Sequential Coronary Artery Bypass Grafting Research Articles

«ХИРУРГИЧЕСКАЯ ФОРМУЛА» КОРОНАРНОГО ШУНТИРОВАНИЯ: НОВЫЕ ВОЗМОЖНОСТИ ДЛЯ КОМПЬЮТЕРНОЙ ОБРАБОТКИ ДАННЫХ И ПЕРСОНАЛИЗИРОВАННОЙ ОЦЕНКИ РЕЗУЛЬТАТОВ ЛЕЧЕНИЯ

The striving of cardiac surgeons for complete myocardial revascularization (MR) and the shortage of conduits resulted in the emergence of various options for sequential and composite coronary artery bypass grafting (CABG), which necessitates unifying specification of its various surgical options for each patient and developing an approach to systematize CABG options. Objective: To develop a “surgical formula” for CABG and evaluate the results of its application for the taxonomy of direct MR options. Methods: Four hundred fifty-two internal mammary artery-aortocoronary bypass (IMA-ACB) using two and three shunts (conduits) were performed from January 2020 to December 2023 at A.O. Makhachev Center for Cardiology and Cardiovascular Surgery, Makhachkala, Dagestan. Off-pump surgeries were performed in 315 patients, while 137 patients underwent on-pump CABG. The MR index was 3.5. Every IMA-ACB option had specifications indicating the particular donor artery, graft, and recipient coronary artery (CA). A “surgical formula” comprising the above specifications was developed for every MR surgery option. Results: There was no in-hospital mortality among the patients enrolled in the study. According to intraoperative monitoring, the incidence of shunt dysfunction was 0.4%. Overall, 32 “surgical formulas” were developed for all types of operations performed in patients enrolled in this study. Conclusion: Introducing “surgical formulas” in the operation records at the cardiac surgery departments facilitates the systematization and classification of CABG options. Keywords: Coronary artery disease, coronary artery bypass grafting, sequential coronary artery bypass grafting, conduit.

Sequential Coronary Artery Bypass Grafting is a Safe Technique for Multi Vessels Disease Patients

Sequential Coronary Artery Bypass Grafting is a Safe Technique for Multi Vessels Disease Patients

The Impact of Sequential Coronary Artery Bypass Grafting on the Early Clinical Outcome

The Impact of Sequential Coronary Artery Bypass Grafting on the Early Clinical Outcome

Distal end side-to-side anastomosis of sequential coronary bypass for size mismatched saphenous vein grafts and coronary arteries.

The distal end anastomosis is critical to the entire sequential grafts in coronary artery bypass grafting (CABG), but caliber mismatch diminishes the quality of the anastomosis. We aimed to introduce a modified distal end side-to-side (deSTS) anastomosis to handle the size mismatch and compared with classic distal end end-to-side (deETS) anastomosis. From January 2014 to December 2018, 185 patients who underwent off-pump CABG with size mismatched sequential vein grafts (≥3.5mm) and target coronaries (1.0-1.5mm) at the distal end anastomoses were included. We retrospectively reviewed the data of the patients, perioperative and follow-up outcomes were analyzed. The deSTS group (n = 67) showed higher anastomotic flow (19.8 ± 8.0 vs 14.9±6.8mL/min; p < 0.001) and lower pulsatility index (2.7 ± 0.8 vs 3.2 ± 1.0; p = 0.001) than the deETS group (n = 118). Higher incidence of in-hospital myocardial infarction (MI) was found in the deETS group but without significant difference (9.0% vs. 15.3%; p = 0.220). Kaplan-Meier analysis illustrated a relatively lower MI and major adverse cardiovascular and cerebrovascular events (MACCE) incidence in the deSTS group, and the deSTS group was associated with a reduction in long-term death, MI and MACCE in the adjusted Cox regression model. In addition, relatively higher graft patency was found in the deSTS group. The deSTS anastomosis showed superiority in solving size mismatch in sequential CABG, including better intraoperative flow dynamics, ideal long-term graft patency and reduced the incidence of perioperative and follow-up adverse events especially in MI.

Computational fluid dynamic study of multiple sequential coronary artery bypass anastomoses in a native coronary stenosis model.

The objective of this study was to evaluate the hemodynamic characteristics of multiple sequential coronary artery bypass grafting using a computational fluid dynamics study. First anastomosis was configured into parallel and diamond anastomoses, and the second anastomosis was set as end-side anastomosis. The anastomosis incision lengths were fixed at 2 mm. Various combinations of the degree of first and second stenoses were studied. The diameter of both the native and graft vessels was set at 2 mm. The inlet boundary condition was set by a sample of the transient time flow measurement, which was measured intraoperatively. Both swirl and stagnation were observed at the outlets of the stenosis and the anastomosis sites. When the severity of the second stenosis was larger than that of the first, the flow at the outlet of the second stenosis was more unstable. Higher wall shear stress and larger oscillatory shear index regions were observed when the severe stenosis was bypassed by the first anastomosis, especially with diamond anastomoses. Less energy loss and higher energy efficiency were present when the vessel with more severe stenosis was bypassed as the second anastomosis. Energy loss was lower and energy efficiency was higher with parallel anastomosis than diamond anastomosis when the severity of the two stenoses was the same. It is ideal to bypass the less severe stenosis vessel first with a parallel anastomosis method when employing multiple sequential bypass grafting. This improves hemodynamic stability and energy efficiency, according to a computational fluid dynamics model.

