Total-arterial, anaortic, off-pump coronary artery surgery: Why, when, and how

Central MessageTotal-arterial, anaortic, off-pump surgery with complete revascularization offers reduced neurologic injury by avoiding aortic manipulation and increased survival associated with arterial grafts.See Commentaries on pages 149 and 151.“We choose to go to the moon in this decade and do the other things. Not because they are easy, but because they are hard.”—John F. Kennedy. Total-arterial, anaortic, off-pump surgery with complete revascularization offers reduced neurologic injury by avoiding aortic manipulation and increased survival associated with arterial grafts. See Commentaries on pages 149 and 151. Ischemic heart disease remains the leading cause of death worldwide.1World Health OrganizationThe top 10 causes of death..2020https://www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-deathDate accessed: August 4, 2021Google Scholar Coronary artery bypass grafting (CABG) has consistently been shown to be the best treatment for patients with complex left main and multivessel disease.2Neumann F.J. Sousa-Uva M. Ahlsson A. Alfonso F. Banning A.P. Benedetto U. et al.2018 ESC/EACTS guidelines on myocardial revascularization.Eur Heart J. 2019; 40: 87-165Crossref PubMed Scopus (2756) Google Scholar However, coronary surgery for many surgeons, and many surgical units, remains a “commodity” item with little change in the procedure for more than 40 years. This is despite strong evidence for the use of more advanced techniques including multi- and total-arterial grafting, and off-pump techniques that avoid all aortic manipulation (“anaortic” surgery). The most common technique of CABG remains a left internal thoracic artery (LITA) to the left anterior descending (LAD) artery, with reversed saphenous vein grafts (SVGs) to other targets, performed using cardiopulmonary bypass with aortic crossclamping and cardioplegic arrest. This remains a “good” procedure, with superior outcomes to percutaneous coronary intervention (PCI) for complex multivessel disease.2Neumann F.J. Sousa-Uva M. Ahlsson A. Alfonso F. Banning A.P. Benedetto U. et al.2018 ESC/EACTS guidelines on myocardial revascularization.Eur Heart J. 2019; 40: 87-165Crossref PubMed Scopus (2756) Google Scholar The proven long-term patency rate and survival benefits of the LITA to LAD have been known for several decades now. However, it is not a “great” procedure since the long-term failure rates of SVGs have also been known for several decades.3Caliskan E. de Souza D.R. Böning A. Liakopoulos O.J. Choi Y.H. Pepper J. et al.Saphenous vein grafts in contemporary coronary artery bypass graft surgery.Nat Rev Cardiol. 2020; 17: 155-169Crossref PubMed Scopus (54) Google Scholar,4Royse A. Pawanis Z. Canty D. Ou-Young J. Eccleston D. Ajani A. et al.The effect on survival from the use of a saphenous vein graft during coronary bypass surgery: a large cohort study.Eur J Cardiothorac Surg. 2018; 54: 1093-1100Crossref PubMed Scopus (20) Google Scholar This contrasts with the robust data for the long-term benefits of the use of multi- and total-arterial grafting, including the use of the right internal thoracic artery (RITA) and the radial artery as a second or third conduit.5Gaudino M. Benedetto U. Fremes S. Biondi-Zoccai G. Sedrakyan A. Puskas J.D. et al.Radial-artery or saphenous-vein grafts in coronary-artery bypass surgery.N Engl J Med. 2018; 378: 2069-2077Crossref PubMed Scopus (288) Google Scholar, 6Taggart D.P. Benedetto U. Gerry S. Altman D.G. Gray A.M. Lees B. et al.Bilateral versus single internal-thoracic-artery grafts at 10 years.N Engl J Med. 2019; 380: 437-446Crossref PubMed Scopus (215) Google Scholar, 7Gaudino M. Bakaeen F.G. Benedetto U. Di Franco A. Fremes S. Glineur D. et al.Arterial grafts for coronary bypass: a critical review after the publication of aRT and RADIAL.Circulation. 2019; 140: 1273-1284Crossref PubMed Scopus (32) Google Scholar, 8Gaudino M. Benedetto U. Fremes S. Ballman K. Biondi-Zoccai G. Sedrakyan A. et al.Association of radial artery graft vs saphenous vein graft with long-term cardiovascular outcomes among patients undergoing coronary artery bypass grafting: a systematic review and meta-analysis.JAMA. 2020; 324: 179-187Crossref PubMed Scopus (50) Google Scholar, 9Gaudino M. Lorusso R. Rahouma M. Abouarab A. Tam D.Y. Spadaccio C. et al.Radial artery versus right internal thoracic artery versus saphenous vein as the second conduit for coronary artery bypass surgery: a network meta-analysis of clinical outcomes.J Am Heart Assoc. 