The 10 Commandments for Multiarterial Grafting

Coronary artery bypass grafting (CABG), introduced and pioneered over 50 years ago at the Cleveland Clinic by Dr. Rene Favalloro, has remained the gold standard in the treatment of multivessel coronary artery disease with heavy atherosclerotic burden.¹ While utilizing the internal thoracic artery (ITA) to bypass the left anterior descending artery (LAD) has been the cornerstone of CABG since 1986,² there has been growing consensus on the importance of multiarterial grafting (MAG) with the use of at least 2 arterial grafts, resulting in improved survival and freedom from major adverse cardiac events including reinterventions.^3,4 Indeed, the most recent CABG guidelines, set forth by the Society of Thoracic Surgeons, encourage the supplementation of the ITA graft to the LAD, in patients with multivessel disease, with the use of additional ITA and/or radial artery (RA) grafts.⁵ The incremental benefit of a third arterial graft has been somewhat equivocal, although a meta-analysis of observational studies suggested better long-term survival with 3, compared to 2, arterial grafts.⁶