Long-Term Radial Artery Grafts with Previous Midterm Proven Patency

ABSTRACT Introduction: Left internal thoracic artery to left anterior descending artery (LITA-LADA) grafting has become a fundamental part of coronary artery bypass grafting (CABG). This grafting has led to an increased use of other arterial conduits, of which the radial artery (RA) is the most popular. Whether RA can have the same long-term patency as LITA is controversial. The objective of this study is to access the long-term clinical follow-up and, when available, the patency rate of RA grafts. Methods: Twenty-six patients from a previous study with critical stenosis in all target vessels underwent complete arterial CABG with LITA and RA grafts from 1996 to 2003. They all underwent midterm multidetector computed tomography after surgery with the association of at least one patent LITA and one patent RA graft. Results: Twelve patients (46%) are alive with no angina symptoms. Six patients underwent a second image exam 12 to 16 years (average of 14 years) after surgery, with a total of six LITA-LADA and 14 RA grafts with 100% patency rate. Clinical follow-up five to 23 years after surgery (average of 14 years) showed only one death 12 years after surgery related to coronary artery disease (CAD) (3,8%). Another 12 patients died of non-CAD. Conclusion: Patients with midterm associated LITA and RA patent grafts show similar optimal long-term patency rates of both types of grafts with excellent clinical outcome.

Impact of Single versus Double Clamp Technique on Blood Lactate Levels and Postoperative Complications in Coronary Artery Bypass Surgery

Abstract Introduction: Cardiopulmonary bypass (CPB) is associated with hyperlactatemia, which leads to adverse clinical outcomes. No study has examined the effect of different clamping techniques on postoperative hyperlactatemia (PHL). Thus, we aimed to evaluate the impact of two different techniques on PHL and the clinical outcomes in patients undergoing isolated coronary artery bypass surgery. Methods: This retrospective study included 100 patients who underwent isolated CPB either with single clamp technique (SCT, n=47) or double clamp technique (DCT, n=53). Demographic and preoperative laboratory data, as well as operative features and arterial blood lactate levels at the onset and at the end of CPB, were collected from patient charts. Results: Blood lactate levels collected at the end of CPB did not differ significantly between groups whereas intraoperative lactate increased significantly in both groups (P<0.005). PHL developed in 16 patients (32%). There was no meaningful difference in SCT and DCT in this regard. Left internal mammary artery was used more frequently in the DCT group than in the SCT group. While the cross-clamp time was significantly longer in the SCT group, there was no difference regarding CPB time. Among postoperative complications, only the incidence of stroke was significantly higher in the DCT group than in the SCT group (10.6% vs. 0%, P=0.020). CPB time, cross-clamp time and numbers of proximal saphenous graft and distal anastomosis showed a significant positive correlation with the postoperative lactate level. In the regression analysis, CPB time emerged as the only independent predictor of PHL (OR 1.04, CI 95% 1.01-1.07, P=0.011). Conclusion: There was no difference in postoperative blood lactate levels between SCT and DCT groups.

Techniques and Outcomes of the No-Touch Vein Conduit as a Y-Composite Graft

ABSTRACT Although the saphenous vein is a widely used conduit for coronary artery bypass grafting, revascularization using the saphenous vein as an aortocoronary bypass graft has shown disadvantages of lower long-term graft patency rates and subsequently worse clinical outcomes, compared with revascularization using the internal thoracic artery. Of the various efforts to overcome the limitations of vein conduit that are resulting from structural and functional differences from arterial conduit, recent technical improvement in no-touch vein composite graft construction and outcomes of revascularization using no-touch vein composite grafts based on the left internal thoracic artery will be discussed in this topic.

Graft flow analysis of application of bilateral internal mammary artery with different configurations in coronary artery bypass grafting / 中华胸心血管外科杂志

