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Surgery Today
Published in: Surgery Today 1/2016

01-01-2016 | Review Article

The current status of multi-arterial off-pump coronary artery bypass grafting

Authors: Suzuki Tomoaki, Asai Tohru

Published in: Surgery Today | Issue 1/2016

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Abstract

Purpose

Off-pump coronary artery bypass surgery has not become widespread because of its technical difficulty. However, especially in Asia, pioneer surgeons continue with efforts to develop the off-pump technique.

Method

By reviewing past studies, mainly retrospective single-center reports, an up-to-date profile of off-pump surgery was assembled.

Results

Many of the past randomized trials failed to demonstrate the advantages of off-pump surgery. Although many of these were single-center retrospective studies, the data presented, mostly from world-famous surgeons, show that off-pump surgery does have advantages in high-risk patients and results in reduced rates of postoperative morbidity and equal rates of mortality in both the short- and long terms. Moreover, almost all experienced off-pump surgeons noted the benefit of multiple uses of arterial grafts, skeletonization harvesting of arterial conduits and the aorta no-touch technique.

Conclusion

The off-pump procedure has not become a standard technique performed by the average surgeon in daily practice. However, off-pump surgery will continue to provide a significant benefit to high-risk patients with coronary disease.
Literature
1.
Shroyer AL, Grover FL, Hattler B, Collins JF, McDonald GO, Kozora E, et al. On-pump versus off-pump coronary-artery bypass surgery. N Engl J Med. 2009;361:1827–37.CrossRefPubMed
2.
Houlind K, Kjeldsen BJ, Madsen SN, Rasmussen B, Hoime S, Schmidt T, et al. The impact of avoiding cardiopulmonary by-pass during coronary artery bypass surgery in elderly patients: the Danish On-pump Off-pump Randomisation Study (DOORS). Trials 2009;10–47.
3.
Légaré JF, Buth KJ, King S, Wood J, Sullivan JA, Friesen CH, et al. Coronary bypass surgery performed off pump does not result in lower in-hospital morbidity than coronary artery bypass grafting performed on pump. Circulation. 2004;109:887–92.CrossRefPubMed
4.
Hettler B, Messenger JC, Shroyer AL, Collins JF, Garcia HJA, Baltz JH, et al. Off-pump coronary artery bypass surgery is associated with worse arterial and saphenous vein graft patency and less effective revascularization: results from the Veterans Affaires Randomized On/Off Bypass (ROOBY) trial. Circulation. 2012;125:2827–35.CrossRef
5.
Lamy A, Deveraux PJ, Prabhakaran D, Taggart DP, Hu S, Paolasso E, et al. Off-pump or on-pump coronary-artery bypass grafting at 30 days. N Engl J Med. 2012;366:1489–97.CrossRefPubMed
6.
Lamy A, Deveraux PJ, Prabhakaran D, Taggart DP, Hu S, Paolasso E, et al. Off-pump or on-pump coronary-artery bypass grafting at 1 year. N Engl J Med. 2013;368:1179–88.CrossRefPubMed
7.
Schmidt SE, Jones JW, Thornby JI, Miller CC, Beall ACJ. Improved survival with multiple left-sided bilateral internal thoracic artery grafts. Ann Thorac Surg. 1997;64:9–14.CrossRefPubMed
8.
FitzGibbon GM, Kafka HP, Leach AJ, Keon WJ, Hooper GD, Burton JR. Coronary bypass graft fate and patient outcome: angiographic follow-up of 5,065 grafts related to survival and reoperation in 1,388 patients during 25 years. J Am Coll Cardiol. 1996;28:616–26.CrossRefPubMed
