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The Anaortic Technique with Bilateral Internal Thoracic Artery Grafting - Filling the Gap in Coronary Artery Bypass
Walter J Gomes1, Eduardo N Gomes2, Ayrton Bertini2
1Cardiovascular Surgery Discipline, Hospital São Paulo, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil.
Insights
Anaortic off-pump coronary artery bypass grafting (anOPCAB) significantly reduces stroke risk in high-risk patients by avoiding aortic manipulation. This technique refines outcomes for patients with cerebrovascular disease or aortic calcification.
Area of Science:
- Cardiovascular Surgery
- Neurology
- Vascular Medicine
Background:
- Coronary artery bypass grafting (CABG) is effective for advanced coronary artery disease but carries a stroke risk.
- Aortic manipulation during conventional CABG and cardiopulmonary bypass are linked to perioperative stroke.
- Off-pump CABG (OPCAB) reduces some risks, but ascending aorta clamping for anastomosis remains a concern.
Purpose of the Study:
- To evaluate the efficacy of anaortic off-pump CABG (anOPCAB) in mitigating stroke risk.
- To compare anOPCAB with conventional CABG and standard OPCAB in high-risk patient populations.
- To establish anOPCAB as a preferred technique for specific patient groups.
Main Methods:
- Review of studies comparing anOPCAB with conventional CABG and OPCAB.
- Analysis of perioperative stroke rates in patients undergoing different CABG techniques.
- Focus on patient cohorts with cerebrovascular disease, aortic calcification, or atheromatous plaque.
Main Results:
- Anaortic (aorta no-touch) OPCAB (anOPCAB) virtually eliminates embolism risk from aortic debris.
- anOPCAB demonstrates a further decrease in postoperative stroke risk compared to standard OPCAB.
- This technique is particularly beneficial for higher-risk patients, including those with cerebrovascular disease.
Conclusions:
- anOPCAB represents a significant refinement of OPCAB, enhancing patient outcomes.
- The technique is recommended for patients with cerebrovascular disease or aortic pathology.
- anOPCAB should be preferred in patients with high risk factors for neurological damage and stroke.
Abstract:
Coronary artery bypass grafting (CABG) has consolidated its role as the most effective procedure for treating patients with advanced atherosclerotic coronary artery disease, reducing the long-term risk of myocardial infarction and death compared to other therapies and relieving angina. Despite the recognized benefits afforded by surgical myocardial revascularization, a subset of higher-risk patients bears a more elevated risk of perioperative stroke. Stroke remains the drawback of conventional CABG and has been strongly linked to aortic manipulation (cannulation, cross-clamping, and side-biting clamping for the performance of proximal aortic anastomoses) and the use of cardiopulmonary bypass. Adoption of off-pump CABG (OPCAB) is demonstrated to lower the risk of perioperative stroke, as well as reducing the risk of short-term mortality, renal failure, atrial fibrillation, bleeding, and length of intensive care unit stay. However, increased risk persists owing to the need for the tangential ascending aorta clamping to construct the proximal anastomosis. The concept of anaortic (aorta no-touch) OPCAB (anOPCAB) stems from eliminating ascending aorta manipulation, virtually abolishing the risk of embolism caused by aortic wall debris into the brain circulation. The adoption of anOPCAB has been shown to further decrease the risk of postoperative stroke, especially in higher-risk patients, entailing a step forward and a refinement of outcomes provided by the primeval OPCAB technique. Therefore, anOPCAB has been the recommended technique in patients with cerebrovascular disease and/or calcification or atheromatous plaque in the ascending aorta and should be preferred in patients with high-risk factors for neurological damage and stroke.