2019; 8: e010839Crossref PubMed Scopus (47) Google Scholar, 10Rocha R.V. Tam D.Y. Karkhanis R. Wang X. Austin P.C. Ko D.T. et al.Long-term outcomes associated with total arterial revascularization vs non-total arterial revascularization.JAMA Cardiol. 2020; 5: 507-514Crossref PubMed Scopus (21) Google Scholar, 11Gaudino M. Puskas J.D. Di Franco A. Ohmes L.B. Iannaccone M. Barbero U. et al.Three arterial grafts improve late survival: a meta-analysis of propensity-matched studies.Circulation. 2017; 135: 1036-1044Crossref PubMed Scopus (81) Google Scholar SVGs have the added, and often overlooked, disadvantage of causing progression of native coronary artery disease that may preclude effective reintervention if the vein graft fails.12Dimitrova K.R. Hoffman D.M. Geller C.M. Dincheva G. Ko W. Tranbaugh R.F. Arterial grafts protect the native coronary vessels from atherosclerotic disease progression.Ann Thorac Surg. 2012; 94: 475-481Abstract Full Text Full Text PDF PubMed Scopus (109) Google Scholar,13Jabagi H. Chong A.Y. So D. Glineur D. Rubens F.D. Native coronary disease progression post coronary artery bypass grafting.Cardiovasc Revasc Med. 2020; 21: 295-302Crossref PubMed Scopus (2) Google Scholar Multiarterial and total-arterial grafting have also received significantly more attention recently. The publication of the RADIAL individual participant data meta-analysis demonstrated superior outcomes with the radial artery over SVG.5Gaudino M. Benedetto U. Fremes S. Biondi-Zoccai G. Sedrakyan A. Puskas J.D. et al.Radial-artery or saphenous-vein grafts in coronary-artery bypass surgery.N Engl J Med. 2018; 378: 2069-2077Crossref PubMed Scopus (288) Google Scholar The randomized ART trial has been more controversial.6Taggart D.P. Benedetto U. Gerry S. Altman D.G. Gray A.M. Lees B. et al.Bilateral versus single internal-thoracic-artery grafts at 10 years.N Engl J Med. 2019; 380: 437-446Crossref PubMed Scopus (215) Google Scholar Although the intention-to-treat analysis demonstrated no difference between single versus bilateral internal thoracic artery (ITA) grafting, there was a significant crossover rate (40% received a different therapy to one they were assigned) combined with the high use of radial artery in the single ITA group (22% of patients), which makes this difficult to interpret. The as-treated analysis on the other hand showed a significant advantage in patients who received multiarterial compared with single-arterial grafting (8% difference in absolute survival). Although this analysis is no longer randomized, more than 20 baseline characteristics were similar and provides a compelling argument.14Taggart D.P. Implications of the 10-year outcomes of the Arterial Revascularization Trial (ART) for multiple arterial grafts during coronary artery bypass graft.Eur J Cardiothorac Surg. 2019; 56: 427-428Crossref PubMed Scopus (18) Google Scholar The significant benefit of the radial artery data has meant that the often-used argument of sternal wound complications from bilateral ITA harvesting is less relevant. Nonetheless, the ART trial also demonstrated that the use of a skeletonized harvest technique mitigates the risk of sternal wound issues from bilateral ITA harvesting anyway.15Benedetto U. Altman D.G. Gerry S. Gray A. Lees B. Pawlaczyk R. et al.Pedicled and skeletonized single and bilateral internal thoracic artery grafts and the incidence of sternal wound complications: Insights from the Arterial Revascularization Trial.J Thorac Cardiovasc Surg. 2016; 152: 270-276Abstract Full Text Full Text PDF PubMed Scopus (123) Google Scholar The stroke rate, when compared with PCI, remains the Achilles’ heel of CABG16Head S.J. Milojevic M. Daemen J. Ahn J.M. Boersma E. Christiansen E.H. et al.Stroke rates following surgical versus percutaneous coronary revascularization.J Am Coll Cardiol. 2018; 72: 386-398Crossref PubMed Scopus (61) Google Scholar and is another often used argument to refer patients for PCI in circumstances where the complexity of their coronary artery disease would likely be best served with multivessel surgical revascularization. The main cause of perioperative stroke remains emboli, and the main source of emboli stems from the aortic manipulation associated with cannulation, “sandblasting” from the aortic cannula inflow jet, crossclamping, and proximal anastomoses that are inherent to the on-pump, arrested heart CABG technique.17Ramponi F. Seco M. Brereton R.J.L. Gaudino M.F.L. Puskas J.D. Calafiore A.M. et al.Toward stroke-free coronary surgery: the role of the anaortic off-pump bypass technique.J Card Surg. 2021; 36: 1499-1510Crossref PubMed Scopus (1) Google Scholar Perioperative and delayed stroke have been shown to have a highly significant impact on mortality, with a meta-regression analysis showing that minimizing aortic manipulation, rather than intrinsic patient characteristics, had a protective effect on neurologic outcomes.18Gaudino M. Rahouma M. Di Mauro M. Yanagawa B. Abouarab A. Demetres M. et al.Early versus delayed stroke after cardiac surgery: a systematic review and meta-analysis.J Am Heart Assoc. 