Objective:To analyze the influence of application of bilateral internal mammary artery(BIMA) with different configurations in coronary artery bypass grafting(CABG).Methods:From January 2018 to December 2020, 82 patients underwent CABG using BIMA were included, with 75 males and 7 females, aged(56.9±9.8) years old. According to the target of coronary artery of BIMA, patients were divided into two groups, 23 patients(group B) who underwent the traditional operation(RIMA to the right coronary artery), and 59 patients(group L) whose RIMA were grafted to the left ventricular arteries. Also the patients were divided into two groups according to the RIMA used either in situ(group I, 57 cases) or free(group F, 25 cases). Compare the grafts flow between groups. The CTA angiography of coronary artery was completed to evaluate the grafts patency before discharge.Results:There was 1 early operative death(1.22%). The mean flow(MF) of RIMA was significantly higher in group B( P=0.013). The pulsatility index(PI) of LIMA was significantly lower and the MF of RIMA and BIMA was higher(all P<0.05), fewer patients with LIMA-MF less than 15 ml/min( P=0.023)in the group I. CTA angiography before discharge showed that only 1 RIMA to right coronary artery was occlusion. Conclusion:It is better to use BIMA in situ in CABG, RIMA used in right coronary artery can receive more satisfactory graft flow. BIMA has good patency in early stage, therefore is the ideal and stable coronary bypass graft.

Patients Submitted to Myocardial Revascularization with the Use of Bilateral Internal Thoracic Arteries: Diabetics vs. Non-Diabetics

Abstract Introduction: Use of bilateral internal thoracic artery (BITA) as graft in coronary artery bypass grafting (CABG) is controversial because it is related to higher in-hospital mortality, incidence of sternal wound-related infection, and an increase in surgical time. The primary objective of this study is to evaluate in-hospital mortality and mortality within 30 days from discharge. The secondary objective is to evaluate the occurrence of deep sternal wound infection in a 90-day follow-up. Methods: This is a retrospective review of the medical records of 152 patients undergoing elective CABG with the use of BITA and cardiopulmonary bypass (CPB). These patients were divided into two groups, diabetics and non-diabetics. Patients with acute myocardial infarction and concomitant valvular disease were not included in the sample. Results: Preoperative characteristics did not show significant differences between the groups, which allowed a comparative analysis. The variables electrocardiography time and aortic clamping time were higher in the diabetic group, with a significant statistical difference (P<0.0001). In-hospital mortality occurred in three patients, and there was no mortality up to 30 days in both groups. There was no significant difference in the primary end point between groups (P=0.56). Deep sternal wound infection was present in only one patient and showed no significant difference in the secondary outcome between groups (P=0.40). Conclusion: We did not observe a higher mortality and occurrence of deep sternal wound infection with the use of BITA in diabetic patients compared to non-diabetics, even with greater CPB and aortic clamping times in diabetics.

A Simplest Method to Enhance the Benefits of Internal Thoracic Artery Distal Occlusion

Abstract A common element of internal thoracic artery harvesting techniques is a distal vascular clamp placement at the end of the procedure, not only to avoid bleeding, but also to increase the internal hydrostatic pressure, diameter and flow. The logic indicates that the placement of this clamp at the beginning of the dissection will allow the artery to benefit earlier from these advantages. After more than five years of experience, we present a modification in the classical technique of skeletonized harvesting of the internal thoracic artery, consisting of artery distal occlusion at the beginning of the procedure. Some of its advantages are discussed.

Aortic valve replacement via right anterior mini-thoracotomy: the conventional procedure performed through a smaller incision

Abstract Minimally invasive aortic valve replacement has gained consent due to its good results in terms of minimized surgical trauma, faster rehabilitation, pain control and patient compliance. In our experience, we have tried to replicate the conventional and gold standard approach through a smaller incision. Sparing the right internal thoracic artery, avoiding rib fractures and performing total central cannulation is important to make this procedure minimally invasive from a biological point of view too. In addition, the total central cannulation is pivotal to simplify perfusion and drainage. Moreover, a complete step-by-step procedure optimization and-when possible-the use of sutureless prosthesis help to reduce the cross-clamping and perfusion times. After more than 1000 right anterior thoracotomy (RAT) aortic valve replacements, we have found tips and tricks to make our technique more effective.

