Central Anastomoses: Analysis of Operative Revascularization Techniques in Multi-Vessel Disease

Objective: Recent studies report significant benefit for operative treatment of coronary heart disease in off-pump surgery (OPCAB) and aortic no-touch technique (antOPCAB), particularly regarding stroke rate. We aimed to compare our patient collective undergoing coronary artery bypass grafting (CABG) during the past 7 years.

Methods: We compared all patients undergoing CABG from 2010 to 2016 with more than one distal anastomosis during CABG (3657 patients). Operative procedure and early postoperative results were analyzed in the EQS-database. Retrospective analysis was performed to compare all CABG techniques, including antOPCAB, OPCAB and traditional on-pump CABG with (CBAG) and without central anastomoses (antCABG).

Results: Percentage of revascularization without central anastomoses increased from 28.8% in 2010 to 76.0% in 2016 (p < 0.001). During this period, portion of all OPCAB procedures increased from 32.4% to 40.4%. Patients treated by OPCAB were significantly older (66.1 ± 9.3 versus 69.7 ± 9.5 years, On-pump CABG versus OPCAB, p < 0.001). Absence of central anastomoses revealed significantly different results in CABG regarding hospital mortality (2.1% versus 1.2%, CABG versus ant-CABG, p = 0.005) and 30-day-mortality (2.6% versus 1.4%, p = 0.005). Postoperative stroke rate was not significantly different in this group (1.7% versus 1.3%, p = 0.53). Differences in the use of venous grafts (95% versus 11%, CABG versus antCABG, p < 0.001) and mean number of distal anastomoses (3.2 ± 0.9 versus 2.6 ± 0.6, p < 0.001) were highly significant. Comparison of OPCAB and ant-OPCAB regarding stroke rate was 2.9% with and 0.9% without central anastomoses (p = 0.004). Also hospital mortality (2.9% versus 1.2%, OPCAB versus antOPCAB, p = 0.038) and 30-day-mortality (6.5% versus 2.2%, OPCAB versus ant-OPCAB, p = 0.005) were significantly different. Mean number of distal anastomoses (2.7 ± 0.7 versus 2.5 ± 0.6, OPCAB versus antOPCAB, p = 0.001), venous (1.2 ± 1.0 versus 0.7 ± 0.9, OPCAB versus antOPCAB, p < 0.001) and arterial grafts (1.6 ± 0.8 versus 1.8 ± 0.9, OPCAB versus antOPCAB, p < 0.000) differed significantly as well.

Conclusion: Central anastomoses seem to be a risk factor in all techniques of operative myocardial revascularization. Avoidance of aortic manipulation decreases the risk of post-operative stroke, even in On-pump CABG. Off-pump surgery using the aortic no-touch technique tends to produce lowest stroke rates among this patient collective.