Off-Pump Awake Coronary Revascularization Using Bilateral Internal Thoracic Arteries

The effect of erector spinae plane block on arterial grafts in coronary artery bypass grafting

Background

This study aims to evaluate the sympathectomy effects of erector spinae plane block on the diameters and cross-sectional areas of the left and right internal mammary arteries and of the radial arteries.

Methods

This prospective study included a total of 25 patients (14 males, 11 females; median age: 67 years; range, 23 to 75 years) who underwent erector spinae plane block categorized as the American Society of Anesthesiologists Class III and underwent off-pump coronary artery bypass grafting between June 01, 2020 and March 01, 2021. The effects of erector spinae plane block on the diameters and cross-sectional areas of the left and right internal mammary arteries and radial arteries were assessed using ultrasonography images taken both before and 45 min after the procedure, from the third, fourth, and fifth intercostal spaces for the left and right internal mammary arteries and from 3 cm proximal to the wrist for the radial arteries.

Results

The diameters and cross-sectional areas of the left and right internal mammary arteries and radial arteries significantly increased compared to baseline values after the erector spinae plane block (p<0.05). There was no significant difference in the pre- and post-procedural heart rate and mean arterial pressure values (p>0.05).

Conclusion

The bilateral erector spinae plane block, which was performed at the T5 level, provided vasodilatation of the left and right internal mammary arteries and radial arteries without causing any significant difference in the heart rate and mean arterial pressure. These findings indicate that the sympathetic block produced by the erector spinae plane block may facilitate better surgical conditions by preventing arterial spasms. Thus, bilateral erector spinae plane block may be a promising technique to achieve regional anesthesia for off-pump coronary artery bypass grafting.

Multivessel awake off-pump coronary bypass grafting using median approach: technical considerations

OBJECTIVE

: Several reports of awake off-pump coronary artery bypass grafting (AOCAB) under high thoracic epidural anesthesia (TEA) for single-vessel grafts have been published, but few have described its application in multiple bypass procedures. We report the procedures and safety of AOCAB for multivessel disease.

METHODS

: Fifty-five multivessel AOCAB (52 men, 3 women; aged 68 ± 9.5 years) were performed at our hospital between 2003 and 2010. A medium sternotomy was made after TEA was established. During coronary artery anastomosis, a stabilizer and an apical suction device were used, and a coronary artery active perfusion system was used to maintain flow distal to the anastomosis. Pneumothorax due to pleural opening, when occurred, was repaired using Neoveil sheet and drainage tube.

RESULTS

: There was no operative death and no cerebral ischemia, cardiac arrhythmia, and chronic obstructive pulmonary disease. Operating time was 177 ± 35 minutes. Left internal thoracic artery was used in 55 anastomoses, right internal thoracic artery in 7, gastroepiploic artery in 17, radial artery in 48, and saphenous vein in 24. Time of anastomosis was 4.93 ± 0.92 minutes for left anterior descending coronary artery, 4.75 ± 1.21 minutes for circumflex artery, and 4.98 ± 1.02 minutes for right coronary artery. Intraprocedural pneumothorax occurred in 17 cases; 14 were repaired and nonintubated AOCAB was accomplished, 1 was intubated, and 2 had temporary assisted ventilation and laryngeal mask. Time to discharge was 15.5 ± 8.4 days.

CONCLUSIONS

: Multivessel AOCAB under TEA is not only feasible but also safe. Multiple grafts can be harvested under TEA, and complete vascularization is possible under constant monitoring of blood pressure and consciousness.

Activation of Coagulation and Fibrinolysis after Off-Pump Coronary Artery Bypass Grafting with or without Endotracheal General Anesthesia

Objective

In this study, we measured the activity of coagulation and fibrinolysis and clarified the presence of certain differences between off-pump coronary artery bypass grafting (OPCAB) cases and awake off-pump coronary artery bypass grafting (AOCAB) cases to evaluate whether AOCAB is actually safe from the viewpoint of coagulability.

Methods

8 underwent OPCAB and 6 underwent AOCAB. The following factors inducing coagulation and fibrinolysis were measured for upto 5 days after the operation: platelet counts, prothrombin time, activated partial thromboplastin time, fibrinogen, fibrin degeneration products, D-dimer, thrombin-antithrombin III complex (TAT), α2-plasmin inhibitor-plasmin complex, prothrombin fragment 1, 2 (F1+2), thrombomodulin, β-thromboglobulin (β-TG), and platelet factor-4.

Results

At 5 days after the operation, fibrin degeneration products, D-dimer, α2–plasmin inhibitor-plasmin complex, and F1 + 2 levels of the OPCAB group were significantly higher compared with their baseline values and those of the AOCAB group. At 5 days after the operation, thrombin-antithrombin III complex levels of the OPCAB group were significantly higher than those of the AOCAB group. Fibrinogen levels of the OPCAB group were significantly higher than their baseline values at 3 days after the operation (POD3) and 5 days after the operation (POD5).

