Complex composite conduits for anaortic off-pump coronary artery bypass grafting: Lambda and pi grafts

Objective: Anaortic off-pump coronary bypass grafting (OPCAB) is a technique that aims to minimize the operative risk of stroke by using composite arterial conduits with inflow exclusively from in situ internal thoracic arteries. This article describes our experience with complex composite "lambda"- and "pi"-shaped grafts. Methods: A retrospective review of complex multianastomosis composite grafts was performed for all cases completed by a newly assembled surgical team over an interval of 13 months. The case decision-making and surgical techniques are described. Thirty-day outcomes are reported. Results: From April 2024 to May 2025 our surgical team performed 115 OPCAB cases; 97 were all-arterial; 93 were anaortic; 18 complex multianastomosis composite bypass grafts were performed in 17 patients. The "lambda" graft was used in 14 cases. "Pi" grafts were used in 4 cases. In 13 cases we used an all-arterial anaortic OPCAB technique, whereas 3 cases we used clampless aortic proximal anastomoses. There were no cases of graft failure, death, myocardial infarction, stroke, repeat revascularization, or deep sternal wound infection in hospital or during the 1-year follow-up in any of the 115 patients who underwent OPCAB. Conclusions: Complex composite bypass grafts enhance the surgical team's ability to achieve complete revascularization using an all-arterial anaortic OPCAB technique by increasing the number of coronary targets bypassed while conserving the total length of conduit required. The techniques are safe and achieve excellent short-term outcomes when implemented by a surgical team experienced with composite bypass grafting.