9.
Hirotani T, Kameda T, Kumamoto K, Shirota S, Yamano M. Effect of coronary artery bypass grafting using internal mammary arteries for diabetic patients. J Am Coll Cardiol. 1999;34:532–8.CrossRefPubMed
10.
Rizzoli G, Schiavon L, Bellini P. Does the use of bilateral internal mammary artery (IMA) grafts provide incremental benefit relative to the use of a single IMA graft? A meta-analysis approach. Eur J Cardiathorac Surg. 2002;22:781–6.CrossRef
11.
Taggart DP, D’Amico R, Altman DG. Effect of arterial revascularization on survival: a systematic review of studies comparing bilateral and single internal mammary arteries. Lancet. 2001;358:870–5.CrossRefPubMed
12.
Lytle BW, Blackstone EH, Loop FD, Houghtaling PL, Arnold JH, Akhrass R, et al. Two internal thoracic artery grafts are better than one. J Thorac Cardiovasc Surg. 1999;117:855–72.CrossRefPubMed
13.
Buxton BF, Komeda M, Fuller JA, Gordon I. Bilateral internal thoracic artery grafting may improve outcomes of coronary artery surgery, risk-adjusted survival. Circulation. 1998;98:II-1–6.CrossRef
14.
Chavanon O, Durand M, Hacini R, Bouvaist H, Noirclerc M, Ayad T, et al. Coronary artery bypass grafting with left internal mammary artery and right gastroepiploic artery, with and without bypass. Ann Thorac Surg. 2002;73:499–504.CrossRefPubMed
15.
Tavilla G, Kappetein AP, Braum J, Gopie J, Tjien ATJ, Dion RAE. Long-term follow-up of coronary artery bypass grafting in three-vessel disease using exclusively pedicled bilateral internal thoracic and right gastroepiploic arteries. Ann Thorac Surg. 2004;77:794–9.CrossRefPubMed
16.
Suzuki T, Asai T, Matsubayashi K, Kambara A, Kinoshita T, Takashima N, et al. In off-pump surgery, skeletonized gastroepiploic artery is superior to saphenous vein in patients with bilateral internal thoracic arterial grafts. Ann Thorac Surg. 2011;91:1159–64.CrossRefPubMed
17.
Taggart DP, Altman DG, Gray AM, Lees B, Nugara F, Yu LM, ART investigators, et al. Randomized trial to compare bilateral vs. single internal mammary coronary artery bypass grafting: 1-year results of arterial revascularization trial (ART). Eur Heart J. 2010;31:2470–81.CrossRefPubMed
18.
Higami T, Yamashita T, Nohara H, Iwahashi K, Shida T, Ogawa K. Early results of coronary grafting using ultrasonically skeletonized internal thoracic artery. Ann Thorac Surg. 2001;71:1224–8.CrossRefPubMed
19.
DePaulis R, de Notaris S, Scaffa R, Nardella S, Zeitani L, Del Giudice C, et al. The effect of bilateral internal thoracic artery harvesting on superficial and deep sternal infections: the role of skeletonization. J Thorac Cardiovasc Surg. 2005;129:536–43.CrossRef
20.
Peterson MD, Borger MA, Rao V, Peniston CM, Feindel CM. Skeletonization of bilateral internal thoracic artery grafts lowers the risk of sternal infection in patients with diabetes. J Thorac Cardiovasc Surg. 2003;126:1314–9.CrossRefPubMed
21.
Saso S, Lames D, Vecht JA. Effect of skeletonization of the internal thoracic artery for coronary revscularization on the incidence of sternal wound infection. Ann Thorac Surg. 2010;89:661–70.CrossRefPubMed
22.
Shi J, Iesaki T, Kubota N, Sumiyoshi K, Kajimoto K, Kikuchi K, et al. Skeletonization with an ultrasonic scalpel is as safe as a non-skeletonized dissection in preserving the endothelial function of the human gastroepiploic artery. Interact CardioVasc Thorac Surg. 2009;8:216–20.CrossRefPubMed
23.
