No-touch aorta off-pump coronary surgery: The effect on stroke

• Published in: The Journal of thoracic and cardiovascular surgery Vol. 129; no. 2; pp. 307 - 313
• Main Authors: Lev-Ran, Oren, Braunstein, Rony, Sharony, Ram, Kramer, Amir, Paz, Yosef, Mohr, Rephael, Uretzky, Gideon
• Format: Journal Article
• Language: English
• Published: Philadelphia, PA Mosby, Inc 01.02.2005; AATS/WTSA; Elsevier
• Subjects: Adult; Aged; Aged, 80 and over; Aortic Diseases - epidemiology; Aortic Diseases - surgery; Biological and medical sciences; Cardiology. Vascular system; Coronary Artery Bypass, Off-Pump; Coronary heart disease; Female; Heart; Humans; Male; Medical sciences; Middle Aged; Morbidity; Neurology; Postoperative Complications - epidemiology; Postoperative Complications - etiology; Predictive Value of Tests; Risk Factors; Severity of Illness Index; Statistics as Topic; Stroke - epidemiology; Stroke - etiology; Surgical Instruments; Treatment Outcome; Vascular diseases and vascular malformations of the nervous system; Nervous system diseases; Stroke; Coronary artery; Cardiovascular disease; Coronary heart disease; Cerebral disorder; Vascular disease; Tactile sensitivity; Treatment; Surgery; Central nervous system disease; Aorta; Cerebrovascular disease
• ISSN: 0022-5223; 1097-685X
• DOI: 10.1016/j.jtcvs.2004.06.013

Studies examining the neuroprotective effects of off-pump coronary artery bypass grafting have shown inconsistent results. Most studies, however, have not differentiated between clampless and clamp off-pump techniques. The aim of this study was to evaluate the effect of avoiding aortic manipulation on major neurologic outcomes after off-pump coronary artery bypass grafting. A total of 700 consecutive patients undergoing multiple-vessel off-pump coronary artery bypass grafting between 2000 and 2003 were included. The 429 patients undergoing aortic no-touch technique were compared with 271 patients in whom partial aortic clamps were applied. The aorta was screened by manual palpation, and epiaortic ultrasonography was used selectively. The frequency of detected atherosclerotic aortic disease was higher in the no-touch group (17.4% vs 5.1%, P < .0001). No-touch revascularization was achieved with arterial conduits, arranged in T-graft or in situ configurations (50%). The respective graft/patient ratios were 2.5 ± 0.6 and 2.6 ± 0.6 in the side-clamp and no-touch groups ( P = .009); however, revascularization of the posterolateral myocardial territory was comparable (87% vs 90%, difference not significant). The incidence of stroke (0.2% vs 2.2%, P = .01) was significantly lower in the no-touch group (1/429). Logistic regression identified partial aortic clamping as the only independent predictor of stroke (odds ratio 28.5, confidence interval 0.22-333, P = .009), increasing this risk 28-fold. Peripheral vascular disease ( P = .068), diabetes ( P = .072), and history of stroke ( P = .074) trended toward stroke. Avoiding partial aortic clamping during off-pump coronary artery bypass grafting provides superior neurologic outcome. The results are reproducible and irrespective of the severity of aortic disease or the method of aortic screening. This technique is recommended whenever technically feasible.