Towards stroke-free coronary surgery: the role of the anaortic off-pump
bypass technique
Abstract
Coronary artery and cerebrovascular disease represent a major cause of
cardiovascular morbidity and mortality worldwide. Despite technological
advancements in percutaneous interventions, surgical revascularization
remains the preferred strategy in patients with left main or multivessel
disease and in those with complex lesions with high SYNTAX score. As a
result, an increasing number of older patients with diffuse
atherosclerotic extracoronary disease are referred for coronary artery
bypass grafting (CABG). Cerebrovascular complications after isolated
coronary surgery occurs in 1-5% of patients; the magnitude of injury
ranges from overt neurologic lesions with varying degree of permanent
disability to “asymptomatic” cerebral events detected by dedicated
neuro-imaging, nevertheless associated with significant long term
cognitive and functional decline. Thromboembolic events due to
manipulation of an atherosclerotic aorta are universally recognized as
the leading etiology of early postoperative stroke following CABG.
Coronary bypass surgery performed on an arrested heart relies on
considerable aortic instrumentation associated with significant
atheroembolic risk especially in older patients presenting with diffuse
aortic calcifications. Surgical techniques to deal with a calcified
ascending aorta during isolated coronary surgery have evolved over the
last forty years. Moving away from aggressive aortic debridement or
replacement, surgeons have developed strategies aimed to minimize aortic
manipulation: from pump-assisted beating heart surgery with the use of
composite grafts to complete avoidance of aortic manipulation with
“anaortic” off-pump coronary artery bypass grafting, a safe and
effective approach in significantly reducing the risk of intraoperative
stroke.