Developments in surgical techniques for coronary revascularization.

The wider application of arterial conduits represents a current trend in myocardial revascularization. More complex and demanding surgical techniques are being developed as alternatives to traditional grafting procedures, in order to permit total arterial revascularization in patients with diffuse coronary artery disease. The rationale behind this strategy is the expected higher long-term patency rate of arterial conduits as compared with vein grafts. Avoidance of proximal anastomoses is another argument in favor of coronary revascularization with arterial grafts, particularly in patients with atherosclerotic changes in the ascending aorta. Although the reported operative results are good, total arterial revascularization in multivessel disease is a complex procedure, and serious perioperative complications are possible. In planning the revascularization strategy, therefore, the surgeon should take into account age, clinical condition, coexisting medical problems, coronary anatomy, and left ventricular function. The method of myocardial revascularization is an important aspect of the surgical procedure and plays a major role in the outcome of the operation in the presence of severe left ventricular dysfunction or when the operation requires prolonged ischemic times. To avoid the inevitable damaging effects of cardiopulmonary bypass and aortic cross-clamping, myocardial revascularization is carried out without extracorporeal circulation. This technique should be part of the armamentarium of the cardiac surgeon and should occasionally be considered in patients who have serious coexisting medical problems or severe left ventricular dysfunction.