The Choice of the Second Graft La elección del segundo injerto

The choice of vascular coronary conduits depends on several factors, including the patient’s intrinsic characteristics (age, body mass index, diabetes, pulmonary function, peripheral vascular disease, saphenous vein quality) and extrinsic characteristics (elective or urgent). Additionally, the characteristics of the coronary lesion, such as the degree of stenosis, the minimum lumen diameter, and the fractional flow reserve, affect the choice of conduits. Even after the graft decision has been made, the manner of using the graft is still controversial. Some researchers propose in situ graft use, while others prefer free grafts. When using a free graft, the choice must be made between reimplanting the graft in the aorta or in another graft in a composite fashion. The composite assembly is also debated: is it preferable to use a T or a Y shape, and where do we perform this crucial anastomosis? When used in situ, there is no evidence indicating whether it is better to use the right internal thoracic artery (RITA) on the left anterior descending artery crossing the midline or through the transverse sinus to a first marginal. Moreover, some researchers suggest using one graft to only one distal anastomosis, while others prefer sequential anastomosis. After patient characteristics, the most important consideration is the coronary lesion itself. Most of the surgical literature on graft patency is based on visual inspection for coronary lesion evaluation. Cardiologists have long tried to find a more accurate method to evaluate the severity of the coronary lesion (quantitative coronary angiography, fractional flow reserve); unfortunately, these methods have not been applied to the evaluation of graft performance. Historically, graft patency evaluation has been performed for the saphenous vein graft (SVG) using the Fitzgabon classification. Since arterial conduits display a totally different endothelium response to shear stress and competition flow, these historical definitions of patency have become obsolete, leading to new concepts such as ‘‘graft functioning.’’ Moreover, in contradiction to the evidence-based medical literature, there are few evidence-based cardiac surgery reports. Indeed, most of the graft patency literature is retrospective, with