Abstract
Coronary artery disease remains the leading cause of death in developed countries. Major recent studies such as SYNTAX and FREEDOM have confirmed that coronary artery bypass grafting (CABG) remains the gold standard treatment in terms of survival and freedom from myocardial infarction and the need for repeat revascularization. The current review explores the use of new technologies and future directions in coronary artery surgery, through 1) stressing the importance of multiple arterial conduits and especially the use of bilateral mammary artery; 2) discussing the advantages and disadvantages of off-pump coronary artery bypass; 3) presenting additional techniques, e.g. minimally invasive direct coronary artery bypass grafting, hybrid, and robotic-assisted CABG; and, finally, 4) debating a novel external stenting technique for saphenous vein grafts.
Highlights
left internal mammary artery (LIMA) has been recognized as the optimal conduit in coronary artery bypass grafting (CABG) because of its superior patency rate and freedom from arteriosclerosis compared with the saphenous vein (SV).[3]
multiple arterial grafting (MultArt) grafts remained a strong independent predictor of survival. These findings suggest that in patients undergoing isolated coronary artery bypass graft surgery with LIMA to left anterior descending artery, arterial grafting of the non-left anterior descending vessels conferred a survival advantage at 15 years compared with SV grafting
The overall reported results of Minimally invasive direct coronary artery bypass grafting (MIDCAB) have been excellent,[31,32,33,34,35] as: 1) Procedural success is estimated at 98%; 2) Operative mortality is < 1% in most series; 3) Reoperation rates for bleeding vary from 1% to 3%; 4) Chest wound complications occur in 2%–3%; 5) Pulmonary complications are seen in 1%–3% of patients; 6) Angiographic patency in the early postoperative period and at 6 months has been outstanding; and 7) Re-intervention for ischemic events has been atypical
Summary
Late survival after coronary artery bypass grafting (CABG) is improved when the left internal mammary artery (LIMA) is grafted to the left anterior descending artery (LAD).[1,2] LIMA has been recognized as the optimal conduit in CABG because of its superior patency rate and freedom from arteriosclerosis compared with the saphenous vein (SV).[3]. MultArt grafts remained a strong independent predictor of survival (hazard ratio 0.79, 95% confidence interval 0.66–0.94, P = 0.007). These findings suggest that in patients undergoing isolated coronary artery bypass graft surgery with LIMA to left anterior descending artery, arterial grafting of the non-left anterior descending vessels conferred a survival advantage at 15 years compared with SV grafting. It is still unproven whether these results apply to higher-risk subgroups of patients. Despite previous reports of greater benefit from left than right coronary system grafting with the second arterial graft,[4,15] a careful review of the literature indicates that use of two internal mammary artery (IMA) grafts demonstrates excellent long-term results with no demonstrable difference in outcome between right and left coronary system patients.[16,17] in the study by Locker et al, 20% of MultArt patients received the second arterial bypass to the right system only, with no additional arterial grafting to the circumflex coronary system.[14]
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