Fukata Y, Horike K, Kano M. Histological study on the influences of an ultrasonic scalpel on skeletonized vessel wall. Ann Thorac Cardiovasc Surg. 2002;8:291–7.PubMed
24.
Pym J, Brown PM, Charrete EJ, Parker JO, West RO. Gastroepiploic-coronary anastomosis. A viable alternative bypass graft. J Thorac Cardiovasc Surg. 1987;94:256–9.PubMed
25.
Suma H, Fukumoto H, Takeuchi A. Coronary artery bypass grafting by utilizing in situ right gastroepiploic artery: basic study and clinical application. Ann Thorac Surg. 1987;44:394–7.CrossRefPubMed
26.
Shimizu T, Suesada H, Cho M, Ito S, Ikeda K, Ishimaru S. Flow capacity of gastroepiploic artery versus vein grafts for intermediate coronary artery stenosis. Ann Thorac Surg. 2005;80:124–30.CrossRefPubMed
27.
Asai T. Technique and results for skeletonized GEA using the Harmonic Scalpel in combination with other arterial grafts in off-pump coronary artery bypass surgery. In: He GW, editor. Arterial grafting for coronary artery bypass surgery. 2nd ed. Berlin: Springer; 2006. p. 196–200.CrossRef
28.
Voutilainen S, Verkkala K, Jarvinen A, Keto P. Angiographic 5-year follow-up study of right gastroepiploic artery grafts. Ann Thorac Surg. 1996;62:501–5.CrossRefPubMed
29.
Hirose H, Amano A, Takahashi A. Coronary artery bypass grafting using the gastroepiploic artery in 1000 cases. Ann Thorac Surg. 2002;73:1371–9.CrossRefPubMed
30.
Suma H, Tanabe H, Takahashi A, Horii T, Isomura T, Hirose H, et al. Twenty years experience with the gastroepiploic artery graft for CABG. Circulation. 2007;116(Suppl I):I-188–91.
31.
Kim KB, Cho KR, Choi JS, Lee HJ. Right gastroepiploic artery for revascularization of right coronary territory in off-pump total arterial revascularization: strategies to improve patency. Ann Thorac Surg. 2006;81:2135–41.CrossRefPubMed
32.
Suzuki T, Asai T, Nota H, Kuroyanagi S, Kinoshita T, Takashima N, et al. Early and long-term patency of in situ skeletonized gastroepiploic artery after off-pump coronary artery bypass graft surgery. Ann Thorac Surg. 2013;96:90–5.CrossRefPubMed
33.
Asai T, Tabata S. Skeletonization of the right gastroepiploic artery using an ultrasonic scalpel. Ann Thorac Surg. 2000;74:1715–7.CrossRef
34.
Carpentier A, Guemonprez JL, Deloche A, Frechette C, Dubost C. Tha aorta-to-coronary radial artery bypass graft: a technique to avoid pathological changes in graft. Ann Thorac Surg. 1973;16:111–21.CrossRefPubMed
35.
Lev-Ran O, Paz Y, Penvi D, Kramer A, Shapira I, Locker C, et al. Bilateral internal thoracic artery grafting: mirterm results of composite versus in situ crossover graft. Ann Thorac Surg. 2002;74:704–11.CrossRefPubMed
36.
Legare JF, Buth KJ, Sullivan JA, Hirsch GM. Composite arterial grafts versus conventional grafting for coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2004;127:160–6.CrossRefPubMed
37.
Hwang HY, Kim JS, Cho KR, Kim KB. Bilateral internal thoracic artery in situ versus Y-composite graftings: five-year angiographic patency and long-term clinical outcomes. Ann Thorac Surg. 2011;92:579–86.CrossRefPubMed
38.
Nakajima H, Kobayashi J, Tagusari O, Bando K, Niwaya K, Kitamura S. Competitive flow in arterial composite grafts and effect of graft arrangement in off-pump coronary revascularization. Ann Thrac Surg. 2004;78:481–6.CrossRef
39.
Manabe S, Fukui T, Shimokawa T, Tabat M, Katayama Y, Morita S, et al. Increased graft occlusion or string sign in composite arterial grafting for mildly stenosed target vessels. Ann Thorac Surg. 2010;89:683–8.CrossRefPubMed
