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Page 6 of 9 Dewantoro et al. Vessel Plus 2018;2:20 I http://dx.doi.org/10.20517/2574-1209.2018.50

increase in the risk of postoperative DSWI [26,27] . In fact, a recent meta-analysis showed that skeletonized ITA
appears to reduce the incidence of postoperative SWI in comparison with pedicled ITA after CABG, with
[28]
this effect being modulated by the presence of diabetes . In the sensitivity analysis, the difference in favour
of skeletonized ITA was also observed in subgroups such as diabetic, bilateral ITA and diabetic with bilateral
ITA; also, there was a difference in the type of study, since non-randomized studies together demonstrated
the benefit of skeletonized ITA in comparison with pedicled ITA, but the randomized studies together did
[28]
not show this difference . To summarize, strategies that reduce DSWI target the modifiable risk factors
that include microbiological factors, appropriate antibiotic prophylaxis, tight glycemic control, while surgical
strategies reduce DSWI following BIMA harvest include techniques of IMA harvesting with lesser devas-
cularization of sternum using skeletonized, semiskeletonized and modified pedicle harvest are associated
[29]
with greater preservation of sternal blood supply and sternal closure and stability techniques . Antibiotic
prophylaxis given to patients pre- and post-operatively helps further reduce the chance of wounds infection,
improving the surgical prognosis. Diabetes acts as a risk factors for the development of atherosclerosis as it
[30]
accelerates the formation of atheroma . Its presence in patients who were undergoing revascularization for
atherosclerosis also increased the risk of post-operative complications. A retrospective study with propensity
score matching compared total arterial revascularizations to procedures that involved venous grafts in the
[17]
revascularization of atherosclerosis in diabetic patients . While the rate of perioperative mortality (within
30-days post-operatively) was similar at 1.2% in total arterial CABG group as compared to 1.4% in the non-
total arterial CABG group, nonetheless the rate of late mortality (mean of 4.9 years) was less among the total
[17]
arterial CABG groups at 10.2% as compared to the non-total arterial CABG group at 12.2% . Thus, adding
a point towards the advantage of undergoing total arterial CABG.

Fourthly, the long-term outcome (that is mainly patient’s survival rate) is also an important factor to con-
sider before choosing a procedure. From previous discussion, it has been shown that TACABG provides a
better prognosis than VCABG. However, the long-term outcome of TACABG only showed the survival rate
and did not elaborate on the MACCE that would be more relevant to the finding. Then, there was also no
mentioning of revascularization in this group. However, based on literature and what was known about the
patency of SVG as compared to arterial grafts, it could be concluded that total arterial grafting would wield a
better outcome whenever it is possible to be done. A study confirmed that by using only SVG as compared to
[31]
the use of ITA, there was 1.61 times greater risk of death throughout 10 years post-operation , thus further
favoring arterial conduits [32,33] .

A window for development into the surgical skills that may be beneficial to patients that are undergoing
CABG is by doing such procedures through off-pump method. A paper querying about The Society of Tho-
racic Surgeons National Cardiac Database showed that off-pump coronary artery bypass was associated
with a significant reduction in risk of death, stroke, acute renal failure, mortality or morbidity, and hospital
[34]
stay as compared to on-pump coronary artery bypass . This does not only benefit patients (which would
be one of the main points in considering on a procedure), but also help cut cost for the healthcare system
(which makes the other critical point that need to be balanced together with patient’s benefit and long term
outcome). However, such procedures require experience as surgeons will be required to perform the surgery
while the heart is still beating and thus avoiding the use of cardiopulmonary bypass pump. This would set
an example in which a procedure that would be beneficial for both the patients and healthcare system re-
quires significant investment, that is the amount of training need to be done by surgeons.

The challenge of increasing TACABG procedure lies on assuring surgeons that this procedure provides a
greater benefit for patients and the healthcare system. Although there would be some exceptions for the
procedure, in which VCABG can be used as an alternative when possible. In term of left main disease, there
need to be more studies and results published to show the outcome (both long- and short-term) of using
TACBG in the revascularization of left main disease.