Sequential coronary artery bypass utilizing the internal mammary artery

Fifty consecutive patients underwent sequential bypass grafting of diseased coronary arteries using the left internal mammary artery (IMA) as a sequential bypass graft. There were no perioperative myocardial infarctions, and follow-up from 3 to 5 years revealed that all 50 patients are living and are free of angina. Technical aspects for use of the internal mammary artery as a sequential graft to two or more coronary arteries is technically a feasible procedure when certain guidelines are followed. We advise its use primarily for left anterior descending/diagonal connections and avoid its use when there is a wide angle between the latter vessels to avoid kinking. The distal end-to-side IMA anastomosis is always performed first to the most important coronary artery. With this approach if there is a problem with length or lie of the IMA graft, the sequential anastomosis to the lesser important coronary artery may be aborted. The side-to-side technique is used most often. Postoperative angiograms in 11 patients have revealed no evidence of stenosis, occlusion, or late ill effects.