Comparison of the internal thoracic artery flow dissected by video endoscopy or conventional technique

ABSTRACT Purpose: To compare the blood flow in the internal thoracic artery when dissected endoscopically in a conventional manner, in addition to develop a reliable experimental training model for the surgical team. Methods: Paired experimental study. Ten pigs were operated and had both internal thoracic arteries dissected, the right with a conventional technique and the left by video endoscopy. The main outcomes to be studied were flow, length, and time of dissection of each vessel. Results: Blood flow measurements were performed with mean heart rate of 100 ± 16 bpm and mean arterial pressure of 89.7 ± 13 mm Hg. The mean blood flow of endoscopic dissection of the internal thoracic artery was 170.2 ± 66.3 mL/min and by direct view was 180.8 ± 70.5 (p = 0.26). Thus, there was no statistically significant difference between the flows, showing no inferiority between the methods. Conclusions: The minimally invasive dissection of the internal thoracic artery was shown to be not inferior to the dissection by open technique in relation to the blood flow in the present experimental model. In addition, the model that we replicated was shown to be adequate for the development of the learning curve and improvement of the endoscopic abilities.

obot-assisted bilateral internal mammary arteries harvesting for off-pump coronary artery bypass grafting with 5 grafts by minimally invasive small incision: A case report / 中国胸心血管外科临床杂志

@#Objective    To introduce the method and preliminary experience of robot-assisted bilateral internal mammary arteries (BIMA) harvesting for off-pump coronary artery bypass grafting (OPCAB) with 5 grafts via left anterolateral minithoracotomy. Methods    BIMA were harvested using the da Vinci robotic surgical system, and the right internal mammary artery (RIMA) was pulled out of the thoracic cavity through right second intercostal space. Intercepting the distal part of the RIMA for the BIMA composite Lima-Rima Y graft and anastomosing the great saphenous vein with remaining RIMA end to end. The Y graft anastomosed with left anterior descending (LAD) branch and diagonal branches (DIAG), artery-vein graft sequentially anastomosed with blunt round branch, left ventricular posterior branch and posterior descending branch. Results    The operation succeeded without hemodynamic instability and intra aortic balloon pump (IABP) implantation or cardiopulmonary bypass. The blood flow of Y graft was 24 mL/min, and the blood flow of artery-vein graft was 30 mL/min. Ventilator assistance time was 35 hours, ICU staying time was 62 hours, and postoperative myocardial enzymes increased temporarily. Postoperative coronary CTA showed that all the grafts were patency, and cardiac ultrasound indicated that the heart function was normal. The patient cured and discharged from hospital 7 days after operation. Conclusion    Robot-assisted bilateral internal mammary artery harvesting for OPCAB with 5 grafts via left anterolateral minithoracotomy is feasible, which can achieve complete revascularization.

Comparison of the apoptotic effects of topically applied papaverine, diltiazem, and nitroprusside to internal thoracic artery

Abstract Objective: To detect and to compare the apoptotic effects of intraoperatively topically applied diltiazem, papaverine, and nitroprusside. Methods: Internal thoracic artery segments of ten patients were obtained during coronary bypass grafting surgery. Each internal thoracic artery segment was divided into four pieces and immersed into four different solutions containing separately saline (Group S), diltiazem (Group D), papaverine (Group P), and nitroprusside (Group N). Each segment was examined with both hematoxylin-eosin and the terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling (TUNEL) method in order to determine and quantify apoptosis. Results: Apoptotic cells were counted in 50 microscopic areas of each segment. No significant difference was observed among the four groups according to hematoxylin-eosin staining. However, the TUNEL method revealed a significant increase in mean apoptotic cells in the diltiazem group when compared with the other three groups (Group S=4.25±1.4; Group D=13.31±2.8; Group N=9.48±2.09; Group P=10.75±2.37). The differences between groups were significant (P=0.0001). No difference was observed between the samples of the diabetic and non-diabetic patients in any of the study groups. Conclusion: The benefit of topically applied vasodilator drugs must outweigh the potential adverse effects. In terms of apoptosis, diltiazem was found to have the most deleterious effects on internal thoracic artery graft segments. Of the analyzed medical agents, nitroprusside was found to have the least apoptotic activity, followed by papaverine. Diabetes did not have significant effect on the occurrence of apoptosis in left internal thoracic artery grafts.

