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Off-pump surgical option and minimally invasive vein and radial artery harvesting offer innovations in coronary artery bypass surgery

09/01/2007

From its earliest days, coronary artery bypass surgery had been performed with the heart arrested in a procedure known as a cardiopulmonary bypass, in which the heart and lung functions are taken over by a heart-lung machine. The heart-lung machine oxygenates the blood, removes carbon dioxide and pumps it through the body, providing the surgeon the opportunity to operate on a temporarily blood-free and stationary heart.

The disadvantage of the heart-lung machine is that it can produce a wide range of deleterious effects throughout the body. These can include temporary or permanent neurocogintive deficit; lung, kidney and liver damage that is of particular concern in patients with limited reserve due to other health conditions; hematologic problems including reduced platelet count; and the danger of infection.

Bypass surgery without the cardiopulmonary bypass

Over the past several years, surgeons have tried to avoid these complications by developing techniques to perform bypass surgery without the use of a heart-lung machine. Beginning with the development of minimally invasive bypass surgery, the procedure has evolved back to one in which the bypass is performed through a standard incision, with the advantage of offering access to all the arteries of the heart for potential bypass. Though off-pump surgery was initially envisioned as the successor to surgery with cardiopulmonary bypass, the two procedures appear more likely, based on current experience, to serve as complimentary options to serve different patients based on their health histories.

The majority of patients who need surgical revascularization may be candidates for off-pump bypass surgery. However, in general, patients who have significant comorbidities will benefit the most. This includes patients with significant neurovascular disease or significant hemotologic, liver, or kidney problems that would make the risk of using the heart-lung machine relatively high. Because of the risk of neurocognitive problems associated with cardiopulmonary bypass, patients above age 70 may also benefit from off-pump bypass, though there is not yet adequate research to prove this viewpoint. Another potential advantage to off-pump surgery is that is has been shown to use less transfused blood and blood products than are used during surgery with cardiopulmonary bypass.

Because the heart continues to beat during the surgery, off-pump bypass is a technically demanding procedure for both surgeons and anesthesiologists. Most centers that perform coronary bypass surgery either don’t offer off-pump surgery at all or perform it only on single- or double-bypass patients and not for the more challenging higher multiple-bypass cases. The more diseased the arteries are, the more difficult it is to perform the bypass using this procedure. It still remain unclear if off-pump surgery produces long-term results equal to surgery with ardiopulmonary bypass in terms of graft or anastomotic patency (the graft or surgical connection remaining open or free of obstruction); early data has been mixed and the question awaits more definitive study.

Minimally invasive vein and radial artery harvesting

Traditionally, the blood vessel used in coronary artery bypass surgery has been harvested from the leg via a long incision from the groin to the ankle (sometimes leaving skin bridges along the line of the incision). This type of vein harvesting has been one of the major contributors to the morbidity of bypass surgery. Newer endoscopic techniques now allow surgeons to harvest the vein through a small incision at the knee with stab incisions at the groin and ankle. Endoscopic vein harvesting nearly eliminates wound problems and results in far less postoperative pain, allowing patients to regain their mobility more quickly after surgery. Despite research that has demonstrated its clear advantages, many centers do not offer endoscopic vein harvesting because they lack the necessary expertise in endoscopic techniques. UCLA surgeons exclusively use endoscopic vein harvesting when performing bypass surgery. The radial artery in the arm can be harvested using these same endoscopic techniques, which offers cosmetic advantages through its use of a “wristwatch” incision.

Patient referral

It is advantageous to patients that they be referred for bypass surgery to a center that, like UCLA, has extensive experience in both coronary artery bypass surgery with cardiopulmonary bypass and off-pump surgery. As one of the first centers offering the procedure, and having performed over 500 off-pump bypass surgeries, UCLA surgeons can evaluate patients’ needs and condition and perform the procedure that they feel will produce the best outcome.

For a consultation or to refer a patient, call:
(310) 206-8232 UCLA Division of Cardiothoracic Surgery

Program physicians

The following physicians participate in this program at UCLA:

Abbas Ardehali, M.D.
Associate Professor of Surgery

Ramin Beygui, M.D.
Assistant Professor of Surgery

Fardad Esmailian, M.D.
Associate Professor of Surgery





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