“Awake” CABG Using Internal Thoracic Arteries Safe for Multivessel Disease
“Awake” coronary artery bypass grafting (CABG) using the internal thoracic arteries is a feasible and safe procedure for double or triple vessel disease, findings from a small study suggest. As the name implies, general anesthesia is not given and the patient is conscious throughout the procedure.
The technique, which was developed a few years ago, does away with cardiopulmonary bypass and mechanical ventilation and the risks associated with each. Lead author Dr. Kaan Kirali and colleagues, from the Kosuyolu Heart and Research Hospital in Istanbul, call it “the least invasive revascularization method for the lateral and/or posterior wall of the heart.”
Believing that outcomes would be improved with the use of an in situ arterial graft, the researchers developed a technique for using the bilateral internal thoracic arteries to achieve complete revascularization. This appears to be the first time that these vessels have been used for grafting in awake patients, they note.
In their study, reported in the Annals of Thoracic Surgery for November, seven patients with multivessel disease were treated with awake CABG using the internal thoracic arteries. In all cases, high thoracic epidural anesthesia was administered 1 hour before surgery.
Double bypass grafting was performed in six patients. In the remaining patient, triple bypass grafting was performed using the thoracic arteries as well as a radial artery.
All of the subjects remained conscious throughout the operation and none required conversion to a more conventional procedure, the authors note. Moreover, no cases of perioperative MI or death were observed.
Pneumothorax occurred in three patients during surgery, but was repaired in two. The other patient completed the operation with a unilateral pneumothorax.
No hemodynamic or pulmonary complications occurred during lateral or posterior wall revascularization, the researchers report. However, in two patients, coronary endarterectomy was required during circumflex and right coronary artery anastomoses.
In a related editorial, Dr. John Puskas, from Emory University in Atlanta, comments that “it is likely that a prospective randomized comparison of all-arterial off-pump CABG with and without endotracheal anesthesia would be required to convince more than a small minority of cardiac surgeons and anesthesiologists that this new approach represents an important advance.”
