Off-Pump Coronary Artery Bypass I- and T-Graft Technique With "No-Touch" Aorta

Off-pump coronary artery bypass grafting (OPCAB) has some high ground in reduction of postoperative complications, including systematic inflammatory response, myocardial injury, renal injury, and cerebral injury, compared to on-pump coronary artery bypass grafting.

It is important to reduce myocardial oxygen consumption during anesthesia for OPCAB (1). The anesthesiologists should collaborate with the cardiac surgeons and plan the best perioperative strategy for rapid recovery. The anesthesiologists should pay attention to hemodynamic instability and myocardial ischemia during anastomosis. Fast-track anesthesia offers many benefits which lead to earlier ambulation, earlier discharge, and earlier rehabilitation (2). Further fast-track anesthesia including extubation after OPCAB in the operating room is needed but can only be performed in selected patients. Detection of severe atherosclerotic ascending aorta during coronary artery bypass grafting requires alterations in the standard surgical technique to reduce the probability of stroke-related atheroembolization (3). OPCAB confers the benefits of avoiding aortic cannulation and clamping and may therefore attenuate this risk. Advances in surgical techniques and retractor-stabilizer devices allowing access to all coronary segments have resulted in increased interest in off-pump coronary artery bypass (4). Atherosclerotic or calcified ascending aorta is an important predictor of adverse cerebrovascular events. Using OPCAB with composite and in situ arterial grafting to avoid aortic manipulation and clamping may reduce the risk of stroke related to aortic atheroembolism (5, 6). When the aorta is calcified and cannot serve as a safe place for proximal anastomosis, this anastomosis can be performed using I-graft and T-graft technique (7, 8). However, residual movement at the site of the anastomosis and potential hemodynamic disturbances make this operation technically more difficult. Therefore, the level of skill of the cardiac surgeon should be on top.

References

1. Rocha R V, Yanagawa B, Hussain MA, Tu J V, Fang J, Ouzounian M, et al. Off-pump versus on-pump coronary artery bypass grafting in moderate renal failure. J Thorac Cardiovasc Surg. 2020 April;159(4):1297-1304.e2.
2. Cetin E, Can T, Unal CS, Keskin A, Kubat E. Cardiovascular topics OPCAB surgery with an alternative retraction method : a single-centre experience. July 2019;:1–5.
3. Cartier R. Current trends and technique in OPCAB surgery. J Card Surg. 2000;(514):32–46.
4. Szwed K, Pawliszak W, Szwed M, Tomaszewska M, Anisimowicz L, Borkowska A. Reducing delirium and cognitive dysfunction after off-pump coronary bypass : A randomized trial. J Thorac Cardiovasc Surg. 2019 Oct;1;S0022-5223(19)32091-4.
5. Aklog L. Future technology for off-pump coronary artery bypass (OPCAB). Semin Thorac Cardiovasc Surg. 2003 Jan;15(1):92-102.
6. Polomsky M, Puskas JD, Mortality I. Off-pump coronary artery bypass grafting. Circ J. 2012;76(4):784-790.
7. Arrigoni SC, Mecozzi G, Grandjean JG, Hillege JL, Kappetein AP, Mariani MA. Off-pump no-touch technique : 3-year results compared with the SYNTAX trial. Interact Cardiovasc Thorac Surg. 2015 May;20(5):601-604.
8. Raja SG. Two decades of off-pump coronary artery bypass surgery : Harefield experience. J Thorac Dis. 2016 Nov;8(Suppl 10):S824-S828.

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