascularization. MethodsAmong 1000 consecutive patients undergoing CABG, we performed a propensity-match analysis to compare patients with multi-vessel disease receiving total arterial (G1 = 618 pts) versus conventional myocardial revascularization (LIMA-LAD plus vein grafts, G2 = 382 pts). The primary end-point was survival free from all-cause and cardiac-related mortality, while the secondary end-point was the occurrence of major cardiac and cerebrovascular accidents. ResultsHospital mortality was similar (G1: 0 pts. vs G2: 1 pts., 0.3%, p = .91). At a median follow-up of 101 months (range 11–185 months), total arterial grafting was associated with significantly improved survival free from overall (G1 = 76.5 ± 3.0% vs G2 = 66.0 ± 3.1%; p < .001) and cardiac mortality (general population: G1 = 90.8 ± 2.1% vs G2 = 84.2 ± 1.9%, p = .043; diabetics:G1 = 84.7 ± 2.1 vs G2: 79.3 ± 3.4; p = .035) as well as occurrence of MACCEs (general population:G1 = 80.1 ± 3.2% vs G2 = 70.8 ± 2.9%; p > .001; diabetics:G1 = 77 ± 6 vs G2 = 53 ± 5.8; p < .001). Cox regression analysis identified diabetes (HR = 1.94, CI 95% = 1.12–2.93; p < .001) and the use of veins (HR = 1.81, CI 95% = 1.32–2.65; p < .001) as independent predictors for all-cause mortality; among diabetics, vein grafts was the strongest predictor of MACCEs (HR = 2.41, CI 95% = 1.27–4.59; p = .007) and cardiac mortality (HR = 3.24, CI 95% = 1.69–6.23; p < .001). ConclusionsLong-term survival following total arterial CABG is remarkably improved compared to conventional grafting with vein grafts especially in diabetic patients.

In situ skeletonized bilateral thoracic artery for left coronary circulation: a 20-year experience.

Our goal was to analyse the outcomes in a patient population using a standardized technique for coronary artery bypass grafting (CABG) consisting of total arterial myocardial revascularization utilizing the in situ skeletonized bilateral thoracic artery for left coronary circulation. We also explored potential predictors of long-time unfavourable outcomes. Patients undergoing total arterial myocardial revascularization using in situ skeletonized bilateral thoracic artery for left coronary circulation between January 1997 and May 2017 were included prospectively in this study. The median follow-up (100% complete) was 103 months (interquartile range 61-189 months) and ranged from 1 to 245 months. A total of 1325 consecutive patients were recruited. During the follow-up period, there were 131 deaths (9.8%), 146 repeat revascularizations (11.0%) and 229 major adverse cardiac events (17.2%). The 18-year freedom from major adverse cardiac events was 62.6 ± 9.3%, 62.5 ± 6.3% and 53.9 ± 11.0%, respectively. Multivariable models showed that a left ventricular ejection fraction ≤35%, chronic obstructive pulmonary disease, peripheral vascular disease (P < 0.001), chronic kidney disease and age ≥80 years (P = 0.002) were independent predictors of diminished long-term survival. Moreover, peripheral vascular disease and off-pump coronary artery bypass (both, P < 0.001) predicted repeat revascularization. Finally, age ≥80 years, peripheral vascular disease, left ventricular ejection fraction ≤35%, off-pump coronary artery bypass and chronic pulmonary obstructive disease were independent predictors of major adverse cardiac events during the long-term follow-up period (all, P < 0.001). Coronary artery bypass using the in situ skeletonized bilateral thoracic artery for left coronary circulation configuration for total arterial myocardial revascularization resulted in satisfactory long-term results with a low incidence of death and late events and may represent a technique of choice in selected patients having CABG. Larger and long-term prospective studies are, however, warranted.

Total arterial myocardial revascularization using bilateral internal mammary arteries and the role of postoperative sternal stabilization to reduce wound infections in a large cohort study.

Total arterial myocardial revascularization using bilateral internal mammary arteries shows improved results for mortality, long-term survival and superior graft patency. It has become the standard technique according to recent guidelines. However, these patients may have an increased risk of developing sternal wound infections, especially obese patients or those with diabetes. One reason for the wound complications may be early sternum instability. This situation could be avoided by using a thorax support vest (e.g. Posthorax® vest). This retrospective study compared the wound complications after bilateral internal mammary artery grafting including the use of a Posthorax vest. Between April 2015 and May 2017, 1613 patients received total arterial myocardial revascularization using bilateral internal mammary artery via a median sternotomy. The Posthorax support vest was used from the second postoperative day. We compared those patients with 1667 patients operated on via the same access in the preceding 26 months. The end points were the incidence of wound infections, when the wound infection occurred and how many wound revisions were needed until wound closure. The demographic data of both groups were similar. A significant advantage for the use of a thorax support vest could be seen regarding the incidence of wound infections (P = 0.036) and the length of hospital stay when a wound complication did occur (P = 0.018). As seen in this retrospective study, the early perioperative use of a thorax stabilization vest, such as the Posthorax vest, can reduce the incidence of sternal wound complications significantly. Furthermore, when a wound infection occurred, and the patient returned to the hospital for wound revision, patients who were given the Posthorax vest postoperatively had a significantly shorter length of stay until wound closure.

Bilateral Internal Thoracic Artery Grafting in Women: A Word of Caution.

Despite the superior hemodynamic performance of internal thoracic arteries, total arterial revascularization with exclusive bilateral internal thoracic arteries (BITA) is less frequently used especially in specific subsets of patients, including females. We report our experience with total arterial revascularization with exclusive BITA regardless of sex and analyze the impact of female sex on the early and midterm outcomes. Total arterial revascularization with exclusive BITA was performed with equal frequency in females (79/99, 80%) and males (392/477, 82%; P = .68) undergoing isolated CABG for 3-vessel disease. Pre, intra and postoperative data were compared between these two groups. Complete revascularization was achieved in 77% of females and 72% of males (P = .08). Early mortality did not differ between the groups (6.3% versus 4.6%, P = .7). The incidence of re-sternotomy for bleeding, postoperative stroke, myocardial infarction, new onset atrial fibrillation, and hemofiltration for renal failure did not differ between the two groups. However, there were significantly more wound revision for combined superficial and deep sternal wound infection in females (26.5% versus 5.1%, P = .0001). Nevertheless, midterm survival, freedom from repeat revascularization, myocardial infarction, stroke, and major adverse cardiovascular and cerebral events at five years were very good and compared favorably between females and males. Our findings suggest that total arterial myocardial revascularization with exclusive internal thoracic arteries in females carries the same midterm benefits as in males. Early outcomes are comparable except for a higher incidence of wound revision for combined superficial and deep sternal wound infections in females compared to males. Benefits of bilateral internal thoracic artery grafting in females should be weighed against increased risk of early wound revision.

Total arterial myocardial revascularization

The review presents the current concept oftotal arterial myocardial revascularization, main studies focusing on it, recent guidelines and commonly used techniques, which let speak about high efficacy this kind procedure. However, in medical society there is a certain part of disbelief with respect to performance of coronary artery bypass grafting using only arterial conduits, and even in justifiable cases when the choice is obvious, the percentage of mentioned operations is still low. It can be explained by both technically much more difficult manipulations and particular risk factors, which contribute discreet approach in the wide use of total arterial myocardial revascularization.