Conclusions

In this study, the hypercoagulable state at POD5 was suggested in the patients in the OPCAB group, but not in those in the AOCAB group. Further study is necessary to confirm these results, and future studies would evaluate the potential benefit of AOCAB procedure from the viewpoint of perioperative coagulability.

[Coronary artery bypass grafting in conscious patients: a procedure with a perspective?]

Patients undergoing coronary artery bypass grafting increasingly show severe co-morbidities, which can negatively affect the outcome. Recent developments in cardiac surgery have therefore focused on minimizing the invasiveness of the procedure by revascularization on the beating heart without cardiopulmonary bypass, and by reducing surgical trauma using smaller surgical incisions. Progress in minimally invasive cardiac surgery has led to minimally invasive anesthesia, i.e. using high thoracic epidural anesthesia as the sole technique in the conscious patient (awake coronary artery bypass grafting, ACAB). Published data on ACAB procedures in smaller cohorts have demonstrated that the procedure is safe. Significant complications occurred in 7.1% of patients. A particular cause of concern during ACAB surgery is the development of spinal epidural hematoma the risk of which has been estimated to be as high as 1:1,000. A thorough risk-benefit analysis has therefore to be made. Currently, ACAB surgery remains limited to few specialized centers and highly selected patients.

Anaesthesia and analgesia: contribution to surgery, present and future

Anaesthetists provide comprehensive perioperative medical care to patients undergoing surgical and diagnostic procedures, including postoperative intensive care when needed. They are involved in the management of perioperative acute pain as well as chronic pain. This manuscript considers some of the recent advances in modern anaesthesia and their contribution to surgery, from the basic mechanisms of action, to the delivery systems for general and regional anaesthesia, to the use of new drugs and new methods of monitoring. It assesses the resulting progress in acute and chronic pain services and looks at patient safety and risk management. It speculates on directions that may shape its future contributions to the management of the patient undergoing surgery.

Arterial grafting for myocardial revascularization: how better is it?

PURPOSE OF REVIEW

Arterial conduits are becoming popular in cardiac surgery. Clinical studies and long-term follow-ups have proven that this technique provides satisfactory long-lasting results. The purpose of this review is to give an overview of the main articles from recent literature and compare the latest results.

RECENT FINDINGS

Arterial conduits are currently used in cardiac surgery and clinical follow-ups are confirming some advantages in performing multiple arterial revascularization compared to the saphenous vein and the mammary artery. Mid-term follow-ups are encouraging the use of the radial artery as the second conduit of choice after the internal mammary artery. Moreover, off-pump cardiac surgery is an alternative to perform extensive myocardial revascularization in selected patients. Use of in-situ mammary arteries and off-pump surgery has already been described as the ideal solution to guarantee the 'no touch aorta technique'. Recent results lead us to use the radial artery and the gastroepiploic artery as complement composite grafts to perform total arterial myocardial revascularization during off-pump coronary surgery.

SUMMARY

Arterial grafting provides satisfactory results. The second graft of choice after the mammary artery is the radial artery, but long-term results are still not available. To reduce the risk of major neurological complications, selected patients benefit from off-pump arterial revascularization.

Reversed-J inferior versus full median sternotomy: which is better for awake coronary bypass surgery

BACKGROUND

The aim of this study was to ascertain whether the approach with a less invasive reversed-J inferior sternotomy could improve intraoperative patient compliance and postoperative recovery than the standard median sternotomy.

METHODS

Seventeen patients underwent elective single coronary artery bypass graft operation under high thoracic epidural anesthesia without endotracheal intubation. The reversed-J sternotomy was performed in 10 patients (Group A) and full sternotomy in 7 patients (Group B). The technical and surgical difficulties, pulmonary functions (by spirometric tests) and hospital stay were assessed.

RESULTS

Through the reversed-J sternotomy coronary revascularization was accomplished without any additional technical difficulties and with a good exposure of both the left anterior descending artery and the left internal thoracic artery. No conversion to standard sternotomy and no intubation were observed. Additional doses of local anesthetic at jugular notch was not required in Group A. Pleura was opened more in Group B (57% vs. 20%; p = 0.14). Oxygen saturation was better in Group A during the surgical procedure (98.8 +/- 0.7% vs. 97.1 +/- 2.1%; p = 0.033), however, intraoperative PaCO2 was similar in both the groups. The patients in Group A were discharged from the hospital earlier (3.2 +/- 1.5 vs. 7.3 +/- 3.5 days; p = 0.004).

CONCLUSIONS

Less invasive approach to coronary artery bypass graft operations is possible through combination of the high thoracic epidural anesthesia and a reversed-J sternotomy. This technique is less traumatic for patient and provides practical better oxygenation and shorter hospital stay.