Long-term follow-up of coronary artery bypass grafting in three-vessel disease using exclusively pedicled bilateral internal thoracic and right gastroepiploic arteries

BACKGROUND: Considerable data now exist that show that coronary artery bypass grafting with bilateral internal thoracic artery (ITA) grafts produce better outcomes than the use of a single ITA graft. The benefit of a third arterial graft has been less well established. Therefore this article describes the survival and cardiac-related event-free survival in patients having bilateral ITA and gastroepiploic artery (GEA) grafting for 3-vessel disease. METHODS: From November 1992 to May 2002, 201 patients (mean age 53 +/- 7 years) presented with 3-vessel disease and received exclusively bilateral internal thoracic (ITAs) and right gastroepiploic (GEA) arteries as pedicled grafts for coronary artery bypass procedure. Twenty-seven (13%) patients were not elective, 10 (5%) were reoperations, 115 (57%) had one or more myocardial infarction, 21 (10%) had diabetes. In total 733 anastomoses were constructed (3.7/patient), with sequential grafting in 124 (62%) patients. The clinical follow-up was complete. The patients were followed for up to 10 years (mean 6.4 +/- 2.7 years). RESULTS: Ten-year actuarial survival (including in-hospital death) was 87%. The actuarial freedom from angina pectoris, after hospital discharge, was 97% and 86% at 5 and 10 years respectively. None of the patients needed a repeat surgical revascularization after leaving the hospital, whereas 9 (5%) patients underwent a percutaneous transluminal coronary angioplasty. At 5 years 86% and at 10 years 69% of the patients remained free of any cardiac-related event. CONCLUSIONS: The results of this study clearly indicate that the exclusive and extensive use of pedicled bilateral ITA and GEA in coronary bypass grafting provides excellent 10-year patient survival and functional improvement in terms of freedom from return of angina pectoris and, more impressive, freedom from any cardiac-related event. Our findings clearly corroborate the concomitant use of bilateral ITA and GEA grafts in selected patients with 3-vessel disease.     

Important anatomical and physiological considerations in performance of complex mammary-coronary artery operations

One or more internal mammary artery (IMA) anastomoses were performed in 87% of 692 consecutive coronary artery bypass operations performed over a 20-month period. One IMA was used in 68% (N = 469) and both IMAs were used in 19% (N = 130). Only saphenous vein grafts were used in 13% (N = 93). The mean number of anastomoses (all types) was 3.5. Fifty-seven patients were having a reoperation; bilateral IMA grafting was performed in 23% (N = 13). In 60 patients, 3 or more IMA anastomoses were performed: 3 IMA anastomoses, 50 patients; 4, 9 patients; and 5, 1 patient. In 27 patients, repeat coronary arteriography was performed within 30 days of operation to evaluate dynamics of IMA, saphenous vein, and native coronary artery flow. Major flow or all flow was through the graft (vs. the native coronary artery) in 62% of in situ IMA bypass grafts, 86% of free IMA grafts and 94% of saphenous vein grafts. Hospital mortality excluding patients having reoperation was 1.7% (11/635); it was less than 1% for patients having either single IMA grafting procedures (4/437) or bilateral IMA grafting procedures (1/117). Hospital mortality for patients receiving only saphenous vein grafts was surprisingly high, 7.4% (6/81). Major determinants of flow through the in situ IMA sequential graft are the size and flow of the IMA, the degree of proximal native coronary artery narrowing, the distally grafted to proximally grafted coronary artery size ratio, and probably the size of the side-to-side anastomosis.(ABSTRACT TRUNCATED AT 250 WORDS)     

Place of the right gastro-epiploic artery in coronary revascularization by exclusive arterial grafts]

From March 1990 to July 1991, 35 patients underwent coronary artery bypass grafts using the right gastro-epiploic artery (GEA). Twenty-nine patients had exclusively arterial grafts using a combination of GEA and internal mammary artery (IMA) in situ. The selection criteria for this group of 29 patients included a life expectancy exceeding ten years to avoid the need for reoperation due to deterioration of the grafts. This group consisted of 27 men and two women under the age of 70 years (mean age: 58 years, range: 36 to 70), 11 patients (38%) were under the age of 50 years and 15 (52%) were under the age of 60 years. Cardiac status was relatively well preserved. The mean ejection fraction was 58% (range: 25-70%). Fourteen patients (48%) had had a preoperative myocardial infarction. Fifty-five p. cent were smokers, 41% suffered from HT and 31% had a dyslipidaemia. Six patients (20%) had respiratory failure, 6 others (20%) were severely overweight and 2 patients were diabetic. According to the NYHA classification, 14 patients (48%) were stage IV, 9 patients (31%) were stage III and 6 patients (20%) were stage II. The mean number of bypass grafts per patient was 2.8 and 8 sequential bypass grafts (27%) were performed. The GEA was used in 29 cases, the left IMA was used in 28 cases, the right IMA was used in 13 cases and the epigastric artery was used as a free graft in 3 cases. Associated lesions included a resected left ventricular aneurysm. No associated valve procedures were performed.(ABSTRACT TRUNCATED AT 250 WORDS)     

