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

Disclosures/Conflicts

Royalties from coronary surgical

instruments invented by the author and

marketed by Scanlan, Inc.

No other relevant financial COI’s.

Effect of Aortic Clamping Strategies on Neurologic OutcomesDaniel…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

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

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)

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

Strategies to Reduce Stroke

No CPB

No or miminal aortic clamp

Anaortic OPCAB is the gold standard to reduce stroke after CABG

Moss…Halkos…Puskas et al. J Thorac Cardiovasc Surg. 2015;149:175-80.

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

LIMA-RIMA T-Graft

Anaortic CABG: BITA plus RA

Kobayashi “K”-Graft: 2 Arterial Grafts, 3 or More Targets

Radial-DiagLIMA-LAD

Radial-OM

Anaortic BITA plus RA: “K” Graft

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)

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.