The Society of Thoracic Surgeons Clinical Practice Guidelines on Arterial Conduits for Coronary Artery Bypass Grafting

Abstract

Internal thoracic arteries (ITAs) should be used to bypass the left anterior descending (LAD) artery when bypass of the LAD is indicated (class of recommendation [COR] I, level of evidence [LOE] B). As an adjunct to left internal thoracic artery (LITA), a second arterial graft (right ITA or radial artery [RA]) should be considered in appropriate patients (COR IIa, LOE B). Use of bilateral ITAs (BITAs) should be considered in patients who do not have an excessive risk of sternal complications (COR IIa, LOE B). To reduce the risk of sternal infection with BITA, skeletonized grafts should be considered (COR IIa, LOE B), smoking cessation is recommended (COR I, LOE C), glycemic control should be considered (COR IIa, LOE B), and enhanced sternal stabilization may be considered (COR IIb, LOE C). As an adjunct to LITA to LAD (or in patients with inadequate LITA grafts), use of a RA graft is reasonable when grafting coronary targets with severe stenoses (COR IIa, LOE: B). When RA grafts are used, it is reasonable to use pharmacologic agents to reduce acute intraoperative and perioperative spasm (COR IIa, LOE C). The right gastroepiploic artery may be considered in patients with poor conduit options or as an adjunct to more complete arterial revascularization (COR IIb, LOE B). Use of arterial grafts (specific targets, number, and type) should be a part of the discussion of the heart team in determining the optimal approach for each patient (COR I, LOE C).

Modern trends in coronary surgery

“…В коронарной хирургии, несмотря на давно доказанные преимущества аутоартериального шунти-рования, использования значительного оптического увеличения и ультратонкого шовного материала, не произошло значительных изменений в предпочтени-ях хирургов. В США в последние годы применение второй внутренней грудной артерии (ВГА) при коро-нарном шунтировании отмечается менее чем в 7% слу-чаев, а в России -менее чем в 10% [3,26]. Подобная осторожность вероятно связана с давно отмеченным двух-трехкратным увеличением количества раневых ос-ложнений, особенно среди женщин, пациентов с диа-бетом и ожирением.…”

Transatlantic editorial: A comparison between European and North American guidelines on myocardial revascularization

“…The 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update [4] does not contain any new guidelines with respect to radial artery (RA) grafting. The STS has recently published Clinical Practice Guidelines on Arterial Conduits that do address the RA [5]. The recommendations of the STS Practice Guidelines regarding RA grafting will be outlined as well.…”

“…The very recent STS Practice Guidelines [5] recommend a Heart Team approach for decisions regarding revascularization, including the type of grafts (COR I, LOE C). The STS Practice Guidelines recommend a second arterial graft, either a second IMA or an RA (COR IIa, LOE B in appropriate patients), recognizing that patient comorbidities affect the risks and relative benefits of different approaches.…”

“…The European task force directly discusses the potential impact of BIMA grafting on the diabetic patient and suggests that BIMA grafting should be considered (COR IIa, LOE B). Although both sets of guidelines express concern regarding the potential for increased risk of sternal wound infection with IMA harvest in diabetic patients, it was not until the recent release of the STS Clinical Practice Guidelines on Arterial Conduits for CABG [5] that specific strategies for reducing this risk through the use of a 'skeletonized' harvest approach is directly addressed as a COR IIa, LOE B.…”

“…Since these early times, MR techniques have gained clinical importance worldwide and are now one of the most commonly performed interventions in modern medicine. On the other side of the Atlantic, the American societies have also published several guidelines on MR: in 2011, the ACCF/AHA Guidelines for CABG Surgery [2]; the 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischaemic heart disease [3]; the 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update [4] and in 2015, the Society of Thoracic Surgeons (STS) Clinical Practice Guidelines on Arterial Conduits [5].…”