2019; 8: e012447Crossref PubMed Scopus (31) Google Scholar A network meta-analysis performed by our group in 2017 identified that stepwise reduction and ultimately elimination of aortic manipulation resulted in superior neurologic outcome (and also superior early mortality, renal failure, bleeding, atrial fibrillation, and shorter length of intensive care) (Figure 1).19Zhao D.F. Edelman J.J. Seco M. Bannon P.G. Wilson M.K. Byrom M.J. et al.Coronary artery bypass grafting with and without manipulation of the ascending aorta: a network meta-analysis.J Am Coll Cardiol. 2017; 69: 924-936Crossref PubMed Scopus (125) Google Scholar Anaortic off-pump CABG (OPCAB) decreased the risk of postoperative stroke by −78% versus on-pump CABG (single or double clamp), −66% versus OPCAB with partial occlusion clamping, and −52% versus OPCAB with the Heartstring device. In a separate subgroup analysis, anaortic OPCAB decreased risk by −81% versus double-clamp on-pump CABG, and −77% versus single-clamp on-pump CABG. The 2018 European Society of Cardiology/European Association for Cardiothoracic Surgery Coronary Revascularization Guidelines (Figure 2) recommends minimization of aortic manipulation as a Class 1B indication and off-pump (preferably anaortic) in high-risk patients and those with calcified aortas.2Neumann F.J. Sousa-Uva M. Ahlsson A. Alfonso F. Banning A.P. Benedetto U. et al.2018 ESC/EACTS guidelines on myocardial revascularization.Eur Heart J. 2019; 40: 87-165Crossref PubMed Scopus (2756) Google Scholar Likewise, a recent Scientific Statement from the American Heart Association on the prevention of stroke after CABG has confirmed anaortic OPCAB as an essential technique for the reduction of stroke during CABG.20Gaudino M. Benesch C. Bakaeen F. DeAnda A. Fremes S.E. Glance L. et al.Considerations for reduction of risk of perioperative stroke in adult patients undergoing cardiac and thoracic aortic operations: a Scientific Statement from the American Heart Association.Circulation. 2020; 142: e193-e209Crossref PubMed Scopus (21) Google ScholarFigure 22018 European Society of Cardiology/European Association for Cardiothoracic Surgery Coronary Revascularization Guideline recommendations for specific surgical techniques.2Neumann F.J. Sousa-Uva M. Ahlsson A. Alfonso F. Banning A.P. Benedetto U. et al.2018 ESC/EACTS guidelines on myocardial revascularization.Eur Heart J. 2019; 40: 87-165Crossref PubMed Scopus (2756) Google ScholarReprinted with permission.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Total-arterial, anaortic, OPCAB therefore represents the culmination of advanced techniques based on the aforementioned evidence for conduit selection and reducing perioperative neurologic injury. It involves the use of single or bilateral ITA inflows, combined with the radial artery to manufacture composite grafts. Complete surgical revascularization is then accomplished using sequential grafting techniques off-pump, without manipulating the aorta. The procedure, until recently, has occupied a niche (even “fringe”) position within the CABG community. However, more recently the outcomes of the technique and the principles behind the thesis that avoiding cerebral emboli and providing multiarterial revascularization provides better short and long-term outcomes have received more widespread attention. The changes in treatment guidelines and scientific statements from these august bodies, confirming the benefits of these advanced techniques, have served to bring them into the mainstream as well. This raises some of the other, perhaps more compelling reasons for pursuing multiarterial and anaortic techniques. Patients and referrers also have access to this information and will eventually realize that not all CABGs are the same. Adverse events may be scrutinized with more attention as to the conduct of the operation, the expertise and experience of the surgeon, and the specific techniques used. It