The choice of conduit, graft configuration (in situ versus composite), and the number of grafts required to achieve complete revascularization have traditionally been central considerations in planning CABG. In this context, the present study focuses specifically on patients with triple-vessel disease in whom complete revascularization was accomplished using three in situ arterial grafts.

This single-centre study initially included 323 patients out of 1034 diagnosed with triple-vessel disease who underwent OPCAB (31.2%), in whom the BITA–rGEA combination was used exclusively. Twenty-one patients were subsequently excluded due to the need for additional grafts or conversion to on-pump CABG, resulting in a final cohort of 302 patients. All procedures were performed by a single surgeon, ensuring technical consistency but limiting external generalizability.

The median age was 67 years. Age ≥60 years was the only variable that, in univariable analysis, was significantly associated with reduced overall survival and lower MACCE-free survival. Despite this, the incidence of stroke was 0% within the first 30 postoperative days and 2.6% during long-term follow-up.

Overall survival at 5, 10, and 13 years was 92.6%, 85.8%, and 77.7%, respectively. Corresponding MACCE-free survival rates were 89.9%, 79.9%, and 69.2%.

Regarding the rGEA, the authors recommend skeletonized harvesting and restricting its use to cases with right coronary artery stenosis >90% and a graft diameter >2 mm to minimize competitive flow and reduce the risk of occlusion. This strict anatomical selection was associated with excellent early graft patency.

The authors conclude that total arterial revascularization using skeletonized in situ BITA and rGEA grafts is associated with excellent early and long-term outcomes, provided that careful patient selection and strict anatomical criteria for rGEA use are applied.

COMMENTARY:

When facing patients with multivessel coronary artery disease who are candidates for surgical revascularization, it is inevitable to question which strategy can provide both complete and durable revascularization whenever technically feasible (although in previous articles you can find different points of view on the matter, such as this blog comment that addresses some important aspects of complete revascularization). In this setting, the concomitant use of BITA and rGEA as in situ grafts represents a particularly appealing alternative.

This approach offers potentially superior long-term durability compared with venous grafting and avoids the inherent risks of composite configurations, in which proximal occlusion may jeopardize more than one coronary territory. The functional independence of in situ grafts adds an additional layer of safety for both surgeon and patient.

However, beyond its theoretical advantages and the favourable results reported in this series, it must be acknowledged that this is a technically demanding strategy. Its successful implementation requires substantial surgical expertise, not only in patient selection but also in the harvesting and intraoperative management of the rGEA, a conduit that is not routinely used in many centres.

Although multiple arterial grafting has historically raised concerns regarding local complications, particularly in diabetic patients, this study suggests that the use of OPCAB combined with skeletonization may mitigate this risk when patients are appropriately selected.

In summary, despite methodological limitations that restrict universal extrapolation, this study provides meaningful evidence supporting the role of total arterial revascularization with in situ grafts. Rather than serving as a universally applicable recommendation, it should be viewed as an incentive to continue refining surgical strategies that expand our therapeutic armamentarium and ultimately enhance patient care.

REFERENCE:

Niinami H, Endo Y, Morita K, Hattori M, Domoto S, Ichihara Y, et al. A. Long-Term Outcomes Following Off-pump Coronary Artery Bypass Grafting Using Only 3 In situ Arterial Grafts. Eur J Cardiothorac Surg. 2025 Sep 2;67(9):ezaf289. doi: 10.1093/ejcts/ezaf289.