40.
Kim WS, Lee J, Lee YT, Sung K, Yang JH, Jum TG, et al. Total arterial revascularization in triple-vessel disease with off-pump and aortic no-touch technique. Ann Thorac Surg. 2008;86:1861–5.CrossRefPubMed
41.
Kapetanakis EI, Stamou SC, Dullum MKC, Hill PC, Haile E, Boyce SW, et al. The impact of aortic manipulation on neurological outcomes after coronary artery bypass surgery: a risk-adjusted study. Ann Thorac Surg. 2004;78:1564–71.CrossRefPubMed
42.
Misfeld M, Brereton JL, Sweetman EA, Doig GS. Neurologic complications after off-pump coronary artery bypass grafting with and without aortic manipulation: meta-analysis of 11398 cases from 8 studies. J Thorac Cardiovasc Surg. 2011;142:11–7.CrossRef
43.
Lev-Ran O, Braunstein R, Sharony R, Kramer A, Paz Y, Mohr R, et al. No-touch aorta off-pump coronary surgery : the effect on stroke. J Thorac Cardiovasc Surg. 2005;129:307–13.CrossRefPubMed
44.
Kim KB, Kang CH, Chang W-I, Lim C, Kim JH, Ham BM, et al. Off-pump coronary artery bypass with complete avoidance of aortic manipulation. Ann Thorac Surg. 2002;74:S1377–82.CrossRefPubMed
45.
Ascione R, Narayan P, Rogers CA, Lim KHH, Capoun R, Angelini GD. Early and midterm clinical outcome in patients with severe left ventricular dysfunction undergoing coronary artery surgery. Ann Thorac Surg. 2003;76:793–800.CrossRefPubMed
46.
Arom KV, Flavin TF, Emery RW, Kshetty VR, Petersen RJ, Janey PA. Is low ejection fraction safe for off-pump coronary bypass operation? Ann Thorac Surg. 2000;70:1021–5.CrossRefPubMed
47.
Shennib H, Endo M, Benhamed O, Morin JF. Surgical revascularization in patients with poor left ventricular function: on- or off-pump? Ann Thorac Surg. 2002;74:1344–7.CrossRef
48.
Keeling WB, Mattew LW, Slaughter MS, Zhao Y, Puskas JD. Off-pump and on-pump coronary revascularization in patients with low ejection fraction: a report from The Society of Thoracic Surgeons National Database. Ann Thorac Surg. 2013;96:83–9.CrossRefPubMed
49.
Hamm CW, Bassand JP, Agewall S, Bax J, Boersma E, Bueno H, et al. ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. The task force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Euro Heart J. 2011;32:2999–3054.CrossRef
50.
Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, et al. ACCF/AHA guideline for coronary artery bypass graft surgery. a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2011;124:2610–42.CrossRefPubMed
51.
Every NR, Maynard C, Cohran RP, Martin J, Weaver WD. Characteristics, management, and outcome of patients with acute myocardial infarction treated with bypass surgery: myocardial infarction triage and intervention investigators. Circulation. 1996;94(Suppl):I-81–6.
52.
Tomasco B, Cappiello A, Fiorilli R, Leccese A, Lupino R, Romiti A, et al. Surgical revascularization for acute coronary insufficiency: analysis of risk factors for hospital mortality. Ann Thorac Surg. 1997;64:678–83.CrossRefPubMed
53.
Monteiro P. Impact of early coronary artery bypass graft in an unselected acute coronary syndrome patient population. Circulation. 2006;114(Suppl):I467–72.PubMed
54.
Rastan AJ, Eckenstein JL, Hentschel B, Funkat AK, Gummert JF, Doll N, et al. Emergency coronary artery bypass graft surgery for acute coronary syndrome: beating heart versus conventional cardioplegic cardiac arrest strategies. Circulation. 2006;114(Suppl):I477–85.PubMed