Four-Stitch Side-to-Side Anastomosis for Sequential Coronary Artery Bypass Grafting

Sequential bypass (SB) is an effective method of implementing complete myocardial revascularization of complex coronary stenoses. The SB allows a single graft to be used for bypass in several locations, which facilitates multi-branch revascularization. We have developed a simple SB technique, four-stitch side-to-side anastomosis, and report its clinical effectiveness in 428 patients.

Intra-operative graft blood flow measurements for composite and sequential coronary artery bypass grafting.

Intraoperative assessment of coronary artery bypass grafts (CABG) anastomotic quality can be performed using transit-time flowmetry (TTF). The aim of this study was to compare on- versus off-pump coronary graft TTF and early postoperative outcomes. Between January 2009 and January 2010, 521 distal graft flows were assessed using TTF measurements in 253 consecutive patients undergoing primary isolated CABG surgery. Data were analyzed using multilevel models accounting for clustering among surgeons and grafts performed in the same patient. Mean age was 66 ± 10 years and 22% were female (n = 55) with 34% diabetics (n = 86) and 40% preoperative myocardial infarction (MI) (n = 101). The surgeries were performed off-pump in 67% (n = 170) with sequential vein grafts in 57% (n = 144) of patients. Off-pump patients had higher pre-operative left ventricular ejection fractions (LVEF), fewer urgent surgeries, fewer distal anastomoses, and fewer sequential vein grafts (all p<0.001). Intra-operative coronary graft TTF measurements were lower in sequential vein grafts performed off-pump versus on-pump. More patients in the on-pump group needed milrinone or dobutamine 24-48h postoperatively (p = 0.005). Independent predictors of lower TTF included female gender and off-pump surgery, whereas predictors of better TTF were preoperative MI, larger coronary diameter at the site of the distal anastomosis, and sequential vein grafting. Lower intra-operative TTF measurements were found in sequential vein grafts in off-pump CABG. However, off-pump patients experienced similar short-term outcomes compared to on-pump patients.

Long-term results of sequential vein coronary artery bypass grafting compared with totally arterial myocardial revascularization: a propensity score-matched follow-up study

The aim of the study was to analyse the early and long-term outcomes of a consecutive series of patients who underwent sequential coronary artery bypass grafting (CABG) and to compare them with a matched population of totally arterial revascularized patients. From January 1994 to December 1996, 209 patients underwent total arterial myocardial revascularization at our institution [arterial (ART) group]. In the same period, 2097 patients underwent CABG with left internal thoracic artery on left anterior descending and great saphenous vein on the right and circumflex branches sequentially [sequential vein (SV) group]. The propensity score methodology was used to obtain risk-adjusted outcome comparisons between the two groups (209 vs 243 patients in the ART group and SV group, respectively). In-hospital mortality was 1% in the ART group and 0.4% in the SV group (P = 0.86). Mean follow-up was 14 ± 4 years. Long-term survival was comparable among the two study groups [actuarial 5- and 15-year survival rates were 97 vs 93% and 82 vs 79% in the ART group and the SV group, respectively (P = 0.29)]. At follow-up, recurrence of angina (17 vs 18%; P = 0.99), acute myocardial infarction (MI) (3 vs 5%; P = 0.72) and repeated percutaneous coronary intervention (19 vs 21%; P = 0.69) were similar in the ART group compared with the SV group. In the Cox regression analysis, type of revascularization was not an independent predictor of any long-term outcomes (death or major adverse cardiac events). In asymptomatic patients, exercise stress test at follow-up was comparable between the two groups (P = 0.14). Sequential vein CABG appears to have good early and long-term clinical outcomes. Also, early and long-term incidence of acute MI was not significantly higher in the SV group. However, further studies with a larger population are warranted in order to confirm the present results.

Ten-Year Outcome Analysis of Off-Pump Sequential Grafting: Single Surgeon, Single Center Experience

