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Page 2 of 16 Harik et al. Vessel Plus 2023;7:30 https://dx.doi.org/10.20517/2574-1209.2023.124

poorer outcomes than men, we present special considerations for graft selection in women, as graft type and
grafting strategy may contribute to this sex disparity.

CABG GRAFTS
Grafts used for CABG can be grouped into two categories: arterial or venous. Arterial grafts include the left
internal thoracic and right internal thoracic arteries (LITA and RITA, respectively), which are harvested
from the chest wall, and the radial artery (RA), harvested from the upper extremities. The right
gastroepiploic artery (RGEA), which is harvested from the abdomen, and the inferior epigastric artery,
[1,2]
which is harvested from the abdominal wall, are rarely used in clinical practice . Venous grafts include the
greater and lesser saphenous veins (SVGs), harvested from the lower extremities, and the cephalic vein,
which can be harvested from the upper arm.

USE OF DIFFERENT CABG GRAFTS
The use of the LITA to bypass the left anterior descending artery (LAD) is widely accepted as the gold
standard of CABG practice. A preponderance of observational data has demonstrated that the LITA has
superior patency and outcomes compared with other grafts, venous or arterial, and accordingly,
international professional guidelines give a Class 1 recommendation to use the LITA to bypass the LAD
(American College of Cardiology [ACC]/American Heart Association [AHA]/Society for Cardiovascular
Angiography and Interventions [SCAI] Class 1, Level of Evidence B-NR; European Society of Cardiology
[3,4]
[ESC]/European Association for Cardio-Thoracic Surgery [EACTS]: Class 1, Level of Evidence B) .

The RA is recommended by international professional guidelines as the second arterial graft (after the LITA
to bypass the LAD) to bypass the second most important coronary target (ACC/AHA/SCAI Class 1, Level
of Evidence B; ESC/EACTS: Class 1, Level of Evidence B-R) . As interest in multiple arterial grafting
[3,4]
(MAG), as opposed to single arterial grafting (SAG), has increased in the last two decades, the use rate of
the RA has correspondingly increased. It has reported excellent patency rates but has more musculature
than other arterial conduits, and therefore, vasospasm is a potential risk. In a recent analysis of the United
Kingdom national cardiac surgery database including over 330,000 primary elective CABG patients from
[5]
1996-2018 , 84.4% of patients received SAG and 15.5% received MAG. Of those receiving MAG, the use
rate of the RA ranged from 20% at the start of the study period to 60% at the endpoint of the study, with a
peak of nearly 80% in 2001. The use rate of the RITA in MAG patients was at its peak of 80% at the start of
the study period and fell to 40% at the endpoint of the study, with a nadir of 20% in 2001 . An analysis of
[5]
[6]
the Society of Thoracic Surgeons (STS) database from 2004 to 2015 of over 1.3 million CABG patients
found that 10.6% of patients underwent MAG, with 61.4% of MAG patients receiving the RA and 46.0% of
the MAG patients receiving the RITA (11,718 patients received both RITA and RA). Current ACC/AHA/
SCAI guidelines give a weaker recommendation for the use of the RITA than for the RA, stating that it
should be performed only in appropriately selected patients and only by surgeons with adequate experience
[3]
(Class 2a, Level of Evidence B-NR) , which is consistent with existing ESC/EACTS recommendations for
bilateral ITA grafting . This caution regarding the use of the RITA for MAG may be partly due to the
[4]
[7,8]
reported increased risk of sternal wound infection seen when bilateral ITA grafting is used , and should be
considered during preoperative planning, particularly in high-risk patients .
[3]
Despite professional guideline recommendations for the use of other grafts, SVGs remain the most
commonly used CABG graft , with a global use rate of nearly 90% . Its high use rate despite its described
[6]
[6,9]
poorer patency is likely due to the relative ease of harvesting the SVG, as well as surgeon familiarity, along
with possible physician concerns such as spasm or sternal wound infection regarding the use of arterial
[10]
grafts such as the RA and RITA, respectively .