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Royse et al. Vessel Plus 2020;4:5 I http://dx.doi.org/10.20517/2574-1209.2019.34 Page 11 of 22

Complications occur in all medical treatments, but, when new techniques are introduced, there is often a
new benchmark established by those resisting change - that of a zero tolerance of complications, different
from normal practice of an acceptable rate of complications as dictated by local guidelines, societies or the
literature. This practice leads to excessive psychological stress on the surgeon attempting the change, often
leading to return to the status quo (the intent of the criticism).

Guidelines are the result of a consultative and consensus opinion of experts reviewing the existing
literature. Level A evidence always relates to techniques that have been in use for a long time, usually
decades. The key intended effect of guidelines is to enforce conformity: for those whose practice lags
behind the mainstream to update to the mainstream practice as well as for pioneers and early adopters of
new techniques to return to the mainstream. “Evidence-based medicine” usually refers to conformity to
guidelines, increasing the risk to the individual practitioner if they practice outside of the guidelines; hence,
risk aversion is a powerful force acting against new change.

Technical difficulty of grafting
The technical difficulty is usually exaggerated. Coronary surgery is fairly basic conceptually and most
surgeons are competent at suturing a conduit to a target coronary artery.

The simple path to evolve practice is to substitute an arterial conduit for a venous conduit - and not to
change any other aspect of the surgical technique. By the use of both IMAs and both RAs, four grafts can
be easily achieved without alteration of the surgeon’s usual operative routine. In this way, the majority of
CABG could achieve TAR and the remainder of the patients could receive multi-arterial grafting. This
change in practice is simple and easily achievable, with minimal risk to the surgeon’s reputation and results
but with long-term survival benefit to the patient.

To achieve routine TAR or at least high rates of TAR does require the use of more complex reconstructive
techniques, which are discussed below, and it is recommended that surgeons who rarely perform TAR
commence with substituting arterial conduits in the first instance before attempting more complex
methods.

The “R” word
Surgeons who infrequently use a RA will usually articulate that the late outcomes of RA are:
(1) “no good”;
(2) RA is difficult to harvest and their assistants are untrained;
(3) RA takes too much time to harvest and they cannot afford the time; or
(4) they have to introduce the use of vasodilators to their practice due to the reports of the high tendency
of RA to spasm, which may then introduce iatrogenic complications related to low blood pressure and
reduced end organ perfusion.

The use of RA is integral to the achievement of TAR for most surgeons (although a BIMAY technique
could be an alternative). In our Australian series, RA represented 47% of all grafts in the TAR group and
25% in the Multi-Arterial Grafting (MAG) group prior to propensity score matching. Our group has a large
experience of RA use and considers:
(1) RA exhibits late angiographic patency very similar to IMA - a patent graft in the short term appears
to remain patent and normal in the long term. This contributes to the TAR group maintaining the highest
late survival, as well as to survival in the MAG group exceeding 1A + SVG. The in-hospital mortality is not
increased in our experience.
(2) RA is the simplest conduit to harvest, and substantially easier than IMA. It is also the easiest harvest
technique to learn. We harvest RA with similar technique methods as for IMA: enter the correct anatomical