Sternotomy Versus Nonsternotomy LIMA-LAD Grafting for Single-Vessel Disease

摘要

Surgical TechniquesMIDCABEndoACABRADCABEndoACABOutcomesStatistical AnalysisDiscussionReferencesSingle-vessel disease of the left anterior descending (LAD) coronary artery may be surgically revascularized by left internal mammary artery (LIMA) grafting either through a sternotomy or a nonsternotomy approach. Nonsternotomy approaches are used in the hope of achieving a less invasive operation. It is unknown whether nonsternotomy approaches impact in-hospital or midterm outcomes.MethodsThe institutional Society of Thoracic Surgeons (STS) database at a single US academic center was reviewed for 597 consecutive patients treated surgically for single-vessel LAD disease from January 1, 2002 to June 30, 2011. In-hospital adverse events and length of stay (LOS) were compared between patients who had LIMA-LAD grafting performed through a sternotomy (sternotomy patients) versus patients who had this procedure performed through a nonsternotomy approach (nonsternotomy patients), adjusted for propensity score (likelihood of receiving sternotomy, calculated on 33 variables). Midterm survival between groups was compared using Kaplan-Meier and Cox regression analysis by referencing the National Social Security Death Index.ResultsThere were 597 consecutive patients who underwent single-vessel grafting by LIMA-LAD coronary artery grafting. Of these patients, 234 underwent sternotomy, whereas 363 patients had nonsternotomy procedures: 239 patients had endoscopic LIMA harvest and left anterolateral thoracotomy, 106 patients had robot LIMA harvest and left anterolateral thoracotomy, and 18 patients had minimally invasive direct coronary artery bypass. There were no strokes in the nonsternotomy group and 3 (1.3%) in the sternotomy group (p = 0.031). Thirty-day mortality, incidence of myocardial infarction, hospital LOS, and midterm survival were similar between groups. Operative time was significantly longer in the nonsternotomy group (1.8 hours, 95% confidence interval [CI], 1.5–2.1).ConclusionsIn this propensity-adjusted comparison, sternal-sparing incisions were associated with similar 30-day adverse events and midterm survival compared with sternotomy for single-vessel LIMA–LAD artery grafting.Abbreviations and Acronyms: AOR (adjusted odds ratio), CABG (coronary artery bypass grafting), CI (confidence intervals), EndoACAB (endoscopic atraumatic coronary artery bypass), ICU (intensive care unit), LAD (left anterior descending), LIMA (left internal mammary artery), LOS (length of stay), MACE (major adverse cardiac events), MIDCAB (minimally invasive direct coronary artery bypass), RADCAB (robotically assisted direct coronary artery bypass), STS (Society of Thoracic Surgeons), TECAB (robotically assisted totally endoscopic coronary artery bypass)CTSNet classification:23Dr Halkos discloses that he has a financial relationship with Intuitive Surgical, Inc; Dr Vassiliades with Medtronic, Inc; and Dr Thourani with Maquet.In the current era, coronary artery bypass grafting (CABG) is typically performed for patients with multivessel disease. However given that the survival advantage of CABG is mainly attributable to the left internal mammary artery (LIMA)-to-left anterior descending (LAD) artery graft [