Skeletonization of gastroepiploic artery graft in off-pump coronary artery bypass grafting: early clinical and angiographic assessment

BACKGROUND: Recently skeletonization has been recognized as an alternative to pedicle harvesting of the internal thoracic artery as a technique that increases the length and caliber size of the graft compared with pedicled internal thoracic artery grafts; however, this is not yet popular for harvesting the gastroepiploic artery (GEA). We report here our experience of skeletonized GEA grafting in off-pump coronary artery bypass grafting with early clinical and angiographic results. The purpose of this study was to evaluate skeletonization of GEA grafting in off-pump coronary artery bypass grafting with a large patient volume. METHODS: One hundred sixty-eight patients including 131 men and 37 women (mean age, 65 years; range, 45 to 87 years) underwent the skeletonized GEA grafting in off-pump coronary artery bypass grafting. These patients represent 41% (168 of 407 patients) of those who underwent off-pump coronary artery bypass grafting operations during the same period. We used the GEA graft of choice in patients with right coronary artery lesion. Skeletonization was performed in a unique manner we developed. RESULTS: There were no in-hospital deaths among the study patients. One patient had a perioperative myocardial infarction, which was considered a result of vasospasm of the GEA graft. None of the other patients had severe morbidity. The patency rate of the skeletonized GEA graft was 98.1% (151 of 154 distal anastomoses). CONCLUSIONS: This study suggests that skeletonization of the GEA graft can enlarge its caliber size and improve its flow capacity. In addition, the acceptable early clinical and angiographic outcome suggests that use of the skeletonized GEA graft in off-pump coronary artery bypass grafting surgery is safe and effective.     

Sequential internal mammary-coronary artery bypass

A total of ten patients have undergone sequential bypass grafting of the internal mammary artery (IMA) to the coronary arteries at Osaka Medical College. Operative procedures included left IMA bypass to the left anterior descending (LAD) artery and its major diagonal branch in six patients; to the obtuse marginal branch and diagonal branch in three patients; and to the first and the second diagonal branches in one patient. The right internal mammary artery was concomitantly utilized in 4 patients and saphenous vein graft was also utilized in 6 patients. Postoperative angiographic studies were performed in nine patients within 6 months after operation and in all 18 sites of IMA anastomoses, the IMA sequential grafts were patent. Since sequential IMA-coronary bypass technique means the increase of arterial graft, we believe that this technique should be used for multivessel coronary revascularization especially in younger patients.     

Two-year assessment by exercise thallium scintigraphy of myocardial revascularization using bilateral internal mammary and gastroepiploic arteries.

OBJECTIVE: To assess the blood flow supply offered to the myocardium by surgical revascularization using bilateral internal mammary (IMAs) and gastroepiploic (GEA) arteries. METHODS: Two-year assessment by exercise thallium myocardial scintigraphy without medical treatment was performed in 122 patients (mean age 61 +/- 9 years) who underwent coronary artery bypass grafting (CABG) with exclusive use of IMAs and GEA. Usually, the right IMA was used to bypass the left anterior descending coronary artery, and the left IMA to bypass the diagonal and the marginal arteries as a sequential graft if required. The GEA was used to bypass the right coronary artery (RCA) in 50 patients and its posterior branches in 72 patients. RESULTS: During maximal or submaximal exercise stress testing, 119 patients (98%) were asymptomatic and 26 patients (21%) exhibited moderate ischemic ECG modifications which were correlated (P < 0.01) with incomplete revascularization and with the use of GEA to bypass the RCA. A third of patients had moderate ischemic thallium defects on exercise reversible after redistribution (anterior, 10; lateral, 2; inferior, 28). Silent residual myocardial ischemia detected by thallium scintigraphy was correlated (P < 0.001) with ECG modifications and incomplete revascularization; and inferior thallium defects were more frequent when GEA bypassed the RCA (P < 0.05). However, 26% of patients had residual ischemia despite a complete revascularization, and in at least 18% of cases for GEA and 8% for right IMA, arterial graft blood flow was insufficient at maximum exercise level and caused silent residual myocardial ischemia detected by thallium scintigraphy. CONCLUSIONS: Myocardial revascularization using bilateral IMAs and GEA offers a satisfactory myocardial perfusion in the majority of cases; however silent residual myocardial ischemia was detected in a third of patients and was related to incomplete revascularization and to insufficient blood flow supply probably due to small diameter of the arterial grafts.     

