Cerebrovascular Events After No‐Touch Off‐Pump Coronary Artery Bypass Grafting, Conventional Side‐Clamp Off‐Pump Coronary Artery Bypass, and Proximal Anastomotic Devices: A Meta‐Analysis

Abstract

BackgroundOff‐pump coronary artery bypass (OPCAB) has been shown to reduce the risk of neurologic complications as compared to coronary artery bypass grafting performed with cardiopulmonary bypass. Side‐clamping of the aorta while constructing proximal anastomoses, however, still carries substantial risk of cerebral embolization. We aimed to perform a comprehensive meta‐analysis of studies assessing 2 clampless techniques: aortic “no‐touch” and proximal anastomosis devices (PAD) for OPCAB.Methods and ResultsPubMed, CINAHL, CENTRAL, and Google Scholar databases were screened for randomized controlled trials and observational studies comparing “no‐touch” and/or PAD with side‐clamp OPCAB and reporting short‐term (≤30 days) outcomes: cerebrovascular accident and all‐cause mortality. A total of 18 studies (3 randomized controlled trials) enrolling 25 163 patients were included. Aortic “no‐touch” was associated with statistically lower risk of cerebrovascular accident as compared to side‐clamp OPCAB: risk ratio 95% CI: 0.41 (0.27–0.61); P<0.01; I2=0%. Event rates were 0.36% and 1.28% for “no‐touch” and side‐clamp OPCAB, respectively. No difference was seen between PAD and side‐clamp OPCAB: 0.71 (0.33–1.55); P=0.39; I2=39%. A trend towards increased 30‐day all‐cause mortality with PAD and no difference with “no‐touch” were observed when compared to side‐clamp OPCAB. In a subset analysis, “no‐touch” consistently reduced the risk of cerebrovascular accident regardless of patients’ baseline risk characteristics. A benefit with PAD was observed in low‐risk patients.ConclusionsAortic “no‐touch” technique was associated with nearly 60% lower risk of postoperative cerebrovascular events as compared to conventional side‐clamp OPCAB with effect consistent across patients at different risk.

Clinical Safety and Effectiveness of Endoaortic as Compared to Transthoracic Clamp for Small Thoracotomy Mitral Valve Surgery: Meta-Analysis of Observational Studies

“…In particular neurologic complications are of interest. The application of an external cross-clamp to an atherosclerotic ascending aorta increases the risk of embolic events and traumatic injury of the aorta [9,10]; similarly, EABO may cause mobilization and embolism of aortic plaques and, in case of dislocation or malposition, the occlusion of innominate artery [11].…”

Multi‐arterial and total‐arterial coronary revascularization: Past, present, and future perspective

“…The risk of stroke occurs with an incidence of 1.4% to 3.8% after CABG procedures, 81 and was proven to be related to the extent of aortic manipulation 82,83 . Accordingly, Albert et al have recently outlined that the use of no‐aortic‐touch off‐pump technique (anOPCAB) provides a reduction in the postoperative stroke rate to 0.49% vs 1.31% in on‐pump patients ( P < .0001) 84 .…”

Prognostic Impact of Asymptomatic Carotid Artery Stenosis in Patients Undergoing Coronary Artery Bypass Grafting

“…9e11 Multivariable analysis and evaluation of individual data of patients who suffered post-operative stroke shed further light on the multifactorial nature of post-operative stroke after adult cardiac surgery and the limited role of CS in the occurrence of such a severe complication. Indeed, prior observational and randomised studies as well as several pooled analyses 9e11 focused on the role of carotid intervention in these patients without considering that manipulation of the ascending aorta, 12 and cardioembolic events from the left cardiac chambers related to postoperative atrial fibrillation 13 could be the main determinants of post-operative neurological events in patients undergoing cardiac surgery. Indeed, in this series, only 30% of patients with ischaemic brain injury on computed tomography had a stroke ipsilateral to a CS !…”