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Improving neurologic outcome in off-pump surgery: the "no touch" technique
Marzia Leacche1, Michel Carrier, Denis Bouchard
1Department of Cardiac Surgery and Research Center, Montreal Heart Institute, Montreal, Quebec, Canada. rc2910@aol.com
Insights
The "no touch" technique (NTT) for coronary artery bypass grafting (CABG) is safe for high-risk patients with aortic and carotid disease. This approach avoids aortic manipulation, potentially reducing stroke and improving early outcomes in older, complex surgical candidates.
Area of Science:
- Cardiovascular Surgery
- Vascular Surgery
- Cardiac Anesthesia
Background:
- Increasingly older patients undergoing cardiac surgery present with complex comorbidities like cerebrovascular disease, carotid disease, and aortic atherosclerosis.
- Minimizing ascending aorta manipulation during coronary artery bypass grafting (CABG) may be crucial for patient safety in this high-risk population.
Purpose of the Study:
- To evaluate the safety and efficacy of the "no touch" technique (NTT) in off-pump CABG, specifically in patients with severe aortic and carotid disease.
- To assess the impact of avoiding aortic manipulation on perioperative outcomes and early results.
Main Methods:
- Retrospective review of 640 off-pump CABG patients, identifying 84 who underwent the NTT.
- Revascularization utilized internal thoracic arteries (ITAs) and additional grafts (saphenous vein, radial artery) in T or Y configurations.
- Brachiocephalic artery was used as an alternative inflow site in reoperation cases.
Main Results:
- The NTT group had higher frequencies of severe aortic atherosclerosis (13% vs. 0%), carotid disease (25% vs. 16%), and prior cerebrovascular accidents (17% vs. 8%).
- Complete revascularization rates were comparable (96% off-pump CABG vs. 90% NTT).
- No significant differences in low cardiac output syndrome, intra-aortic balloon pump use, perioperative myocardial infarction, or 30-day mortality were observed. The NTT group showed trends toward lower delirium, stroke, and shorter ICU and hospital stays.
Conclusions:
- Avoiding aortic manipulation via NTT is technically feasible in patients with severe atherosclerosis, carotid disease, and cerebrovascular history.
- This technique is associated with low mortality and favorable short-term outcomes.
- Adopting NTT may decrease stroke incidence and enhance early outcomes in selected high-risk patients.
Background:
As patients referred for cardiac surgery include increasingly older individuals, the prevalence of comorbid factors, such as previous cerebrovascular disease, carotid disease, aortic atherosclerosis, and reoperations, is on the rise. Avoiding manipulation of the ascending aorta in this high-risk subgroup may become a necessity to perform safe coronary artery bypass grafting (CABG) surgery.
Methods:
We retrospectively reviewed our database of 640 off-pump CABG patients and identified 84 patients in whom we adopted the "no touch" technique (NTT). Revascularization was carried out with single or bilateral internal thoracic arteries (ITA) and by connecting additional coronary grafts (saphenous vein, radial artery) in a T or Y configuration. The right gastroepiploic artery was used as a conduit in 2 patients. The brachiocephalic artery was used as an alternative inflow site in 3 patients (reoperation).
Results:
Age, sex, risk factors, functional class, and history of congestive heart failure were comparable in the two groups. In the NTT group, the frequencies were higher for severe atherosclerosis of the aorta (13% versus 0%; P =.00), carotid disease (25% versus 16%; P =.02), and history of previous cerebrovascular accidents (17% versus 8%; P =.04). Complete revascularization was achieved in 96% of the patients in the off-pump CABG group, compared with 90% in the NTT group (P =.17). No differences in the prevalence of postoperative low cardiac output syndrome, intra-aortic balloon pump use, perioperative myocardial infarction, or operative mortality at 30 days were observed between the two groups. In the NTT group, weak trends toward a lower incidence of postoperative delirium (8% versus 15%; P =.12), a lower incidence of stroke (0% versus 1%; P =.85), and a shorter intensive care unit stay (P =.07) were observed. Hospital stay was also shorter in the NTT group (P =.04).
Conclusion:
Avoiding aortic manipulations in patients with severe atherosclerosis of the aorta, carotid disease, and a previous history of cerebrovascular accidents is technically feasible and is associated with a low risk of mortality and good shortterm results. Adopting this practice may reduce the incidence of stroke and improve early outcome in this subset of patients.