behooves the specialty to embrace more advanced techniques and move toward a better CABG for all patients. One of the most frequently used arguments against OPCAB is the “technical issues and difficulty” of the procedure. This was certainly the observation made after the ROOBY trial.21Shroyer A.L. Hattler B. Wagner T.H. Collins J.F. Baltz J.H. Quin J.A. et al.Five-year outcomes after on-pump and off-pump coronary-artery bypass.N Engl J Med. 2017; 377: 623-632Crossref PubMed Scopus (64) Google Scholar Interestingly, both sides of the OPCAB debate have held the ROOBY trial up as a beacon for their arguments. The CORONARY trial, on the other hand, demonstrated equivalent results with on-pump and OPCAB.22Lamy A. Devereaux P.J. Prabhakaran D. Taggart D.P. Hu S. Straka Z. et al.Five-year outcomes after off-pump or on-pump coronary-artery bypass grafting.N Engl J Med. 2016; 375: 2359-2368Crossref PubMed Scopus (238) Google Scholar The surgeons participating in the ROOBY trial were relatively inexperienced (including residents), whereas the CORONARY trial surgeons were all experienced surgeons, with a need to have performed more than 200 cases to be eligible. Other series of “experienced” OPCAB surgeons have still reported higher rates of incomplete revascularization and repeat revascularization, with negative effects on long-term outcomes.23Chikwe J. Lee T. Itagaki S. Adams D.H. Egorova N.N. Long-term outcomes after off-pump versus on-pump coronary artery bypass grafting by experienced surgeons.J Am Coll Cardiol. 2018; 72: PubMed Scopus Google Scholar Although the “technical difficulty” argument may have some this not be used as a for not pursuing techniques that have the advantage of long-term survival benefit multiarterial grafting and significantly reduced it that anastomoses and complete revascularization in all patients is not as demonstrated by the recent have stepwise that individual surgeons and surgical to from the on-pump CABG to these more advanced techniques, including total-arterial anaortic OPCAB (Figure M.F.L. S. G. Fremes S.E. Coronary of the European Association for to a coronary artery bypass a stepwise J Cardiothorac Surg. 2020; PubMed Scopus Google C.M. G. Puskas J.D. in advanced coronary surgery: need and Thorac Cardiovasc Surg. 2021; Full Text Full Text PDF PubMed Scopus Google Scholar that have these advanced techniques have shown in patient outcomes over A. J. S. G. et of the aortic technique to stroke after off-pump coronary Thorac Cardiovasc Surg. 2018; Full Text Full Text PDF PubMed Scopus (20) Google Scholar of many surgeons is that OPCAB and anaortic OPCAB be for high-risk patients would that anaortic OPCAB be the to in all patients. The reasons for this are The evidence for reduced neurologic injury has been in meta-analysis of all D.F. Edelman J.J. Seco M. Bannon P.G. Wilson M.K. Byrom M.J. et al.Coronary artery bypass grafting with and without manipulation of the ascending aorta: a network meta-analysis.J Am Coll Cardiol. 2017; 69: 924-936Crossref PubMed Scopus (125) Google Scholar and not high-risk the use of grafts is inherent to the anaortic OPCAB which is of benefit to all patients and in and it is to be at anaortic surgery for when a patient it with many other in it be a or S. A.M. J. J.A. et of surgery in the Cardiol. 2020; 5: PubMed Scopus Google Scholar the more one the better one at This not that all patients have the procedure, that one to they are not it in patient or a of This will have the benefit of patient outcomes and increased surgical expertise to and increased technique for anaortic multiarterial OPCAB is in the A of main principles is are also in our on surgical M. F. Brereton R.J.L. A.M. off-pump coronary artery bypass using multiple arterial surgical 2021; 5: Scopus (1) Google Scholar, F. Seco M. Edelman Brereton R.J.L. Wilson M.K. et anaortic, off-pump coronary artery bypass grafting: to do Cardiothorac Surg. 2018; PubMed Scopus Google Scholar, F. Seco M. Edelman Brereton R.J.L. Wilson M.K. Total-arterial, anaortic, off-pump coronary artery bypass grafting surgical Gaudino M. of Coronary Scholar, M. Edelman F. Wilson M.K. off-pump, total-arterial coronary artery bypass grafting T. Google Scholar, A. G. E. Puskas J. total arterial coronary artery bypass grafting: a Cardiothorac Surg. 2020; Scholar, B. Puskas J.D. coronary artery bypass Thorac Cardiovasc Surg. 2016; 21: Full Text Full Text PDF Scopus Google Scholar grafts based on inflow from one or both anaortic OPCAB have been many of composite grafts over the