Status Quo of Hybrid Coronary Revascularization for Multi-Vessel Coronary Artery Disease
2013; Elsevier BV; Volume: 96; Issue: 6 Linguagem: Inglês
10.1016/j.athoracsur.2013.07.093
ISSN1552-6259
AutoresRalf E. Harskamp, Zhe Zheng, John H. Alexander, Judson B. Williams, Ying Xian, Michael E. Halkos, J. Matthew Brennan, Robbert J. de Winter, Peter K. Smith, Renato D. Lópes,
Tópico(s)Cardiac Valve Diseases and Treatments
ResumoHybrid coronary revascularization (HCR) combines bypass grafting of the left anterior descending (LAD) coronary artery with percutaneous coronary intervention (PCI) of non-LAD vessels. HCR has been performed as an alternative to CABG or multi-vessel PCI in thousands of patients since the late 1990s. In this review article, we provide an overview on patient selection, procedural sequence and timing, use of surgical techniques and anti-platelet agents. Additionally, patient recovery, satisfaction, costs and clinical outcomes of individual studies after HCR are evaluated. Future directions are also discussed, including the need for adequately powered randomized trials. Hybrid coronary revascularization (HCR) combines bypass grafting of the left anterior descending (LAD) coronary artery with percutaneous coronary intervention (PCI) of non-LAD vessels. HCR has been performed as an alternative to CABG or multi-vessel PCI in thousands of patients since the late 1990s. In this review article, we provide an overview on patient selection, procedural sequence and timing, use of surgical techniques and anti-platelet agents. Additionally, patient recovery, satisfaction, costs and clinical outcomes of individual studies after HCR are evaluated. Future directions are also discussed, including the need for adequately powered randomized trials. Coronary revascularization provides symptomatic relief and improves long-term outcomes in patients with multi-vessel coronary artery disease [1O'Connor C.M. Velazquez E.J. Gardner L.H. et al.Comparison of coronary artery bypass grafting versus medical therapy on long-term outcome in patients with ischemic cardiomyopathy (a 25-year experience from the Duke Cardiovascular Disease Databank).Am J Cardiol. 2002; 90: 101-107Abstract Full Text Full Text PDF PubMed Scopus (145) Google Scholar]. The optimal revascularization strategy remains controversial, and depends on the anatomic complexity of the lesions requiring revascularization, comorbidities, and the ability to use dual antiplatelet therapy [2Serruys P.W. Morice M.C. Kappetein A.P. et al.Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease.N Engl J Med. 2009; 360: 961-972Crossref PubMed Scopus (3222) Google Scholar, 3Farkouh M.E. Domanski M. Sleeper L.A. et al.Strategies for multivessel revascularization in patients with diabetes.N Engl J Med. 2012; 367: 2375-2384Crossref PubMed Scopus (1345) Google Scholar]. Although coronary artery bypass graft (CABG) surgery is a long-established revascularization approach and hence considered "gold standard," rapid developments in percutaneous techniques and devices as well as advances in medical therapy continue to challenge the status quo [4Jang J.S. Choi K.N. Jin H.Y. et al.Meta-analysis of three randomized trials and nine observational studies comparing drug-eluting stents versus coronary artery bypass grafting for unprotected left main coronary artery disease.Am J Cardiol. 2012; 110: 1411-1418Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar]. The major therapeutic benefits of CABG surgery over percutaneous coronary intervention (PCI) is the use of the left internal mammary artery (LIMA) to bypass the left anterior descending (LAD) artery irrespective of its lesion complexity. The superior patency of LIMA-to-LAD graft provides prophylaxis against future proximal LAD lesions, which translates into better event-free survival and relief of angina [5Tatoulis J. Buxton B.F. Fuller J.A. Patencies of 2127 arterial to coronary conduits over 15 years.Ann Thorac Surg. 2004; 77: 93-101Abstract Full Text Full Text PDF PubMed Scopus (349) Google Scholar]. The benefits of bypassing other non-LAD coronary vessels are much less clear [6Mehta R.H. Honeycutt E. Shaw L.K. et al.Clinical and angiographic correlates of short- and long-term mortality in patients undergoing coronary artery bypass grafting.Am J Cardiol. 