55.
Fattouch K, Guccione F, Dioguardi P, Sampognaro R, Corrado E, Caruso M, et al. Off-pump versus on-pump myocardial revascularization in patients with ST-segment elevation myocardial infarction: a randomized trial. J Thorac Cardiovasc Surg. 2009;137:650–7.CrossRefPubMed
56.
Biancari F, Mahar MA, Mosorin M, Heikkinen J, Pokela M, Taskinen P, et al. Immediate and intermediate outcome after off-pump and on-pump coronary artery bypass surgery in patients with unstable angina pectoris. Ann Thorac Surg. 2008;86:1147–52.CrossRefPubMed
57.
Moscarelli M, Harling L, Ashrafian H, Athanasiou T. Should we consider off-pump coronary artery bypass grafting in patients with acute coronary syndrome? Interact Cardio Vascular Thoracic Surg. 2013;16:350–5.CrossRef
58.
Suzuki T, Manabu O, Handa M, Yasuda F, Miyake Y. Usefulness of preoperative intraaortic balloon pump therapy during off-pump coronary artery bypass grafting in high-risk patients. Ann Thorac Surg. 2004;77:2056–60.CrossRefPubMed
59.
Leavitt BJ, Sheppard L, Maloney C, Clough RA, Braxton JH, Charlesworth DC, et al. Effect of diabetes and associated conditions on long-term survival after coronary artery bypass graft surgery. Circulation. 2004;110((11Suppl I)):II-41–4.
60.
Alserius T, Hammar N, Nordqvist T, Ivert T. Improved survival after coronary artery bypass grafting has not influenced the mortality disadvantage in patients with diabetes mellitus. J Thorac Cardiovasc Surg. 2009;138:1115–22.CrossRefPubMed
61.
Rajakaruna C, Rogers CA, Suranimala C, Angelini GD, Ascinone R. The effect of diabetes mellitus on patients undergoing coronary surgery: a risk-adjusted analysis. J Thorac Cardiovasc Surg. 2006;13:802–10.CrossRef
62.
Zhang H, Yuan X, Osnabrugge RLJ, Meng D, Gao H, Zhang S, et al. Influence of diabetes mellitus on long-term clinical and economic outcomes after coronary artery bypass grafting. Ann Thorac Surg. 2014;18:2073–9.CrossRef
63.
Farkouh ME, Domanski M, Sleeper LA, Siami FS, Dangas G, Mack M, et al. Strategies for multivessel revascularization in patients with diabetes. N Engl J Med. 2012;367:2375–84.CrossRefPubMed
64.
Magee MJ, Dewey TM, Acuff TA, Edgerton JR, Hebeler JF, Prince SL, et al. Influence of diabetes on mortality and morbidity: off-pump coronary artery bypass grafting versus coronary artery bypass grafting with cardiopulmonary bypass. Ann Thorac Surg. 2001;72:776–81.CrossRefPubMed
65.
Emmert MY, Salzberg SP, Seifert B, Rodriguez H, Plass A, Hoerstrup SP, et al. Is off-pump superior to conventional coronary artery bypass grafting in diabetic patients with multi-vessel disease. Eur J Cardiothorac Surg. 2011;40:233–9.CrossRefPubMed
66.
Renner A, Zittermenn A, Aboud A, Puhler T, Hakim-Meibodi K, Quester W, et al. Coronary revascularization in diabetic patients: off-pump versus on-pump surgery. Ann Thorac Surg. 2013;96:528–34.CrossRefPubMed
67.
Hwang HY, Choi JS, Kim KB. Diabetes does not affect long-term results after total arterial off-pump coronary revascularization. Ann Thorac Surg. 2010;90:1180–6.CrossRefPubMed
Metadata
Title
The current status of multi-arterial off-pump coronary artery bypass grafting
Authors
Suzuki Tomoaki
Asai Tohru
Publication date
01-01-2016
Publisher
Springer Japan
Published in
Surgery Today / Issue 1/2016
Print ISSN: 0941-1291
Electronic ISSN: 1436-2813
DOI
https://doi.org/10.1007/s00595-015-1124-4

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