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.