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Dewantoro et al. Vessel Plus 2018;2:20 I http://dx.doi.org/10.20517/2574-1209.2018.50 Page 5 of 9

Table 1. 5-year outcome of patients in TACABG and VCABG in patients with left main disease
VCABG TACABG
ART TAR TAR
NOBLE* RAPCO**
Single- graft group Non-TAR group TAR group
Average age (years) 66.2 63.5 64.7 60.1 64.4
Number of patients 592 1554 6232 140 6232
MACCE 80 (18%) 198 (12.7%)* N/A N/A N/A
All-cause mortality 32 (9%) 130 (8.4%) 9.9%*** 3 (2%) 8.7%***
Cardiac death 15 (3%) N/A N/A N/A N/A
Vascular death 1 (< 1%) N/A N/A N/A N/A
Non-procedural myocardial infarction 10 (2%) N/A N/A N/A N/A
Revascularisation (total) 47 (10%) 103 (6.6%) N/A N/A N/A
Revascularisation with PCI 45 (10%) N/A N/A 3 (2%) N/A
Revascularisation with CABG 2 (< 1%) N/A N/A N/A N/A
Target lesion revascularisation 36 (8%) N/A N/A N/A N/A
Target LMCA revascularisation 33 (9%) N/A N/A N/A N/A
De novo lesion revascularisation 11 (3%) N/A N/A N/A N/A
(new lesion in non-grafted segment)
Symptomatic graft occlusion or definite stent thrombosis 15 (4%) N/A N/A N/A N/A
Stroke 7 (2%) 49 (3.2%) N/A N/A N/A

*Composite death, myocardial infarction, and stroke; **RAPCO only take RA conduit; ***Derived from Kaplan-Meier survival. CABG:
coronary artery bypass graft; TACABG: total arterial CABG; VCABG: CABG that involves venous graft; PCI: percutaneous coronary
intervention; LMCA: left main coronary artery; MACCE: major adverse cardiac and cerebrovascular events; TAR: total-arterial
revascularization; NOBLE/ART/RAPCO refer to names of clinical trials

check for saphenous vein collateral circulation. However, it has been shown that checking for saphenous vein
[16]
through the use of Doppler ultrasound improves the prognosis of SVG .

Secondly, in term of operation time, the total of cross-clamp time and perfusion time is shorter in the TA-
CABG than in VCABG (as has been discussed above), a retrospective study has shown that the operative
[17]
time taken for total arterial revascularization was 30 minutes longer . This is true especially when bilateral
ITA or RA was used. The paper further added that the additional time taken was due to the extra conduit
[17]
harvest and not to actual grafting procedure .

Also, BIMA could be performed using two different configurations, in situ versus Y-graft. A recent study
evaluated whether graft configuration might affect long-term outcomes in 2150 patients using a propensity-
[18]
score approach . Late mortality and incidence of MACCES were similar between groups, and therefore the
clinical outcome of BIMA grafting is independent of surgical configuration. However, Y-grafting increases
the flexibility of BIMA grafting and should be taken into account when a surgical strategy for myocardial
[18]
revascularization needs to be planned .

Thirdly, it is important to consider the short term post-operative outcome of a surgical procedure. An ex-
ample of this is the healing of any surgical wounds inflicted during CABG procedure, especially in high risk
[19]
patients (such as those with diabetes mellitus) . One of the main topic of interest is the healing outcome of
the sternum and chest wall after the collections of ITA, especially if bilateral ITAs were harvested. However,
through careful harvesting of such grafts while preserving pleural cavities’ integrity, it reduces the post-
operative morbidity as well as lowering hospital cost [19,20] . One of the fear of TACABG is deep sternal wound
infection (DSWI), especially if bilateral ITA was used. However, reports from various studies have shown
that there were low rates of DSWI, that is lower than 1%, in TACABG [4,21-24] . The incidence of DSWI may be
significantly higher after the harvest of both internal thoracic arteries in the elderly, with an odds risk of 1.86
[25]
(P < 0.01) . However, the risk of deep sternal wound infection can be minimized in diabetic patients under-
going CABG by performing ITA harvested in a skeletonized manner with meticulous attention to preserv-
ing sternal blood flow. Pedicled harvest is to be discouraged when utilizing both ITA owing to a significant