Defining the Role of Anaortic Coronary Artery Bypass Grafting

Abstract

As the population ages and co-morbidities become more prevalent, the complexity of patients presenting for coronary artery bypass surgery is increasing. Cardiopulmonary bypass and aortic cross-clamping in these patients carry increased risk and, indeed, in some patients, with ascending aortic disease, the risks are prohibitive. Total-arterial anaortic coronary artery surgery is a technique that provides complete surgical coronary artery revascularization without cardiopulmonary bypass and without manipulating the ascending aorta. The technique essentially eliminates the risk of cerebral embolization of aortic atheroma and aortic injury. Anaortic techniques are an essential skillset for coronary artery surgery centers treating higher-risk patients.

Keywords: anaortic; coronary surgery; off-pump; stroke.

Figure 3

(Panel 1): Common configurations of composite arterial grafts. (A) LITA to LAD and RITA-LRA extension though the transverse sinus to the lateral and inferior system [1]; (B) LITA to LAD and RITA as a Y graft from LITA to the lateral and inferior systems [33]; (C) in situ RTA to LAD and LITA to obtuse marginal [34]; (D) LITA to LAD, LRA as a Y graft from LITA to diagonal branch and RITA to obtuse marginal [33]. Figures reprinted according to CC BY-NC-ND 4.0 license. (Panel 2): (A) Right superior pericardial slit. During a brief period of apnea, a vertical pericardial slit is made with diathermy down to and including the pericardial fold at the right atrial/SVC junction. The assistant retracts the thymus with their right hand using the Yankeur sucker head and retracts the aorta using reversed De Bakey forceps in their left hand. Extreme care must be taken not to injure the right phrenic nerve. (B) Right inferior pericardial slit. A vertical pericardial incision is made with diathermy down to the IVC. Care is taken to remain extra-pleural and to avoid injury to the right phrenic nerve [35]. Figures reprinted according to CC BY-NC-ND 4.0 license. (LITA: left internal thoracic artery; RITA: right internal thoracic artery; LRA: left radial artery).

Figure 1

(Panel 1): Coronal (A) and axial (B) views of a chest CT showing extensive ascending aortic calcifications in a 75-year-old lady admitted with unstable angina; coronary angiogram showed severe distal left main disease. (Panel 2): Intraoperative TOE showing grade IV (>5 mm) (A) and grade 5 (mobile) (B) aortic arch atheroma of a 72-year-old man undergoing combined right carotid endarterectomy and anaortic OPCAB.

Figure 2

(Panel 1): The 2018 ESC/EACTS Coronary Revascularization Guideline recommendations for specific surgical techniques [6]. Reprinted with permission. (Panel 2): Four surgical methods of coronary artery bypass grafting with increasing degrees of aortic manipulation. Percentages pictured represent the relative decrease in risk of perioperative stroke using anOPCABG compared to the other techniques [4]. Reprinted with permission. (CABG: coronary artery bypass grafting with cardiopulmonary bypass; anOPCABG: anaortic off-pump coronary artery bypass grafting; LIMA: left internal mammary artery; OPCABG-HS: off-pump coronary artery bypass grafting with the Heartstring system; OPCABG-PC: off-pump coronary artery bypass grafting with partial clamp; RIMA: right internal mammary artery).

Figure 4

(Panel 1): Stepwise progression to multiple arterial grafting from the basics of acquiring the core skills to total arterial anOPCAB [30]. Reprinted with permission. (Panel 2): Integrated approach to reducing neurologic injury during surgical coronary revascularization [3]. Reprinted with permission. (MAG: multiple arterial grafting; anOPCAB: anaortic off-pump coronary artery bypass grafting; BITA: bilateral internal thoracic artery; CABG, coronary artery bypass grafting; CPB, cardiopulmonary bypass; CT, computed tomography.)