Background-The best second arterial conduit for multiple arterial revascularization (MAR) is still a matter of debate.Previous studies on the benefit of either using the radial artery (RA) or the right internal thoracic artery (RITA) in coronary artery bypass grafting are not conclusive.

We thank Drs Ahmed and Edelman for their interest in our article. 1 They expressed concerns about a possible bias toward radial artery (RA) use in comparison with right internal thoracic artery (RITA), because more than two thirds of multiple arterial revascularization (MAR) cases have a RA as a second arterial conduit.The proportion of RA and RITA patients directly reflects the current epidemiological distribution of RA and RITA grafts used. In the United States, the RA is used more than twice as frequently as a RITA graft. 2 When applying the inclusion criteria of our study, our institutional MAR rate has been 35% during the past 9 years, reflecting high experience with MAR on a daily routine basis. Only 4 surgeons performed MAR during the whole study period, and there was a high fluctuation of surgeons during this period. Moreover, this further underlines the fact that MAR can be easily performed by surgeons routinely but not exclusively performing coronary surgery, irrespective whether using a RA or a RITA. We limit our results to the shortcomings of an observational study; however, results from randomized, controlled trials are missing. Significant shortcomings exist in randomized, controlled trials, namely unreal overselection of patients, heterogenous surgical techniques (regarding on-and offpump strategy, in situ grafts and t grafts, pedicle/skeletonized), and the problem of crossover is due to intention-to-treat analysis. 3,4 Previous studies have shown that the level of stenosis has an impact on graft patency for arterial grafts. In our study, arterial grafts were exclusively grafted to target areas with at least 80% stenosis (otherwise conventional coronary artery bypass grafting was performed by using a saphenous vein graft not to waste an arterial graft); furthermore, the degree of stenosis was not different in our study within both treatment groups. In addition, moderate supraphysiological distension of the RA after harvesting was performed in all cases.Cardioembolic stroke, as a complication of cardiac surgery, has a tremendous impact on quality of life, leaving a significant proportion of patients with remaining disability. Our study has clearly shown that a reduction of central aortic anastomoses can reduce the risk of aortic plaque rupture in patients undergoing coronary artery bypass grafting. Therefore, the use of 2 in situ internal thoracic artery grafts might possibly be protective, especially for patients with severe aortic sclerosis. Hence, as we have previously shown, modification of surgical technique to produce less aortic manipulation (either on-pump with single-crossclamp or off-pump procedures) in case of heavily calcified aorta should be a mandatory approach in all coronary artery bypass grafting procedures. 5 However, off-pump coronary surgery has a significant limitation. Many previous large studies and meta-analyses have shown offpump surgery to be associated with reduced long-term survival and an increased risk for subsequent revascularization and incomplete revascularization, ...

Patients and Methods. 140 patients with aortic dissection type A were admitted for cardiac surgery. Seventy-seven patients experienced their dissection in the winter season (from November to April). We analyzed cases of ascending aortic dissection associated with alpine skiing. Results. In 17 patients we found skiing-related aortic dissections. Skiers were taller (180 (172–200) cm versus 175 (157–191) cm, P = 0.008) and heavier (90 (68–125) kg versus 80 (45–110) kg, P = 0.002) than nonskiers. An extension of aortic dissection into the aortic arch, the descending thoracic aorta, and the abdominal aorta was found in 91%, 74%, and 69%, respectively, with no significant difference between skiers and nonskiers. Skiers experienced RCA ostium dissection requiring CABG in 17.6% while this was true for 5% of nonskiers (P = 0.086). Hospital mortality of skiers was 6% versus 13% in nonskiers (P = 0.399). The skiers live at an altitude of 170 (0–853) m.a.s.l. and experience their dissection at 1602 (1185–3105; P < 0.001) m.a.s.l. In 82% symptom start was during recreational skiing without any trauma. Conclusion. Skiing associated aortic dissection type A is usually nontraumatic. The persons affected live at low altitudes and practice an outdoor sport at unusual high altitude at cold temperatures. Postoperative outcome is good.

DESCRIPTIONFirst described by Lucke in 1869, melanoma of the nasal cavity and paranasal sinuses is estimated to account for less than 1% of all malignant melanomas and 2-8% of malignant neoplasms of the sinonasal tract. 1Malignant melanoma of the nose and paranasal sinuses can be a devastating disease, typically presenting at an advanced stage, with a 5-year survival rate ranging between 20% and 35%.2 It is an uncommon process, often misdiagnosed both clinically and pathologically.The peak age incidence is between the fifth and eighth decade, 3 seen slightly more commonly in men than women.A 53-year-old male patient had a 2-month history of progressively worsening left-sided epistaxis and nasal obstruction and therefore consulted his physician.A CT scan showed a widespread but continuous tumour mass in the left nasal cavity and the left maxillary sinus ( figure 1A). The diagnosis of malignant melanoma was made by intranasal biopsy.A further total body CT scan, immediately performed after the first CT scan, revealed extended metastases of the thyroid gland, lungs, epicardium and pericardium of the heart, liver, stomach, pancreas, colon, peritoneal cavity, urinary bladder, bones and jugular, omental and mesenterial lymph nodes.The skin metastases were located on the chest wall, the right angulus mandibulae and the left axilla. The patient underwent debulking of the tumour mass in the left paranasal sinus and received two chemotherapeutical cycles of dacarbazine.Two months after initial diagnosis he was admitted to hospital for the third round of chemotherapy. But in the night he complained about worsening abdominal pain and died a few hours later.Autopsy revealed tumour haemorrhage as cause of death with 3 litres of blood and blood clots in the abdominal cavity ( postmortem photographs: heart metastases figure 1B; liver and gastric metastases figure 1C). Learning points▸ Malignant melanoma is a rare disorder of the nasal cavity and paranasal sinus mucosa. ▸ Sinonasal malignancies produce few, if any, signs while the tumour is in its early stages (eg, unilateral epistaxis and nasal obstruction). ▸ The patient and clinician often ignore or minimise the initial presentation of these tumours and treat early-stage malignancy as a benign sinonasal disorder. Treatment includes surgery, chemotherapy or radiation therapy. ▸ Melanoma with distant metastases is generally considered incurable.Competing interests None.Patient consent Obtained.

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