Outcomes of surgical patch angioplasty of the coronary artery for diffuse coronary artery disease

Abstract Introduction: Diffuse coronary artery disease (CAD) has a poor prognosis and many patients are ineligible for conventional coronary artery bypass grafting (CABG). This study evaluated the 12-month outcomes of coronary artery reconstruction and surgical patch angioplasty of the coronary artery for diffuse CAD. Methods: A retrospective cohort study of patients who underwent CABG with surgical patch angioplasty of the coronary artery (reconstruction group) or standard CABG alone (standard group) at the Cardiovascular Surgery Department of the local Hospital between January 2014 and January 2016. Follow-up was censored at 12 months after surgery. Results: Cardiopulmonary bypass and aortic cross-clamping durations were longer in the reconstruction group (n=32) than in the standard group (n=125) (P<0.05). There were no differences in graft blood flow and postoperative levels of cardiac markers between the two groups (P>0.05). In the reconstruction group, one patient died; a vein graft showed occlusion. In the standard group, two patients died; one left internal mammary artery graft and three vein grafts showed occlusion. There were no significant differences in mortality, major adverse cardiovascular and cerebrovascular events, and patency between the two groups (P>0.05). Conclusion: Coronary artery reconstruction and surgical patch angioplasty of the coronary artery can be performed for diffuse CAD. Patient outcomes were not significantly different from those of patients who underwent standard CABG.

State-of-the-art pediatric coronary artery bypass surgery: a literature review

Abstract Objective: To examine the results of various myocardial revascularization techniques in pediatric patients to better understand the strategies for surgical treatment of coronary artery pathologies. Methods: We analyzed 61 publications dedicated to the indications, methods, and results of coronary bypass surgery in children. Due to the small size of this cohort, case reports are also included in our review. Results: The main indications for coronary bypass grafting in children are Kawasaki disease, myocardial revascularization as a necessary procedure during the congenital cardiac surgery, to manage intraoperative iatrogenic damage to coronary arteries, and homozygous familial hypercholesterolemia. The use of internal thoracic arteries as conduits for coronary bypass grafting in children with Kawasaki disease showed significantly better results in long-term functionality compared to autovenous conduits (87% and 44%, respectively, P<0.001). Acute and late coronary events after arterial switch operation for the transposition of the great arteries, anomalous origin of the left coronary artery from the pulmonary artery, and left main coronary artery atresia are the main congenital heart diseases where surgical correction involves interventions on the coronary arteries. Conclusion: The internal thoracic artery is a reliable and durable conduit that demonstrates proven growth potential in children.

Echocardiographically measured epicardial fat predicts new-onset atrial fibrillation after cardiac surgery

Abstract Objective: The current study aims to investigate the role of echocardiographically measured epicardial adipose tissue (EAT) thickness in the prediction of new-onset atrial fibrillation (AF) following coronary artery bypass grafting (CABG) surgery. Methods: One hundred and twenty-four patients scheduled to undergo isolated on-pump CABG due to coronary artery disease were enrolled to the current study. Patient characteristics, medical history and perioperative variables were prospectively collected. EAT thickness was measured using transthoracic echocardiography (TTE). Any documented episode of new-onset postoperative AF (POAF) until discharge was defined as the study endpoint. Fortyfour participants with POAF served as AF group and 80 patients without AF served as Non-AF group. Results: Two groups were similar in terms of baseline echocardiographic and laboratory findings. In laboratory findings, the groups were similar in terms of the studied parameters, except N-terminal pro-brain natriuretic peptide (NT Pro-BNP), which was higher in AF group than in Non-AF group (P=0.035). The number of left internal mammary artery (LIMA) grafts was not different in both groups. AF group had higher cross-clamp (CC) and cardiopulmonary bypass (CPB) times than Non-AF group (P=0.01 and P<0.001). In multivariate logistic regression analysis, EAT was found an independent predictor for the development of POAF (OR 4.47, 95% CI 3.07-5.87, P=0.001). Conclusion: We have shown that EAT thickness is associated with increased risk of AF development and can be used as a prognostic marker for this purpose.

Twenty-five years of no-touch saphenous vein harvesting for coronary artery bypass grafting: structural observations and impact on graft performance

Abstract The saphenous vein is the most common conduit used in coronary artery bypass grafting (CABG) yet its failure rate is higher compared to arterial grafts. An improvement in saphenous vein graft performance is therefore a major priority in CABG. No-touch harvesting of the saphenous vein is one of the few interventions that has shown improved patency rates, comparable to that of the left internal thoracic artery. After more than two decades of no-touch research, this technique is now recognized as a Class IIa recommendation in the 2018 European Society of Cardiology and the European Association for Cardio-Thoracic Surgery guidelines on myocardial revascularization. In this review, we describe the structural alterations that occur in conventional versus no-touch saphenous vein grafts and how these changes affect graft patency. In addition, we discuss various strategies aimed at repairing saphenous vein grafts prepared at conventional CABG.

