A New No-Touch Aorta Technique for Arterial-Source, Off-Pump Coronary Surgery

Saphenous vein to the right coronary system from the right thoracic artery or the aorta. Long-term propensity-matched results of 2 groups

OBJECTIVES

Since 2000, we anastomosed the saphenous vein graft to the right coronary artery system using the stump of the right internal thoracic artery as inflow. The long-term results of patients where the right coronary artery was grafted with the right internal thoracic artery or the ascending aorta as saphenous vein inflow has not been reported.

METHODS

From 2000 to 2018, 699 consecutive patients had right internal thoracic artery elongated with saphenous vein (I-graft group, n = 358, 51.2%) or saphenous vein from the aorta (Ao-graft group, n = 341, 48.8%) on right coronary artery system. Inclusion criteria were age ≤75 years, bilateral internal thoracic arteries as a Y graft on the left system (three-vessel disease, n = 603, 86.3%) or as a left internal thoracic artery on left anterior descending and right internal thoracic artery elongated with saphenous vein on the right coronary artery system (two-vessel disease, n = 96, 13.7%), only 1 saphenous vein per patient. Propensity-matching identified 272 patients per group. One-hundred and twenty-two patients underwent coronary computed tomographic angiography to asses grafts patency after a median follow-up of 88 (65-93) months.

RESULTS

In the paired samples, there was no difference in the early outcome. Ten-year survival and freedom from death, non-fatal acute myocardial infarction and repeat revascularization were higher in I-graft group: 90.6 [standard error (SE): 2.0] vs 78.2 (SE: 5.3), P = 0.0266, and 85.2 (SE: 2.4) vs 69.9 (SE: 5.3), P = 0.0179. Saphenous vein graft, at a long-time follow-up, showed a higher patency rate (81.6% (SE: 7.0) vs 50.7% (SE: 7.9), P < 0.0001) and a smaller internal lumen diameter (2.7, standard deviation: 0.4 vs 3.4, standard deviation: 0.6 mm, P < 0.0001) when right internal thoracic artery was the inflow.

CONCLUSIONS

Grafting the right coronary artery with saphenous vein may entail higher patency rate and better outcome when the inflow is the right internal thoracic artery than when is the ascending aorta. Prospective randomized data are needed to test this hypothesis.

Immediate results of bypass grafting of the territory of the right coronary artery using the 'Penza Coronary Technology'

Coronary artery bypass grafting (CABG) is known to be an effective method of treatment for multivessel obstructive coronary disease with low rates of reintervention and excellent long-term survival and freedom from angina. Graft patency lies at the heart of its procedural success and durability, which in its turn largely depends on the appropriate choice of the conduit, as well as the target coronary artery (CA). It should be mentioned that patency of one and the same conduit used for bypass grafting of the territory of either the left or right coronary artery (LCA and RCA, respectively) may differ, which is probably determined by differences in physiology, size, territory of runoff, and local flow characteristics between different coronary targets. Previous reports have supported the use of bilateral internal thoracic arteries to revascularize the left coronary circulation. If this becomes standardized practice, the optimal conduit for the right coronary system remains to be established. Proposed in the present article is a variant of bypass grafting of the RCA territory using a composite I-graft formed from the proximal portion of the right internal thoracic artery (ITA) in situ and the great saphenous vein (GSV) harvested by the 'no-touch' technique. This technique is part of a CABG schematic algorithm worked out in our Clinic and called the 'Penza Coronary Technology'.

Clinical Validation of a Coronary Surgery Technique That Minimizes Aortic Manipulation

BACKGROUND

To minimize aortic manipulation and maximize use of arterial conduits are aims of modern coronary surgery.

METHODS

From March 2012 to October 2016, 890 consecutive patients with multivessel coronary disease underwent isolated coronary operations using both internal thoracic arteries (ITAs). In 205 (23%; mean age, 67.6 ± 9.2 years), the right ITA was proximally transected and used as a free graft, while its in situ stump was elongated with a saphenous vein graft. The new arteriovenous I conduit was directed to the inferolateral cardiac wall. Operative data and early outcomes of these patients (I group) were compared with the remaining 685 patients (control [C] group). Early and late outcomes were also compared in 184 pairs identified with propensity score matching.

RESULTS

Between the I and C groups there was no significant difference in expected operative risk (European System for Cardiac Operative Risk Evaluation II, p = 0.28), although diseased ascending aorta (p < 0.0001) and critical preoperative state (p = 0.027) were more frequent in the I group. Despite a higher number of coronary anastomoses (mean, 4 ± 0.9 vs 3.7 ± 1, p < 0.0001), cardiopulmonary bypass time was shorter in the I group both in overall (86.7 ± 23.7 vs 105.7 ± 34.2 minutes, p < 0.0001) and matched series (86.8 ± 24.1 vs 108.8 ± 31.9 minutes, p < 0.0001). In-hospital mortality (1% vs 1.9%, p = 0.54) and the rates of postoperative complications were similar. During the follow-up period, no intergroup difference was found in matched patients in the nonparametric estimates of freedom from all-cause death (p = 0.39) and major adverse cardiac and cerebrovascular events (p = 0.44).

CONCLUSIONS

Surgery using this arteriovenous I conduit is safe, minimizes aortic manipulation, shortens cardiopulmonary bypass time, and aids complete revascularization.

New technique "Right Anterior Small Thoracotomy (RAST operation)" for beating heart grafting of the right internal thoracic artery to the posterior descending artery to the posterior descending artery in a third redo CABG patient. A novel coronary technique

Third REDO-CABG is a challenge for the surgical team. Usually a patent mammary is the only graft working and the sternotomy becomes a risky procedure. Injury to a patent graft has been associated to a high mortality rate. Many different approaches have been proposed. We describe a novel technique to approach the right coronary artery through a right anterior small thoracotomy using the right mammary prolonged with saphenous vein for grafting the posterior descending artery on the beating heart. The technique is very simple and feasible because anatomically the right coronary artery and the right mammary are very close and the mobilization of the heart is minimal.