2007; 100: 1538-1542Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar]. Conduits for a non-LAD vessel may include other arterial grafts ("multi-arterial" or "complete arterial" revascularization) but the saphenous vein is by far the most commonly used. A major limitation of CABG with saphenous vein grafts (SVG) lies in the high graft failure rates with reports ranging from 13% to 29% at 1 year and up to 50% at 10 years after surgery [7Alexander J.H. Hafley G. Harrington R.A. et al.Efficacy and safety of edifoligide, an E2F transcription factor decoy, for prevention of vein graft failure following coronary artery bypass graft surgery: PREVENT IV: a randomized controlled trial.JAMA. 2005; 294: 2446-2454Crossref PubMed Scopus (484) Google Scholar, 8Harskamp R.E. Lopes R.D. Baisden C.E. de Winter R.J. Alexander J.H. Saphenous vein graft failure after coronary artery bypass surgery: Pathophysiology, management, and future directions.Ann Surg. 2013; 257: 824-833Crossref PubMed Scopus (236) Google Scholar, 9Puskas J.D. Williams W.H. Mahoney E.M. et al.Off-pump vs conventional coronary artery bypass grafting: early and 1-year graft patency, cost, and quality-of-life outcomes: a randomized trial.JAMA. 2004; 291: 1841-1849Crossref PubMed Scopus (481) Google Scholar]. Although direct comparison data between SVG failure and PCI is not available, restenosis rates (<10%) and stent thrombosis rates (<1%) of drug-eluting stent (DES) in non-LAD lesions are markedly lower [10Marzocchi A. Saia F. Piovaccari G. et al.Long-term safety and efficacy of drug-eluting stents: two-year results of the REAL (REgistro AngiopLastiche dell'Emilia Romagna) multicenter registry.Circulation. 2007; 115: 3181-3188Crossref PubMed Scopus (136) Google Scholar, 11Varani E. Saia F. Balducelli M. et al.Percutaneous treatment of multivessel coronary disease in the drug eluting stent era: comparison of bare-metal stents, drug-eluting stents and a mixed approach in a large multicentre registry.EuroIntervention. 2007; 2: 474-480PubMed Google Scholar, 12From A.M. Al Badarin F.J. Cha S.S. et al.Percutaneous coronary intervention with drug-eluting stents versus coronary artery bypass surgery for multivessel coronary artery disease: a meta-analysis of data from the ARTS II, CARDia, ERACI III, and SYNTAX studies and systematic review of observational data.EuroIntervention. 2010; 6: 269-276Crossref PubMed Scopus (25) Google Scholar] (also see Fig 1). Additionally, subsequent revascularization for SVG failure is challenging and associated with much higher rates of periprocedural complications than native vessel PCI [8Harskamp R.E. Lopes R.D. Baisden C.E. de Winter R.J. Alexander J.H. Saphenous vein graft failure after coronary artery bypass surgery: Pathophysiology, management, and future directions.Ann Surg. 2013; 257: 824-833Crossref PubMed Scopus (236) Google Scholar, 13Harskamp R.E. Beijk M.A. Damman P. et al.Clinical outcome after surgical or percutaneous revascularization in coronary bypass graft failure.J Cardiovasc Med. 2012; 14: 438-445Crossref Scopus (23) Google Scholar, 14Brilakis E.S. Rao S.V. Banerjee S. et al.Percutaneous coronary intervention in native arteries versus bypass grafts in prior coronary artery bypass grafting patients: a report from the National Cardiovascular Data Registry.JACC Cardiovasc Interv. 2011; 4: 844-850Abstract Full Text Full Text PDF PubMed Scopus (139) Google Scholar]. From a patient perspective, PCI also has the advantage of being minimally invasive with less patient discomfort, faster return to normal activities, and lower risk of complications such as stroke [15Palmerini T. Biondi-Zoccai G. Reggiani L.B. et al.Risk of stroke with coronary artery bypass graft surgery compared with percutaneous coronary intervention.J Am Coll Cardiol. 