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(Circulation. 1998;97:2384-2385.)
© 1998 American Heart Association, Inc.

Editorials

Coronary Bypass Grafting With Bilateral Internal Thoracic Arteries and the Right Gastroepiploic Artery

Denton A. Cooley, MD

From the Texas Heart Institute and the University of Texas Medical School, Houston.

Correspondence to Denton A. Cooley, MD, Surgeon-in-Chief, Texas Heart Institute, PO Box 20345, Houston, TX 77225.

Key Words: Editorials • bypass • grafting • arteries

Now that coronary artery bypass grafting has entered its fourth decade, cardiac surgeons unanimously agree that arterial grafts yield a more satisfactory long-term clinical outcome than do autologous saphenous vein grafts. With time, venous grafts are vulnerable to accelerated atherosclerosis, which may necessitate high-risk repeat coronary bypass surgery. In contrast, arterial grafts are highly resistant to atherosclerosis. If patent immediately after surgery, they tend to remain patent indefinitely; if angina recurs, it is usually manageable with medical therapy, so repeat coronary bypass may be avoided.

Why do arteries offer superior long-term patency? Apparently, the elastic and smooth muscle elements in the arterial wall are better able to withstand pulsatile flow. An important key appears to be the integrity of the arterial endothelium, which serves as a barrier between the blood and vascular smooth muscle. After implantation as bypass conduits, arteries continue to have a basically intact endothelium¹; any endothelial defects that do develop are essentially nonthrombogenic. Moreover, the arterial endothelium releases vasoactive mediators that confer additional protection.² These mediators include prostacyclin and nitric oxide, vasodilators that prevent atherogenesis and thrombogenesis by limiting platelet aggregation and cell adhesion. Saphenous vein grafts also produce these vasodilators but not to such a great extent.

The arterial conduit of choice is the internal thoracic artery (ITA), also known as the internal mammary artery. Use of the ITA as a bypass graft was pioneered by Green and associates³ in 1968. Critics doubted its ability to provide sufficient flow, and early experience yielded a . . . [Full Text of this Article]

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