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Raja. Vessel Plus 2019;3:23 I http://dx.doi.org/10.20517/2574-1209.2019.05 Page 5 of 11

RITA
LITA RITA LITA
LITA

RA

RA
RA

Figure 5. Composite configurations of radial artery. A: Radial artery (RA) Y or T graft from the in situ left internal mammary artery (LITA)
anastomosed to the circumflex marginal branches and distal branches of right coronary artery; B: RA Y or T graft from the in situ right
internal thoracic artery (RITA) anastomosed to the distal branches of right coronary artery; C: Extension of RITA with RA. (Figure courtesy
Marcie Bunalade)

skeletonization and can be lengthened with recycled LIMA or radial artery [Figure 5]. The RIMA should
not be anastomosed to the main RCA because of the possibility of competitive flow due to size disparity
[12]
and ultimately evolution of progressive disease at the crux .
Right gastroepiploic artery
The right gastroepiploic artery can be combined with in situ RIMA to the LAD and LIMA to the obtuse
marginal. Right gastroepiploic artery is particularly useful for grafting an occluded dominant ungrafted
RCA or one with a failed graft in the presence of patent grafts to the left side. Grafting of the PDA can be
achieved off-pump through a reasonably small incision via the lower sternum.

OUTCOMES
Perioperative outcomes
The perioperative outcomes of TAR are similar to those of conventional CABG. Majority of the
studies report 1% mortality and a 1%-3% rate for stroke, intra-aortic balloon pump use and myocardial
infarction [18-21] . There is increasing acceptance that TAR should be offered only to younger patients (usually
now perceived as less than 70 years old), predominantly with preserved ventricular function and absence
of significant co-morbidity, as they are more likely to benefit from the superior long-term patency of the
[12]
arterial grafts . However, TAR in combination with off-pump CABG can also be offered to the elderly to
allow a true “no touch aortic technique” where there is robust evidence for a reduction in the risk of most
[22]
major complications and, in particular, stroke . There is evidence from RCTs that TAR with composite
grafts is a safe and useful procedure in the elderly [23-25] .

Long-term outcomes
The added value of TAR in CABG becomes particularly apparent when assessing long-term results.
[26]
Tavilla et al. recently reported 20-year outcomes of TAR using BIMA and gastroepiploic artery as
in situ grafts in patients with 3-vessel disease. The Kaplan-Meier estimated survival probabilities were
73.9% (95%CI: 67.2%-79.5%) and 63.5% (95%CI: 55.7%-70.4%) for overall survival and 57.9% (95%CI: 50.7%-
64.5%) and 47.9% (95%CI: 40.1%-55.3%) for freedom from major adverse cardiac events at 15 and 20 years
respectively. The respective estimated cumulative incidences at 15 and 20 years were 7.0% (95%CI: 3.5%-
10.6%) and 7.8% 95%CI: 4.0%-11.6%) for myocardial infarction, 8.6% (95%CI: 4.7%-12.5%) and 9.3% (95%CI:
5.2%-13.3%) for percutaneous reintervention, 7.0% (95%CI: 3.5%-10.5%) and 7.0% (95%CI: 3.5%-10.5%) for