2012; 60: 798-805Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar]. In order to combine the superior patency of the LIMA-to-LAD graft with the low restenosis rates of PCI to non-LAD regions, a hybrid approach was introduced to coronary revascularization. The present study provides an overview of evidence for the use of hybrid coronary revascularization (HCR) in the current DES era and explores strategies that may help improve the future role and implementation of HCR in patients with multi-vessel coronary artery disease.Material and MethodsTwo authors (R.E.H., R.D.L.) searched the MEDLINE database using the PubMed interface to identify published studies that examined hybrid coronary revascularization and were published from January 1, 1996 through May 1, 2013. The search was performed using the following terms: "hybrid coronary revascularization," "integrated coronary revascularization," and "hybrid myocardial revascularization." Additionally, we reviewed references from these articles for studies not found through the initial search. Both original and review articles were included, and publications were restricted to studies published in the English literature. From the available literature we distilled information on patient selection, timing and sequence of procedures, surgical and interventional techniques, antiplatelet drugs, clinical outcomes, patient satisfaction, and costs.Patient Selection for Hybrid Coronary RevascularizationPatients who would qualify for HCR are those with symptoms or signs of ischemia, due to multi-vessel disease with significant proximal LAD disease, along with lesions suitable for PCI in the left main, left circumflex or right coronary artery territories. As such, cases with chronic total occlusions, highly calcified segment, and diffusely diseased and bifurcation coronary lesions were usually deferred to conventional CABG. Patients with a lack of suitable conduits, prior sternotomy, severe ascending aortic disease, or coronary arteries not amenable for bypass, may also be suitable candidates. Those cases in which the decision to perform additional PCI based on intraoperative findings (poor conduits, ungraftable vessels, graft defects) and patients who underwent CABG after PCI, either for ongoing ischemia or complications, are considered unplanned HCR [16Zhao D.X. Leacche M. Balaguer J.M. et al.Routine intraoperative completion angiography after coronary artery bypass grafting and 1-stop hybrid revascularization results from a fully integrated hybrid catheterization laboratory/operating room.J Am Coll Cardiol. 2009; 53: 232-241Abstract Full Text Full Text PDF PubMed Scopus (172) Google Scholar]. This also includes cases in the setting of acute coronary syndrome, where PCI of the culprit vessel is followed by CABG during the same hospitalization for grafting of the non-culprit coronary arteries. Table 1 summarizes clinical and angiographic characteristics that one should consider when opting for HCR. Decision making when opting for hybrid CABG, should involve close consultation between interventional cardiologist and cardiac surgeon, preferably in the setting of a "heart team."Table 1Recommendations for Suitable Candidates for Hybrid Coronary Revascularization Versus Conventional Coronary RevascularizationCharacteristicPCIHCRCABGAngiographic characteristics ULMD-++ Intramyocardial LAD+-- Complex LAD lesion 53Fihn S.D. Gardin J.M. Abrams J. et al.2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.Circulation. 2012; 126: e354-e471Crossref PubMed Scopus (589) Google Scholar, 54Levine G.N. Bates E.R. Blankenship J.C. et al.2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions.J Am Coll Cardiol. 