How to deal with nonsevere stenoses in coronary artery bypass grafting – a critical perspective on competitive flow and surgical precision

Abstract

Purpose of reviewFor invasive treatment of coronary artery disease (CAD), we assess anatomical complexity, analyse surgical risk and make heart-team decisions for percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). With PCI, treating flow-relevant lesions is recommended, and reintervention easily treats disease progression. For CABG, some stenoses may only be borderline or nonsevere despite a clear surgical indication. As reoperations are not easy, the question on how to address these lesions has been around from the start, but has never satisfactorily been answered. Recent findingsWith a new mechanistic perspective, we had suggested that infarct-prevention by surgical collateralization is the main prognostic mechanism of CABG in chronic coronary syndrome. Importantly, the majority of infarctions arise from nonsevere coronary lesions. Thus, surgical collateralization may be a valid treatment option for nonsevere lesions, but graft patency moves more into focus here, because graft patency directly correlates with the severity of coronary stenoses. In addition, CABG may even accelerate native disease progression.

Cardiac Surgery 2022 Reviewed

“…To complete this confusion, Urso et al 26 presented the best long-term outcomes with bilateral internal thoracic artery grafting compared with left internal thoracic artery plus radial artery, but the differences only appeared after 10 years. We reviewed various factors influencing patency of grafts 27 and suggested that surgical precision and experience taking all factors into account may influence patency rates more than only one factor (such as graft type, degree of competitive flow, or target vessel quality; ►Fig. 2B).…”