Is total arterial coronary artery bypass grafting the next step forward?

Abstract

Total arterial coronary artery bypass grafting (TAR) has emerged as a superior strategy in coronary revascularization due to its ability to enhance long-term graft patency and reduce postoperative adverse cardiac events compared to traditional saphenous vein graft (SVG)-based approaches. While coronary artery bypass grafting (CABG) remains the cornerstone for treating multivessel coronary artery disease, its historical reliance on SVG has been increasingly challenged by the recognized durability and superior clinical outcomes associated with arterial grafts, such as the internal mammary artery (IMA) and radial artery. This article highlights the advantages of TAR over both single arterial grafting (SAG) and multiple arterial grafting (MAG), emphasizing its potential to eliminate the long-term vulnerabilities associated with venous conduits. However, the adoption of TAR faces significant barriers, including perceived technical complexity, increased operative duration, and concerns over complications such as deep sternal wound infections, particularly when bilateral IMA grafts are used. In contrast, MAG represents a transitional approach that incorporates arterial grafts alongside SVG to mitigate these challenges, offering surgeons flexibility while advancing toward arterial revascularization. Despite growing evidence favoring TAR, its widespread implementation is limited by a lack of large-scale randomized trials and logistical challenges in training and execution. This article provides a balanced discussion of the benefits and limitations of TAR, exploring its role in contemporary CABG practice and its potential to redefine coronary revascularization strategies.

Keywords

Coronary artery bypass grafting / total arterial revascularization / multiple arterial grafting / survival outcomes / radial artery / internal mammary artery / saphenous vein graft

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