Despite increasing recognition that off-pump coronary artery bypass surgery and sequential grafting strategy individually are associated with improved outcomes, concerns persist regarding the safety and efficacy of combining these 2 techniques. We compared in-hospital and midterm outcomes for off-pump multivessel sequential and conventional coronary artery bypass grafting. From September 1998 to September 2008, 689 consecutive patients received off-pump multivessel sequential coronary artery bypass grafting performed by a single surgeon. These patients were propensity matched to 689 patients who underwent off-pump coronary artery bypass grafting without sequential anastomoses. A retrospective analysis of prospectively collected perioperative data was performed. In addition, medical notes and charts of all the study patients were reviewed. The mean duration of follow-up was 5.1 ± 2.0 years. The major in-hospital clinical outcomes in the sequential and control groups were found to be similar. After adjusting for clinical covariates, sequential grafting was not an independent predictor of in-hospital adverse events (odds ratio [OR], 1.18; 95% confidence interval [CI], 0.86-1.50; P = .31), medium-term mortality (hazard ratio [HR], 1.26; 95% CI, 1.06-1.32; P = .92), and readmission to hospital (HR, 1.12; 95% CI, 0.96-1.20; P = .80). Sequential grafting was an independent predictor of receiving more than 3 distal anastomoses (OR, 7.46; 95% CI, 4.27-11.45; P < .0001). Risk-adjusted survival was 89% for sequential grafting patients and 88% for conventional grafting patients (P = .96) during the medium-term follow-up. Our analysis confirms the short- and midterm safety and efficacy of off-pump sequential coronary artery bypass grafting.

Methodological approach in adopting off-pump coronary artery bypass surgery in a British cardiothoracic unit: Harefield experience.

The theoretical and practical disadvantages of coronary artery bypass graft surgery using cardiopulmonary bypass with cardioplegic arrest are well reported in the literature. Encouraged by our work and others, we adopted a systematic approach to the application of off-pump coronary artery bypass surgery. We aimed to validate the non-selective use of the off-pump technique in all patients and assess the outcome in specific patient groups including: patients with ischaemic left ventricular dysfunction, female and high-risk patients. We investigated specific technical details related to off-pump surgery including: the potential effect of the distortion of the mitral valve on haemodynamic stability intraoperatively and the feasibility of sequential coronary artery bypass grafting using the off-pump technique. We also compared the outcome to the national United Kingdom performance in a risk-stratified manner. An extensive retrospective data review for comparative analysis of outcome was carried out at both local and multi-centre levels. This showed that off-pump surgery was feasible for all patients, and provided a better outcome in patients with ischaemic left ventricular dysfunction, female and high-risk patients. The distortion of the mitral valve contributed to the haemodynamic instability. In conclusion, off-pump surgery is safe and provides better outcome in specific patient groups.

The early clinical and angiographic outcome of sequential coronary artery bypass grafting with the off-pump technique

Objective: The emergence of the off-pump coronary artery bypass technique has made surgeons consider combining it with other techniques developed and learned with conventional coronary artery bypass grafting with cardiopulmonary bypass. One of these techniques is the construction of a sequential graft to bypass more than one coronary vessel. The purpose of this study is to review the outcome of combining sequential coronary artery bypass grafting with off-pump techniques. Methods: We retrospectively reviewed the records of 45 consecutive patients who underwent isolated coronary bypass surgery with off-pump and sequential grafting techniques at Harefield Hospital (Harefield, UK) between July 1999 and December 2000. The registry database, medical notes and charts were studied for preoperative and postoperative data of the patients. Ten patients consented and underwent early postoperative angiography to check the quality of the grafts and anastomoses. Results: There were no deaths among the study patients. Morbidity consisted of atrial fibrillation in 6 patients (13.3%), leg wound infection in 2 patients (4.4%), and pleural effusion in 1 patient (2.2%). Early angiography of the 10 consenting patients revealed 10 patent sequential grafts (100%) with 20 satisfactory end-to-side and side-to-side anastomoses (100%). Conclusion: The combination of sequential grafting and off-pump techniques is feasible, is safe, and provides good early clinical and angiographic outcomes.J Thorac Cardiovasc Surg 2002;123:525-30

Multivessel sequential bypass grafting without cardiopulmonary bypass

Background Multivessel sequential coronary artery bypass grafting without cardiopulmonary bypass has become a reality. Initially the revascularization of posterior coronary arteries (obtuse marginal branches of the circumflex artery) was difficult due to access and difficulty in stabilization of the heart as well as compromising the haemodynamic status of the heart. With stabilization of the heart with Octopus II (Medtronic, Inc. Minnesota, USA) we have demonstrated that sequential grafts as well as composite arterial grafts can easily and safely be used in complete arterial revascularization of the myocardium.

Sequential coronary artery bypass grafting and orthotopic liver transplantation: A case report

We report a case of combined coronary artery by‐pass grafting and orthotopic liver transplantation on cardiopulmonary bypass, in a 56‐yr‐old man with rapidly progressive ischaemic heart disease and end‐stage liver disease. Three months after surgery he is asymptomatic with normal liver function.

冠動脈 （３） 冠動脈バイパス手術におけるｓｅｑｕｅｎｔｉａｌ ｇｒａｆｔ施行例の検討 とくにｇｒａｆｔ ｄｅｓｉｇｎの開存率に及ぼす影響について

冠動脈 （３） 冠動脈バイパス手術におけるｓｅｑｕｅｎｔｉａｌ ｇｒａｆｔ施行例の検討 とくにｇｒａｆｔ ｄｅｓｉｇｎの開存率に及ぼす影響について