Tratamento endovascular de aneurisma de artéria torácica interna esquerda / Endovascular treatment of left internal thoracic artery aneurysm

Resumo O aneurisma da artéria torácica interna é uma entidade rara, com apresentação variável e risco potencial de ruptura e de morte. A angiotomografia é o exame diagnóstico de escolha, sendo útil para o planejamento terapêutico. Considerando morbidade do acesso torácico para abordagem direta e o risco imprevisível de ruptura, o procedimento endovascular se apresenta como modalidade terapêutica de escolha para tratamento desse tipo de aneurisma. Descrevemos um caso de aneurisma de artéria torácica interna, com descoberta incidental na investigação de síncope tratado com embolização com micromolas de baixo perfil e de liberação controlada.

Abstract Aneurysm of the internal thoracic artery is a rare entity, with variable presentation and a potential risk of fatal rupture. Angiotomography is the diagnostic test of choice and is useful for planning treatment. Considering the morbidity of thoracic access for a direct approach and the unpredictable risk of rupture, an endovascular procedure is the treatment modality of choice for this type of aneurysm. We describe the case of an internal thoracic artery aneurysm discovered incidentally during investigation of syncope and treated by embolization with low-profile and controlled-release microcoils.

A Rare Cause of Angina After Coronary Bypass Grafting; Left İnternal Mammary Artery to Pulmonary Artery Fistula and Successful Treatment with Transcatheter Coil Embolization / Uma Causa Rara de Angina Após Revascularização do Miocárdio: Fístula da Artéria Mamária Interna Esquerda para Artéria Pulmonar e Tratamento Bem-Sucedido com Embolização Transcateter com Molas

Abstract Fistula from left internal mammary artery (LIMA) to pulmonary artery (PA) is rarely encountered in daily practice. In recent years, endovascular therapy options have emerged for the treatment of fistula formations and replaced with surgery. A 53-year-old man admitted to our outpatient clinic with symptoms of typical angina and shortness of breath despite optimal medical therapy. In his relevant history, he had a coronary artery bypass graft (CABG) operation in 2009 in which his LIMA was anastomosed to left anterior descending (LAD) and ramus artery sequentially. Coronary angiography including selective imaging of LIMA demonstrated a fistula formation originating from the proximal portion of the LIMA and draining to PA. After successful closure of fistula with transcatheter coil embolization, the patient was discharged without any complication and symptom. In conclusion, although LIMA to PA fistula is an infrequent clinical condition, it should be considered as a potential cause of persistent angina after CABG operation. Treatment options include conservative medical therapy, surgical ligation and endovascular interventions. The best therapy should be individualised for each patient in respect to patient's symptoms, surgical compatibility and anatomy of fistula.

Resumo A fístula da artéria mamária interna esquerda (AMIE) para a artéria pulmonar (AP) é raramente encontrada na prática diária. Nos últimos anos, opções de terapia endovascular surgiram para o tratamento de formações de fístula e foram substituídas por cirurgia. Um homem de 53 anos de idade, internado em nosso ambulatório com sintomas de angina típica e falta de ar, apesar da terapia clínica ideal. Em seu histórico relevante, ele teve uma cirurgia de revascularização miocárdica (CRM) em 2009, na qual sua AMIE foi anastomosada à descendente anterior esquerda (DAE) e à artéria ramus sequencialmente. A angiografia coronária, incluindo imagens seletivas da AMIE, demonstrou uma formação de fístula proveniente da porção proximal da AMIE e drenando para AP. Após o fechamento bem-sucedido da fístula com embolização transcateter com mola, o paciente recebeu alta sem qualquer complicação e sintoma. Em conclusão, embora fístula entre AMIE e AP seja uma condição clínica pouco frequente, deve ser considerada como uma causa potencial de angina persistente após a operação de revascularização do miocárdio. As opções de tratamento incluem terapia médica conservadora, ligadura cirúrgica e intervenções endovasculares. A melhor terapia deve ser individualizada para cada paciente em relação aos sintomas do paciente, compatibilidade cirúrgica e anatomia da fístula.

