Arterial end-to-side grafting in coronary artery bypass grafting: the Tector procedure Background. The current treatment of choice in patients with three-vessel coronary disease is coronary artery bypass grafting. The use of the left internal mammary artery in bypass grafting has shown superior long-term outcomes compared with venous grafting. In our study we assess the safety and feasibility of all-arterial coronary artery bypass graft surgery using the procedure as described by Tector et al. in 2001. Methods. Between June 2001 and February 2007, we studied 133 patients eligible for non-emergency surgical revascularisation. Primary endpoints were death or re-infarction within a 30-day period. Secondary endpoints were the need for emergency coronary surgery, angioplasty and mediastinitis. Long-term follow-up had a mean duration of 33 months postoperatively. Results. All 133 patients were successfully revas- cularised, 98% with the off-pump technique. In 93% of the patients (n=124) full arterial grafting was achieved using both internal mammary arteries. Thirty-day mortality was 1.5% (n=2), ten re-thoracotomies were performed, one myocardial infarction and one case of mediastinitis were reported. In the next four years six additional patients died. Most of these deaths were due to non-cardiovascular causes. Two patients required angioplasty because of distal bypass graft failure and one for new native coronary artery disease. Conclusion. All-arterial bypass grafting using both internal mammary arteries with the technique as described by Tector is safe and feasible without excess deep sternal wound infections. Late major adverse cardiac events are rare and due to distal graft dysfunction, which can be treated by per- cutaneous coronary intervention. (Neth Heart J 2010;18:7-11.) Keywords: coronary artery disease; bypass grafting; angina; all arterial revascularisation; off-pump CABG C oronary artery disease is the main cause of death in the Western world. The current treatment of choice in patients with complex three-vessel disease is coronary artery bypass grafting (CABG). This pro- cedure is performed using both arterial and venous grafts. A major concern regarding the use of venous grafts is graft failure. This leads to a higher risk of recurrent angina, new myocardial infarction and the necessity of renewed interventions. 1,2 Currently, many efforts are put into the comparison of bypass surgery with drug-eluting stenting to overcome the potential hazards and graft failures after CABG. The initial one-year follow-up results of the SYNTAX trial 3 do not show a superiority of one of these techniques despite the fact that all the patients in the surgery group had been grafted with venous material and the left internal mammary artery (LIMA). Earlier, the ARTS trial 4 found a need for revascular- isation of 7% at three years of follow-up. Coronary bypass grafting with the use of the LIMA has shown superior long-term outcomes compared with CABG with only venous grafts 5,6 with respect to patency and reduced ischaemia rates. However, total arterial revascularisation was limited by technical dif- ficulties. In 2001 Tector et al. 7 described a technique in which both intra-thoracic arteries are used as grafts, making it possible to acquire full arterial revascular- isation. Total arterial revascularisation may be con- M. de Mulder, C.J.M. Broers, E.K. Jansen, H.B.R.M. de Swart, H.O.J. Peels, M.L.M. Lieuw-a-Fa, V.A.W.M. Umans M. de Mulder C.J.M. Broers H.B.R.M. de Swart H.O.J. Peels M.L.M. Lieuw-a-Fa V.A.W.M. Umans Department of Cardiology, Medical Centre Alkmaar, Alkmaar, the Netherlands E.K. Jansen Department of Cardiothoracic Surgery, VU University Medical Centre, Amsterdam, the Netherlands Correspondence to: V.A.W.M. Umans Medical Centre Alkmaar, PO Box 501, 1800 AM Alkmaar, the Netherlands E-mail: v.umans@mca.nl ORIGINAL ARTICLE Netherlands Heart Journal, Volume 18, Number 1, January 2010 7