INTRODUCTION:
Landmark trials have suggested that coronary artery bypass grafting
(CABG) should be considered the revascularization method of choice in
patients with multi-vessel disease (1, 2). The benefits of CABG in these
patients are largely accrued by the unique advantages of the left
internal mammary artery (LIMA) to left anterior descending (LAD) bypass
graft, which, in itself, affords a significant long-term survival
advantage, and which has consistently demonstrated 10-year patency rates
well above 90% (3). On the other hand, saphenous venous grafts to
non-LAD targets are more prone to atherosclerotic degeneration and
failure, and have been observed to occlude as early as 1 year
postoperatively in 6 - 32% of cases (4, 5). By contrast, angiographic
surveillance has demonstrated that rates of clinically relevant in-stent
restenosis (ISR) after percutaneous coronary intervention (PCI) are less
than 5% at 1 year follow-up, especially with the increasing utilization
of newer generation drug-eluting stents (DES) (6). One further potential
pitfall of traditional CABG is an increased incidence of stroke, as
compared to PCI (1, 2).
Hybrid coronary revascularization (HCR) affords the patient the
advantages of the LIMA to LAD graft, usually completed via a
minimally-invasive approach, coupled with PCI for all non-LAD lesions.
Utilizing a minimal access, ‘off-pump’ technique to complete the LIMA to
LAD bypass virtually negates the risk of stroke that is associated with
traditional CABG, whilst also reducing the infection rate and the
perioperative transfusion rate, and hastening recovery time by avoiding
a median sternotomy (7, 8).
In the American College of Cardiology Foundation/American Heart
Association (ACCF/AHA) Guidelines for Coronary Artery Bypass Graft
Surgery, HCR, for the treatment of triple vessel disease (TVD), was
denoted a Class IIb recommendation as an alternative method of
revascularization to PCI or CABG, in an attempt to improve the overall
risk-benefit ratio of the procedures (9). Despite the fact that the
first HCR was performed more than two decades ago, this treatment option
has constituted less than 0.5% of all CABG volume in the United States
(10). A paucity of long-term data has undoubtedly contributed, at least
in part, to the relative under-utilization of HCR. Consequently, we
sought to evaluate the 8-year survival data after HCR for TVD, and we
compared it with that of concurrent matched patients who had either
traditional CABG via sternotomy or multi-vessel PCI.