Clinical and angiographic assessment of complex mammary artery bypass grafting

The internal mammary artery has become the coronary bypass graft of choice in recent years because of enhanced long-term patency. Along with this trend, sequential, bilateral, and free mammary grafts have been employed more frequently in an effort to maximize the number of distal internal mammary anastomoses. This approach of maximally using the internal mammary artery (complex mammary grafting) seems logical, but at present little information about patency of the newer types of internal mammary artery grafts is available to justify the more complicated procedures. Over a 15 month period, 207 patients underwent bypass graft angiography from 1 to 32 weeks after operation. This is an 85% restudy rate for a consecutive series of coronary bypass procedures. Patency was defined as complete filling of the graft and distal vessel bypassed. A total of 841 distal vessels were grafted, or 4.1 per patient. The overall patency rate was 91% for 503 distal vein graft anastomoses and 99% for 338 internal mammary artery grafts. Individual patency rates of distal anastomoses, expressed as number patent/total (percent patent), were as follows: simple vein grafts, 262/285 (92%); sequential vein grafts, 196/218 (90%); left internal mammary artery to left anterior descending coronary artery, 109/110 (99%); left internal mammary to circumflex marginal artery, 14/14 (100%); right internal mammary to right coronary artery, 19/20 (95%); right internal mammary to left anterior descending coronary artery, 10/10 (100%); right internal mammary to circumflex marginal artery via transverse sinus, 18/20 (90%); sequential left internal mammary artery to left anterior descending system, 133/134 (99%); sequential left internal mammary to circumflex marginal system, 15/15 (100%); free internal mammary artery, 9/9 (100%); free sequential internal mammary artery, 6/6 (100%). Of the 18 patent transverse sinus right internal mammary grafts to the circumflex marginal artery, three exhibited very slow flow and probably were not functional. The hospital mortality associated with internal mammary revascularizations was 0.4% for nonemergency cases and 3.1% for emergency procedures. On the basis of clinical and postoperative graft patency data, expanded use of more complicated types of mammary grafts seems justified. Function of the right internal mammary graft to the circumflex marginal artery was suboptimal, and this method has been discontinued. All other complex mammary techniques had excellent patency rates as compared to vein grafts, and these differences may become even more significant in the late postoperative period.(ABSTRACT TRUNCATED AT 400 WORDS)     

Right gastroepiploic artery as a coronary bypass graft

Between November 1987 and April 1988, the right gastroepiploic artery (GEA) was used as a coronary artery bypass graft in 11 patients, 9 men and 2 women. In 1 of them, the GEA was used because no veins were available; in the others, the GEA was used to avoid the use of vein grafts. The GEA was anastomosed to the right coronary artery in all patients, and internal mammary artery grafts were used to bypass the left anterior descending and circumflex coronary arteries. All patients survived the operation. There were no early and, to date, there have been no late complications of the abdominal component of the operation. Postoperative coronary angiography showed a patent right GEA in 9 patients (82%). In 1 patient the GEA was occluded, probably because of an enlarged liver. If the long-term patency of right GEA grafts is similar to that of internal mammary artery grafts, wider use of this viable graft is indicated.     

Coronary artery reoperation utilizing "free" gastroepiploic artery

A 57-year-old female underwent coronary artery bypass reoperation successfully by utilizing the free gastroepiploic artery (GEA) graft in combination with the in situ left internal mammary artery (IMA) graft. The left IMA was anastomosed to the left anterior descending artery and the "free" GEA was anastomosed to the left IMA proximally and to the first diagonal branch distally. The patient recovered well with a disappearance of angina. Postoperative angiogram at 6 weeks showed good patency of both grafts and improvement of left ventricular contraction was obtained. Thus, GEA can be utilized not only as an "in situ" graft, but also as a "free" graft, effectively.     

