Contemporary use of arterial and venous conduits in coronary artery bypass grafting: anatomical, functional and clinical aspects

Although the benefits of using the left internal mammary artery to bypass the left anterior descending artery (LAD) have been extensively ascertained, freedom from major cardiovascular events and survival after coronary artery bypass grafting (CABG) also correlate with the completeness of revascularisation. Hence, careful selection of the second-best graft conduit is crucial for CABG success. The more widespread use of saphenous vein grafts contrasts with the well-known long-term efficacy of multiple arterial grafting, which struggles to emerge as the procedure of choice due to concerns over increased technical difficulties and higher risk of postoperative complications. Conduit choice is at the discretion of the operator instead of being discussed by the heart team, where cardiologists are not usually engaged in such decisions due to a hypothetical lack of technical knowledge. Furthermore, according to the ESC/EACTS guidelines, traditional CABG remains the gold standard for multi-vessel coronary artery disease with complex LAD stenosis, but hybrid procedures using percutaneous coronary intervention for non-LAD targets could combine the best of two worlds. With the aim of raising the cardiologist's awareness of the surgical treatment options, we provide a comprehensive overview of the anatomical, functional and clinical aspects guiding the decision-making process in CABG strategy.