Resultados a 5 años de la revascularización exclusiva con dos arterias mamarias en pacientes con enfermedad coronaria multivaso / Exclusive coronary revascularization with both mammary arteries: analysis of 73 patients

Background: Exclusive coronary revascularization with both mammary arteries could result in lower rates of adverse events in the long term. Aim: To describe the five-year evolution of a cohort of patients operated on with this technique. Material and Methods: Follow up analyzing survival of 73 patients aged 59 ± 9 years (82% men) who underwent exclusive coronary surgery with two mammary arteries between December 1,2010 and April 12,2017. We studied their clinical characteristics, surgical results, operative morbidity and mortality and adverse events up to June 30, 2018. Results: Six patients had two-vessel lesions and 67 three-vessel lesions. The operative risk calculated by additive and logistic EuroSCORE was 2.5 and 2.3%, respectively. A mean of 3.75 anastomoses /patient were performed, 116 with left mammary artery (73 to the anterior descending artery, 38 to a diagonal artery and 5 for other objectives) and 158 with right mammary artery (69 to a first marginal artery, 23 to a second marginal artery and 64 to posterior descending artery). There was one case of mediastinitis and one (1.5%) patient died. The mean follow-up was 64.6 ± 23.7 months. The 5-year survival was 90.4%. Conclusions: Coronary revascularization with two exclusive mammary arteries allowed a complete revascularization of the heart with a low rate of complications and adverse effects at five years.

Left lateral intercostal region versus subxiphoid position for pleural drain during elective coronary artery bypass graft surgery: randomized clinical trial

ABSTRACT BACKGROUND: The pleural drain insertion site after coronary artery bypass graft (CABG) surgery may alter lung function, especially respiratory muscle strength. The main objective of this study was to compare the effectiveness and safety of use of the left lateral intercostal region versus the subxiphoid position for pleural drainage during elective CABG surgery using extracorporeal circulation (ECC). DESIGN AND SETTING: Randomized trial conducted in a tertiary-level hospital in Porto Alegre, Brazil. METHODS: 48 patients were assigned to group 1 (pleural drain in the left lateral intercostal region) or group 2 (pleural drain in the subxiphoid position). Respiratory muscle strength was measured in terms of maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP), in cmH2O, by means of manovacuometry preoperatively, 24 and 72 hours after drain removal and before discharge from hospital. Painand dyspnea scales, presence of infections, pleural effusion and atelectasis, duration of drain use, drainage volumes and surgical reinterventions were also evaluated. RESULTS: After adjustments, there were no significant differences between the groups at the end of the study (before discharge), in predicted percentages either for MIP (delta group 1: -17.21% versus delta group 2: -22.26%; P = 0.09) or for MEP (delta group 1: -9.38% versus delta group 2: -13.13%; P = 0.17). Therewere no differences between the groups in relation to other outcomes. CONCLUSION: There was no difference in maximal respiratory pressures in relation to the pleural drain insertion site among patients who underwent CABG surgery using ECC. TRIAL REGISTRATION: ReBEc V1111.1159.4447.

Surgical aspects of no-touch saphenous vein graft harvesting in cabg: clinical and angiographic follow-up at 3 months

Abstract With more than 800,000 coronary artery bypass grafting (CABG) operations annually worldwide and the saphenous vein being the most common conduit used, there is no question that improving saphenous vein graft patency is one of the most important tasks in CABG. This video describes the no-touch harvesting procedure of the saphenous vein on an 80-year old man with hypertension, hyperlipidemia and a previous myocardial infarction with percutaneous coronary intervention to the right coronary artery. He was complaining of exertional chest pain and was diagnosed with stable angina pectoris. The coronary angiography showed advanced three vessel disease with significant stenoses in the left anterior descending (LAD) artery, two marginal arteries (MAs) and the posterior descending artery (PDA), in addition to an occluded diagonal artery (DA). The patient received a triple sequential no-touch vein graft to the PDA and two MAs together with a double sequential no-touch vein graft to the DA and LAD. A vein graft was used to bypass the LAD due to the age of the patient and the low degree of stenosis in the LAD. The no-touch harvesting technique is described in detail in the film with complete narration. A follow-up of this patient was performed at three months both clinically and with a computed tomography angiography (CTA). No angina pectoris symptoms were reported by the patient and the wounds in the chest and lower limb were completely healed. The CTA showed patent no-touch saphenous vein grafts to all the distal anastomoses.