F. Seco M. Edelman Brereton R.J.L. Wilson M.K. et anaortic, off-pump coronary artery bypass grafting: to do Cardiothorac Surg. 2018; PubMed Scopus Google The of arterial arterial revascularization in patients with coronary artery Cardiothorac Surg. Google D.P. arterial Cardiothorac Surg. 2018; PubMed Scopus Google Scholar for coronary disease is an in skeletonized and an in skeletonized with the radial artery and the to the and vessels (Figure 4, This for all coronary to be and complete revascularization the anterior from the of the the of the and grafts from the in sternal is in the In patients with disease and for complete revascularization in and or graft to and (Figure 4, have demonstrated long-term outcomes with this R. S. S. T. et al.Radial artery vs bilateral composite coronary artery grafting: Thorac Surg. 2021; Full Text Full Text PDF PubMed Scopus Google A.P. Ou-Young J. Pawanis Z. Canty survival of left internal Am Coll Cardiol. 2018; 72: PubMed Scopus (32) Google Scholar The advantage of the composite graft is the to harvest both and the advantage of the composite graft is the of a second and better In patients with coronary the aforementioned grafts may be used or an in and in is (Figure 4, In patients in a grafting, the is not to a sequential using the a short of radial artery be used as a graft (Figure 4, This be performed in with an in with the radial are circumstances where it is not to use arterial or it risk to do may not be to or artery the radial artery may have been used for access for coronary a may preclude them or a coronary with an of the bilateral may also be high risk in and patients. 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Pawlaczyk R. et al.Pedicled and skeletonized single and bilateral internal thoracic artery grafts and the incidence of sternal wound complications: Insights from the Arterial Revascularization Trial.J Thorac Cardiovasc Surg. 2016; 152: 270-276Abstract Full Text Full Text PDF PubMed Scopus (123) Google Scholar are also as skeletonized grafts are longer than grafts and the of makes them to the and the and to sequential the have been and the bilateral are and the are their The is then in an with the up behind the sternal are then performed at the and at the radial This the to the heart to the right on the which and access to the for are used for all using that are made from the used to vessels (Figure The are and to and and to a from if they are during an are main reasons for using an (1) during the including the with a (2) they a relatively for the and they to the during the Other reasons for using the of of the native coronary artery by or that are to the coronary artery, and they also injury to as the right or coronary from The of grafting is the by and anterior This more in the heart grafting the injury to the and for sequential revascularization of the However, if the patient has critical left main or LAD disease then the LAD be and LITA is longer to the in the heart when grafting the other It is also that the of the grafts are and then The of the and the are to a and for the grafts. and expertise with sequential anastomoses on a still heart are on sequential grafting on a The between grafts need to be to if the graft is short or if the graft is the grafts are the be and using and of F.J. Sousa-Uva M. Ahlsson A. Alfonso F. Banning A.P. Benedetto U. et al.2018 ESC/EACTS guidelines on myocardial revascularization.Eur Heart J. 2019; 40: 87-165Crossref PubMed Scopus (2756) Google Scholar there are issues or then anastomoses be on are R.J.L. in composite arterial Cardiothorac Surg. 2018; PubMed Scopus Google S. Taggart D.P. of to graft patency at Thorac Surg. 2016; Full Text Full Text PDF PubMed Scopus Google Scholar during grafting be in patients with recent critical left main large and It is to have a cardiopulmonary bypass in the in these is then it is still to avoid crossclamping the and to The ascending is with and for a there is significant then the right artery be used The heart is left and the conduit and anastomoses are performed in the as the left during then a is in the right superior Coronary artery surgery remains a “commodity” procedure for many surgeons, with little among surgeons or surgical CABG with a LITA to LAD and SVGs to other has been the of surgical revascularization for the best of decades now. This is despite outcomes from the use of arterial including the and radial Likewise, avoiding aortic manipulation OPCAB techniques has been shown to significantly perioperative neurologic injury.