Patient selection, operative strategy and procedures
We have a no-refusal policy for surgical revascularization, although
some exclusion criteria are applied. One is for patients with mental
disorders such as schizophrenia or severe dementia. Another is for very
fragile or bedridden patients. We regard three factors as important in
achieving recovery from the surgery: the ability to take a deep breath
and cough; the ability to eat well; and the ability to stand and walk.
We therefore do not recommend surgical therapy for bedridden or severely
fragile patients. We do not apply any upper limit on age for the
surgery, but if the patient cannot perform the above-mentioned three
activities, we do not recommend the surgery, even for patients younger
than 80 years old.
OPCAB is the first-choice procedure for isolated CABG in our
institution. Cardiopulmonary bypass was used when maintaining adequate
hemodynamics proved difficult or when hemodynamic instability was
anticipated. Our standard strategy for surgical coronary artery
revascularization is to use bilateral internal thoracic arteries (ITAs)
where possible and to perform bypass with these vessels to the left
coronary artery system12. However, in cases of
moderate stenosis of the circumflex artery, saphenous vein graft is
considered to avoid graft competition13. In cases of
very ill patients, we avoid bilateral ITA usage and choose saphenous
vein grafts to shorten the operative time. The ITA is harvested in
skeletonized fashion with a harmonic scalpel by experienced surgeons.
The great saphenous vein is mainly used as a graft to the right coronary
artery. However, when the ascending aorta has severe atherosclerotic
disease, the gastroepiploic artery is used to avoid manipulation of the
aorta14. To anastomose the proximal site of the
saphenous vein graft to the ascending aorta, clampless facilitating
devices (either Heart String or Enclose, depending on surgeon
preference) are routinely used.