A method for determining an appropriate length of gastroepiploic artery graft in off-pump coronary artery bypass grafting

The gastroepiploic artery (GEA) is available as a graft to the right coronary artery (RCA). However, it is hard to determine an optimal anastomotic site and GEA graft length after upsetting the heart in off-pump coronary artery bypass grafting (OPCAB). To solve these problems, we traced a target coronary tree on the diaphragm and marked an optimal anastomotic site by skin markers. A small incision was made on the diaphragm at the proximal site of the optimal anastomotic position. Appropriate length of GEA graft was determined according to the schema on the diaphragm. By postoperative coronary angiogram performed in 22 cases (25 anastomoses), 22 anastomoses proved patent (88.0%). Flow competition of GEA-4 posterior descending artery (PD) was observed in 2 anastomoses (8.0%). Occlusion of 4PD-4 atrioventricular node artery (AV) sequential portion was observed in 1 anastomosis (4.0%). There was no angulated, redundant or tense graft in any of the patent grafts. This method was suggested to be useful in determining an optimal anastomotic site and GEA graft length.     

Coronary artery bypass grafting with combined arterial grafts

Coronary artery bypass grafting with combined arterial graft using the left internal mammary artery (IMA), right IMA, and the right gastroepiploic artery (GEA) was performed in 45 patients with saphenous vein graft (SVG) (29 patients) or without SVG (16 patients) from February 1989 to October 1989. The left IMA was used in all patients, the right IMA was used in 9 patients, and the GEA was used in 43 patients. Perioperative myocardial infarction was noted in two patients who had hospital deaths. Reopening the chest for postoperative bleeding was performed in two patients, and the cerebral accident was noted in one patient. Fourteen patients were operated on without the requirement for blood transfusion. Studied within 3 postoperative months, all arterial grafts were patent though the patency was 97.7% (43/44) in SVG. It is concluded that the combined arterial graft utilizing the IMAs and GEA can be used safely and effectively.     

Crossed double internal mammary-to-coronary artery grafts.

Crossed double internal mammary (IMA)-coronary artery grafts (the left to the left anterior descending artery [LAD], the right to a diagonal or marginal coronary branch) were used without mortality and with excellent functional results in 36 patients requiring separate grafts to these vessels (22% of patients undergoing coronary revascularization). Flows were 70 +/- 9 ml/min in the left and 50 +/- 7 ml/min in the right IMA, respectively. All revisualized grafts remained patient. The location and direction of the LAD and of diagonal and marginal branches allow excellent alignment of these shorter and wider double IMA grafts. The left IMA is the graft of choice for the LAD, and the right IMA is the choice for a high diagonal or early arising marginal branch that requires an additional separate graft. The right IMA is not satisfactory for right coronary or LAD bypass.     

Free arterial graft in coronary artery bypass surgery

Free arterial graft of the internal mammary artery (IMA) and the gastroepiploic artery (GEA) has been utilized for coronary artery bypass grafting in 10 patients during 44 months period. There were 6 males and 4 females and age ranged 42 to 73 year old with the mean of 60.8 year old. Eight IMA and 2 GEA were used as a free graft. Sites of distal anastomosis of the free graft were 3 at anterior descending arteries, 3 at diagonal branches and 4 at circumflex arteries. Sites of proximal anastomosis of those grafts were ascending aorta in one, concomitantly utilized saphenous vein graft in 5 and in situ IMA graft in 4 patients. Mean number of grafts was 2.9 (2-5) and mean aortic cross clamp time was 56.2 minutes (16-90 minutes). There was neither operative death, nor perioperative myocardial infarction and intra-aortic balloon pumping was not required. Postoperative angiography was made in 9 patients within 3 postoperative months. Eight (89%) free arterial grafts were patent. Relief of angina was obtained in all patients. We concluded that the complete revascularization with only arterial graft can be achieved more widely by utilizing the free arterial graft with an acceptable patency.     

Revival of the radial artery for coronary artery bypass grafting.

