The Fate of a Composite Arterial Graft in a 58‑year‑old Man Having Strong CoMorbidities and Atherosclerotic Burden

For some difficult subsets of coronary patients having specific comorbidities, such as insulin‑dependent diabetes and chronic renal failure, arterial myocardial revascularization could be a satisfactory option. The key question is which arteries should be used. A 58‑year‑old insulin‑dependent diabetic patient with severe renal failure, despite previous kidney transplantation, underwent treatment of his severe and diffuse coronary disease using a composite arterial Y‑graft and saphenous vein. Both internal thoracic arteries were harvested as skeletonized conduits. The patient’s hospital course was totally uneventful. Fifty‑six months later, the patient underwent hospital readmission due to a new (inferior) myocardial infarction. Coronary angiography showed both the progression of disease into the native vessels and occlusion of the venous graft. The Y‑graft was patent and well functioning despite the presence of a preoperative left upper limb dialysis fistula. This case report emphasizes the concept that both internal thoracic arteries seem to be refractory to most aggressive forms of atherosclerosis, and that a more liberal use even for high‑risk candidates could be a rational practice. However, many surgeons consider the use of both internal thoracic arteries for myocardial revascularization as a too risky strategy that has to be adopted only for young and low‑risk patients.