clampless cabg techniques: anaortic cabg with ita inflows john d. puskas, md, msc, facs, facc...
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Clampless CABG Techniques: Anaortic CABG with ITA Inflows
John D. Puskas, MD, MSc, FACS, FACC
Professor of Cardiothoracic Surgery, Icahn School of Medicine at Mount Sinai
Chairman, Department of Cardiovascular Surgery, Mount Sinai Beth Israel
Director, Surgical Coronary Revascularization, Mount Sinai Health System
95th Annual Meeting of the American Association for Thoracic Surgery
Seattle, WA
April 25, 2015
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Disclosures/Conflicts
Royalties from coronary surgical instruments invented by the author and marketed by Scanlan, Inc.
No other relevant financial COI’s.
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Effect of Aortic Clamping Strategies on Neurologic Outcomes
Daniel…Puskas…Halkos JTCVS 2014;147:652-7
10,054 consecutive isolated CABG cases 141 (1.4%) patients with stroke matched 1:4 to 565
patients without stroke
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Meta-analysis of Stroke After Anaortic OPCAB vs Side-Clamp OPCAB and Anaortic OPCAB vs Conventional CABG
Edelman, et al Heart Lung and Circulation, 2012
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Clampless OPCAB: State of the Art CABGBorgermann et al, Circulation 2012; 126:S176-182
395 consecutive clampless OPCAB (310 PAS-Port; 85 all-arterial without proximals)
Propensity Score matching on 15 preop risk variables to compare outcomes among 394 pairs of clampless OPCAB vs cCABG:
In-hospital death (OR 0.25; 95% CI 0.05-1.18; p=0.08)
Stroke (OR 0.36; 95% CI 0.13-0.99; p=0.048)
Death or Stroke (OR 0.27; 95% CI 0.11-0.67; p=0.005)
2 years F/U: Death (OR 0.39; 95% CI 0.19-0.80; p=0.01),
Death or Stroke (OR 0.58; 95% CI 0.34-1.00; p=0.05) MACCE (OR 0.62; 95% CI 0.37-1.02;
p=0.06) Repeat revasc (OR 0.74; 95% CI 0.40-1.38; p=0.35)
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Aortic No-Touch Technique Makes the Difference in OPCABEmmert et al JTCCVS 2011; 142:1499-506.
Two OPCAB groups: PC n=567 vs HS n=1365 Propensity-adjusted regression, HS vs PC:
Stroke (0.7% vs 2.3%; OR 0.39; CI 95% 0.16-0.90; p=0.04)
MACCE (6.7% vs 10.8%; OR 0.55; CI 95% 0.38-0.79; p=0.001)
Stroke rate similar between cCABG and PC OPCAB
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Strategies to Reduce StrokeNo CPBNo or miminal aortic clampAnaortic OPCAB is the gold standard to reduce stroke after CABG
Moss…Halkos…Puskas et al. J Thorac Cardiovasc Surg. 2015;149:175-80.
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Common Strategies for Anaortic OPCAB
BITA inflow, with multiple possible outflows:
• RITA I-graft with radial segment to RCA
• LITA-RITA “T”-graft; LITA-RA “T”-graft
• ITA and RA sequential grafts
• More complex configurations to revascularize the more targets with fewer grafts: “K”-graft
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LIMA-RIMA T-Graft
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Anaortic CABG: BITA plus RA
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Kobayashi “K”-Graft: 2 Arterial Grafts, 3 or More Targets
LIMA
Radial A
Radial-DiagLIMA-LAD
Radial-OM
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Anaortic BITA plus RA: “K” Graft
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Less Common Strategies for Anaortic OPCAB
• Right Axillary or Left Subclavian inflow
• In-situ GEA inflow
• Descending thoracic aortic inflow (redo CABG via left thoracotomy)
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Summary
• Anaortic OPCAB is associated with lowest risk of stroke during surgical revacsularization.
• Epiaortic U/S should be routinely used to identify patients who will benefit most from this complex grafting strategy.
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