Eighteen years after its first introduction for coronary artery revascularization, the radial artery (RA) was reinvestigated because of unexpected good long-term results in the early series. Since July 1989, 104 patients underwent myocardial revascularization using 122 RA grafts (18 patients received two grafts). The left internal mammary artery (IMA) was concomitantly used as a pedicled graft in 100 cases and the right IMA in 19 cases; a free IMA graft was used in 29 cases and a saphenous vein graft in 24 cases. A mean of 2.8 grafts per patient were performed. Nine patients underwent associated procedures: carotid endarterectomy (3), aortic valve replacement (3), Bigelow procedure (1), and mitral valve repair (2). The target artery receiving the RA was the circumflex (n = 59), diagonal (n = 29), right coronary (n = 27), and left anterior descending (n = 7). One patient died (0.96%) and 2 had perioperative myocardial infarct. Sternal wound infection was noted in 3 cases of double IMA implantation. No ischemia of the hand was observed. All patients received diltiazem started intraoperatively and continued after discharge. In addition aspirin (100 mg/day) was given at discharge. Early angiographic controls (less than 2 weeks) were obtained in the first 50 consecutive patients and revealed 56 of 56 patent RA grafts, 48 of 48 patent left IMA grafts, 11 of 11 patent right IMA grafts, 14 of 18 patent free IMA grafts, and 8 of 9 patent vein grafts.(ABSTRACT TRUNCATED AT 250 WORDS)     

Combined internal mammary artery graft for coronary artery revascularization

Five patients with multiple-vessel coronary artery disease underwent isolated coronary artery bypass grafting with a technique involving both internal mammary arteries and a small piece of interposed saphenous vein. The combined internal mammary artery grafts were used for sequential grafting. A total of 20 anastomoses were performed (average number, 4 anastomoses per patient). There were no operative deaths. Postoperative complications included reoperation for bleeding in 1 patient and diaphragmatic dysfunction in another. Postoperative coronary angiography 2 days before discharge (mean time, 10 days postoperatively) revealed that all the sequential anastomoses with the combined IMA graft were patent. Exercise tolerance tests performed 3 and 11 months postoperatively indicated excellent results and no ischemia. Based on this experience, we conclude that this method appears promising for multivessel coronary artery bypass grafting.     

IMA-graft patency control by thermal coronary angiography during coronary bypass surgery.

Thermal coronary angiography (TCA) was evaluated for the intraoperative assessment of graft patency and flow in internal mammary artery (IMA) bypass grafts. TCA was performed in 210 patients undergoing 460 vein and 153 IMA bypass grafts after completion of the distal anastomoses. The IMA grafts and the recipient coronary arteries were delineated by the temperature differential between a cold epimyocardium and the perfusing warm blood after bulldog clamp release. TCA provided information about graft and anastomosis patency, initial flow patterns, and native coronary stenoses. TCA was performed in all studied IMA bypass grafts: 142 grafts were patent. Low flow but patency was observed in 24 IMA grafts and 11 IMA grafts showed no flow. Subsequently, 8 anastomotic failures and 3 proximal IMA graft occlusions were encountered. Based on these findings, 8 anastomoses were successfully revised and 7 additional vein grafts were added. One low flow IMA graft was not revised leading to postoperative ST elevation. Thirty-one distal native coronary stenoses were detected in the recipient LADs, 3 of which were not seen in the preoperative cineangiogram. In 20 instances, TCAs were obscured by an excess of fat or myocardium impeding image analysis. In 8 cases, TCA results were confirmed by conventional angiography postoperatively showing an excellent correlation in all cases. We conclude that intraoperative TCA demonstrates early IMA graft function and initial flow patterns. During our study, TCA documented a 7.2% IMA graft early failure rate. Intraoperative decision making was aided by TCA in 9.2% of all IMA grafts; this confirmed the clinical relevance of TCA.     

Bilateral internal mammary artery for coronary revascularization. Early experience of 100 cases

One hundred cases are presented in which both right and left internal mammary artery (IMA) were used as coronary bypass grafts. Special indications were thrombosis of previous venous graft (14 cases), poor venous resources (10) and small-vessel (probe less than 1.5 mm) disease (34), but bilateral IMA was used also for routine revascularization (42 cases). The total 212 distal IMA anastomoses included 12 jump grafts, three free grafts and seven thrombendarterectomies. There were 3.8 distal anastomoses per patient, 2.1 with IMA and 1.7 with vein graft. The right IMA was preferably inserted into LAD and the left into diagonal or obtuse marginal coronary artery. Excessive postoperative bleeding was the only major complication attributable to bilateral IMA grafting in the 97 survivors of surgery. In routine revascularization the procedure involved minimal morbidity and no mortality. The superiority of the IMA as regards long-term patency is widely recognized. Since many thrombosed vein grafts will require replacement, we believe that bilateral IMA grafting will become common, and it is also an option when no suitable vein is available.     

