Total arterial grafting strategies for triple-vessel revascularization

Despite evidence demonstrating superior long-term survival outcomes of coronary artery bypass grafting (CABG) using arterial conduits over saphenous vein grafts, total arterial grafting (TAG) remains underutilized in patients with multivessel coronary disease. TAG offers substantial benefits, including enhanced graft patency and improved survival rates. Studies have shown that TAG provides a 10-year survival rate of approximately 85% and graft patency rates of over 90% at 5 years. However, several factors contribute to its underutilization. The technical intricacy of TAG procedures demands a higher skill level and experience from surgeons, presenting a significant barrier. Additionally, the time required for conduit harvesting extends the overall surgical duration, which can be challenging in settings with limited operative time. Increased perioperative complications, such as bleeding and wound infections, further deter the adoption of TAG. Moreover, evidence-related challenges, including a lack of multicenter randomized controlled trials (RCTs) with long follow-up periods and a lack of clarity about indications, contribute to the underutilization of TAG. As a result, many patients with multivessel coronary artery disease are not offered this strategy that could provide the most substantial benefits. Addressing these challenges through improved surgical training, streamlined operative techniques, better management of perioperative risks, and developing an evidence-based consensus about indications from RCTs with longer follow-ups could enhance the utilization of TAG, thereby improving outcomes for a broader patient population. In this comprehensive review, we aim to explore the evolution of TAG and its application in triple-vessel disease. We discuss practical revascularization configurations, debate the limitations hindering widespread adoption, and the future perspectives for TAG.