Coronary Artery Bypass Grafting with Arterial Conduits in the Elderly

Abstract

SummaryAlthough improved long-term outcomes obtained with the use of arterial grafts for coronary revascularization in comparison with the traditional association of a single arterial and saphenous vein grafts have been demonstrated in the overall population, the efficacy of this newer technique in the elderly is difficult to prove because their shorter life expectancy due to advanced heart disease, associated with severe comorbidities. Moreover, more widespread use of this technique is limited by the concerns on the potential morbidity, particularly the longer time required to perform the operation and the possibility of deep sternal wound infection in case of bilateral internal thoracic artery harvesting due to the decreased blood supply to the sternum and surrounding tissues.The review of the recent literature indicates that the use of bilateral internal thoracic arteries in very elderly patients should not be considered routinely. It seems reasonable to avoid it in octogenarians in the presence of well-known predictors of sternal complications such as diabetes, morbid obesity, and severe chronic lung disease.There is also still controversy about the superiority of the radial artery over the saphenous vein graft as a second or third conduit for surgical myocardial revascularization, although the majority of recent studies seem to support more liberal use of the radial artery as second arterial conduit in the elderly. Although a clinical benefit of arterial graft revascularization cannot be formally excluded for elderly patients, the increased complexity of this technique suggests that careful clinical judgment is necessary to select grafts for individual patients.(Int Heart J 2017; 58: 647-653) Key words: Coronary artery disease, Old patients, Arterial grafts N owadays a growing number of patients are older at the time of coronary artery bypass grafting (CABG) and present with a clinical history characterized by more comorbidities than in the past. However, despite the increasing proportions of elderly patients with a worse risk profile for elective CABG, mortality in elderly patients over recent decades has dramatically declined.1) In fact, recent studies on elderly patients operated with CABG reported a 30-day mortality rate ranging between 3.7 and 16.8%, a 1-year mortality between 8% and 10.8% and a 5-year mortality ranging from 28.4% to 31%. 2-6)It is well recognized that octogenarians have a higher risk of post-operative complications, 7) require greater clinical and economic resources, and have worse but acceptable short and long-term survival in comparison with younger patients. However, improvements in technical management, particularly the development of innovative extracorporeal circulatory systems, the use of off-pump CABG and the increased use of pedicled arterial conduits have been proven effective in improving outcomes, although they have not completely eliminated the morbidity in this high-risk population. [8][9][10][11][12][13][14] Although improved long-term outcomes obtained with the use of ...

Factors Influencing the Incidence of Pneumonia after Coronary Artery Bypass Grafting

“…Pulmonary infection is the most common complication in CABG, which has a rapid onset and dangerous condition. It has a great impact on the prognosis of patients [6][7][8][9]. It brings huge obstacles to the work and spirit of patients, as well as huge economic burden and labor loss to families and society [10].…”

Long-Term Patency Rate of Radial Artery Conduits in Chinese Patients Undergoing Off-Pump Coronary Artery Bypass Grafting

“…Several previous reports supported the use of the RA conduit in preference to the saphenous vein (SV) graft, [3][4][5][6][7][8][9][10] while other studies suggested the opposite. [11][12][13][14] Ongoing doubt and debate remained regarding the efficacy of the RA as an aorta-coronary conduit, with few solid data regarding long-term patency. Also, consensus has yet to emerge among experts as to whether the RA conduit was superior long-term patency to the SV graft.…”

Sequential Grafting of in Situ Skeletonized Left Internal Mammary Artery to the Left Coronary System

“…1) For decades, in situ LIMA grafting to the left anterior descending artery (LAD) is considered as the "gold standard" of coronary revascularization. 2,3) To maximize the benefits of the LIMA conduit, previous studies reported a sequential anastomotic technique that uses LIMA for grafting more than one major epicardial coronary artery at one time. [4][5][6][7] The skeletonized harvesting method of internal mammary artery achieves maximal length and facilitates the ease of sequential grafting.…”