Early clinical and angiographic outcome of the pedicled right internal thoracic artery graft to the left anterior descending artery

BACKGROUND: The left internal thoracic artery (LITA) graft to the left anterior descending (LAD) artery became the gold standard graft in coronary surgery. Subsequently, the right internal thoracic artery (RITA) graft was increasingly used. However, there is still some debate about the optimal way of using this conduit. The aim of the present study was to assess our experience in grafting the pedicled RITA graft to LAD in 212 consecutive patients. METHODS: The records of 212 consecutive patients who underwent isolated coronary artery bypass grafting with the pedicled RITA graft to the LAD artery at Harefield Hospital between January 1998 and May 2001 were retrospectively reviewed. We approached the last 35 consecutive patients to obtain an angiographic control group. All 35 patients (16.5%) consented and, before discharge, underwent angiography to look at the quality of anastomoses and the patency of grafts. RESULTS: Successful catheterization and engagement of the RITA grafts was performed in 32 patients. Angiography showed that 32/32 (100%) of the RITA grafts were widely patent with excellent flow. The distal anastomoses of these RITA grafts were also satisfactory. There were no deaths among the study patients. CONCLUSIONS: Our results show that the use of the pedicled RITA graft to the LAD artery provides a good early clinical and angiographic outcome, and suggests that the pedicled RITA graft to the LAD artery is a good alternative to the pedicled LITA graft to the LAD artery.     

Triple sequential grafts using the internal mammary artery. An angiographic and short-term follow-up study.

Between December 1984 and December 1988, coronary artery bypass operations, involving the use of 119 sequential internal mammary artery grafts with three or more anastomoses per conduit, were performed in 116 patients. Patients included 14 women and 102 men, with a mean age of 60 years. They received a total of 629 anastomoses; 373 anastomoses were used in multiple sequential arterial bypass grafts; 116 sequential left and three right internal mammary artery jump grafts were performed. There were 27 patients with bilateral internal mammary artery grafts, but only 17 had completely arterial revascularizations. Perioperative infarction occurred in 3.4% of the patients; 1.7% of infarctions were related to sequential internal mammary artery grafts. There were no hospital deaths. Control angiography was performed within a month of the operation in 72 patients (with 371 anastomoses, of which 229 were in sequential arterial bypass grafts). The overall patency rate was 94.6%, and for the internal mammary artery sequential graft with three or more anastomoses it was 96.1%. The mean follow-up period was 13 months; 110 patients were in New York Heart Association class I; there was one non-cardiac-related death, and three patients (2.6%) had a late myocardial infarction. One was related to the area revascularized by the sequential internal mammary artery graft. Multiple sequential internal mammary artery bypass grafts in coronary artery disease are feasible, with a high short-term patency and a low perioperative morbidity and mortality.     

Right gastroepiploic artery: a third arterial conduit for coronary artery bypass

Experience with 39 patients (32 men, 7 women) undergoing coronary artery bypass grafting with the right gastroepiploic artery (RGEA) is reported. Indications initially included poor-quality or absent saphenous vein, ascending aortic atherosclerosis, and repeat coronary artery bypass grafting. The average number of grafts per patient was 4.10. Arteries bypassed were the posterior descending (22 patients), right coronary (12), diagonal (5), and marginal (4). Distal RGEA internal diameters of all grafts measured 1.5 to 3.25 mm (average diameter, 2.14 mm). Pedicled graft lengths measured 18 to 30 cm (average length, 23.7 cm), and free grafts, 8 to 24 cm (average length, 17.7 cm). In 6 patients, no vein grafts were used, and in all patients, at least one internal mammary artery graft was placed. Early postoperative cardiac catheterization (19 pedicled and ten free grafts) in 29 patients revealed all grafts to be patent without a kink or twist, but three of these free RGEA grafts had vasospasm. Advantages of RGEA grafts are as follows: (1) it is a third arterial conduit with artery-artery anastomoses of comparable sizes; (2) a shorter leg incision or no leg incision is necessary; (3) it can be harvested simultaneously with the internal mammary artery and the saphenous vein; (4) the proximal anastomosis (free grafts) is easy; (5) its use avoids bilateral internal mammary artery grafts in patients at high risk for sternal infection; and (6) atherosclerotic ascending aortas are not clamped. Subintimal hyperplasia and atherosclerosis of RGEA grafts are unlikely.(ABSTRACT TRUNCATED AT 250 WORDS)