2011; 58: e44-e122Abstract Full Text Full Text PDF PubMed Scopus (1918) Google Scholar, 55Wijns W. Kolh P. Danchin N. et al.Guidelines on myocardial revascularization.Eur Heart J. 2010; 31: 2501-2505Crossref PubMed Scopus (26) Google Scholar-++ Complex non-LAD lesion 53Fihn S.D. Gardin J.M. Abrams J. et al.2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.Circulation. 2012; 126: e354-e471Crossref PubMed Scopus (589) Google Scholar, 54Levine G.N. Bates E.R. Blankenship J.C. et al.2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions.J Am Coll Cardiol. 2011; 58: e44-e122Abstract Full Text Full Text PDF PubMed Scopus (1918) Google Scholar--+Comorbidities Advanced age++- Frailty 53Fihn S.D. Gardin J.M. Abrams J. et al.2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.Circulation. 2012; 126: e354-e471Crossref PubMed Scopus (589) Google Scholar, 42Katz M.R. Van Praet F. de Canniere D. et al.Integrated coronary revascularization: percutaneous coronary intervention plus robotic totally endoscopic coronary artery bypass.Circulation. 2006; 114: I473-I476Crossref PubMed Scopus (92) Google Scholar++- LVEF <30%-++ Diabetes mellitus-++ Renal insufficiency-++ Severe chronic lung disease+-- Prior left thoracotomy+-+ Prior sternotomy 55Wijns W. Kolh P. Danchin N. et al.Guidelines on myocardial revascularization.Eur Heart J. 2010; 31: 2501-2505Crossref PubMed Scopus (26) Google Scholar++- Limited vascular access--+ Lack of available conduits 53Fihn S.D. Gardin J.M. Abrams J. et al.2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.Circulation. 2012; 126: e354-e471Crossref PubMed Scopus (589) Google Scholar, 54Levine G.N. Bates E.R. Blankenship J.C. et al.2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions.J Am Coll Cardiol. 2011; 58: e44-e122Abstract Full Text Full Text PDF PubMed Scopus (1918) Google Scholar++- Severe aortic calcification 53Fihn S.D. Gardin J.M. Abrams J. et al.2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.Circulation. 2012; 126: e354-e471Crossref PubMed Scopus (589) Google Scholar, 54Levine G.N. Bates E.R. Blankenship J.C. et al.2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions.J Am Coll Cardiol. 2011; 58: e44-e122Abstract Full Text Full Text PDF PubMed Scopus (1918) Google Scholar++- Contraindication for DAPT--++ = recommended; - = not recommended.CABG = coronary artery bypass graft; DAPT = dual antiplatelet therapy; HCR = hybrid coronary revascularization; LAD = left anterior descending artery; LVEF = left ventricular ejection fraction; PCI = percutaneous coronary intervention; ULMD = unprotected left main disease. Open table in a new tab Timing and Sequence of Hybrid RevascularizationPlanned HCR can be performed as either a concomitant procedure in a hybrid operating room in which CABG and PCI are performed in the same anesthesia setting, or performed in 2 stages in which PCI and CABG are performed separately within hours, days, or weeks. When HCR is performed staged, PCI can be performed first followed by CABG or vice versa. These approaches all have their merits and disadvantages, as displayed in Table 2. However, recommendations on the optimal choice of HCR are based on expert opinion and supported by very few data that actually support one HCR strategy over another. Table 3 summarizes available evidence on comparisons of various HCR strategies.Table 2Advantages and Limitations of Use of Various HCR ApproachesFactorOne-SettingCABG Followed by PCIPCI Followed by CABGLIMA-LAD patencyAssessment directly after completing anastomosisAssessment during follow-up PCINot routinely assessedSuitable in non-elective settingNoNoYesPCI of complex lesionsPossiblePossiblePossible, but more risky with non-revascularized LADArterial access for PCIObtain before anticoagulation administered for surgeryObtain at the time of PCIObtain at the time of PCIAnticoagulationAdministered onceAdministered twiceAdministered twiceDiscontinue DAPTNoNoYes/NoRisk for intraoperative bleedingHighLowHigh (if DAPT continued)Risk of acute stent thrombosisIntermediateLowHighDES useSuitableSuitableNot suitableLOSLikely to be shorterLikely to be longeraThe difference between LOS in 1-setting and staged settings depends primarily on the time interval between the 2 staged procedures.Likely to be longeraThe difference between LOS in 1-setting and staged settings depends primarily on the time interval between the 2 staged procedures.Degree of coordination between teamsHigh degree of coordinationLesser degree of coordinationLesser degree of coordinationCostsHybrid roomTraining of personnelReimbursementTwo proceduresReimbursementTwo proceduresReimbursementCABG = coronary artery bypass graft; DAPT = dual antiplatelet therapy; DES = drug-eluting stent; LAD = left anterior descending artery; LIMA = left internal mammary artery; LOS = length-of-stay; PCI = percutaneous coronary intervention.a The difference between LOS in 1-setting and staged settings depends primarily on the time interval between the 2 staged procedures. Open table in a new tab Table 3Available Data on Outcomes After Simultaneous and Staged HCR StrategiesAuthor, Year (Ref)No.PCI StrategyCABG StrategyIn-Hospital MortalityIn-Hospital StrokeReoperation For BleedingIn-Hospital LIMA PatencyHospital Stay (Days)F/U PeriodSurvivalFreedom From MACCEaIn the case series of Lewis et al [56], PCI and MIDCAB occurred within 1 day, but took place in 2 stages.TLRSimultaneous HCRKon, 2008 17Kon Z.N. Brown E.N. Tran R. et al.Simultaneous hybrid coronary revascularization reduces postoperative morbidity compared with results from conventional off-pump coronary artery bypass.J Thorac Cardiovasc Surg. 2008; 135: 367-375Abstract Full Text Full Text PDF PubMed Scopus (144) Google Scholar15DES (100)MIDCAB0001003.7 ± 1.412 mo100936.7Bonatti, 2008 45Bonatti J. Schachner T. Bonaros N. et al.Simultaneous hybrid coronary revascularization using totally endoscopic left internal mammary artery bypass grafting and placement of rapamycin eluting stents in the same interventional session. The COMBINATION pilot study.Cardiology. 2008; 110: 92-95Crossref PubMed Scopus (70) Google Scholar5DES (100)TECAB0001006 (5–7)6 mo1001000Kiaii, 2008 30Kiaii B. McClure R.S. Stewart P. et al.Simultaneous integrated coronary artery revascularization with long-term angiographic follow-up.J Thorac Cardiovasc Surg. 2008; 136: 702-708Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar58DES (90), BMS (10)Endo-ACAB01.75.2934.3 ± 1.420 mo1001002.3Reicher, 2008 31Reicher B. Poston R.S. Mehra M.R. et al.Simultaneous "hybrid" percutaneous coronary intervention and minimally invasive surgical bypass grafting: feasibility, safety, and clinical outcomes.Am Heart J. 2008; 155: 661-667Abstract Full Text Full Text PDF PubMed Scopus (105) Google Scholar13DES (100)MIDCAB0001003.6 ± 1.514100927.6Zhao, 2009 16Zhao D.X. Leacche M. Balaguer J.M. et al.Routine intraoperative completion angiography after coronary artery bypass grafting and 1-stop hybrid revascularization results from a fully integrated hybrid catheterization laboratory/operating room.J Am Coll Cardiol. 2009; 53: 232-241Abstract Full Text Full Text PDF PubMed Scopus (172) Google Scholar112DES (84), BMS (8)On-pump CABG (90), OPCAB (22)2.71.82.7936 (1–97)————Hu, 2011 28Hu S. Li Q. Gao P. et al.Simultaneous hybrid revascularization versus off-pump coronary artery bypass for multivessel coronary artery disease.Ann Thorac Surg. 2011; 91: 432-438Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar104DES (98), BMS (2)MIDCAB003.8%968.2 ± 2.618100991.9Staged HCR: PCI followed by CABLewis, 1999 56Lewis B.S. Porat E. Halon D.A. et al.Same-day combined coronary angioplasty and minimally invasive coronary surgery.Am J Cardiol. 1999; 84: 1246-1247Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar14BMS (100)MIDCAB0001003.4 ± 2.1aIn the case series of Lewis et al [56], PCI and MIDCAB occurred within 1 day, but took place in 2 stages.1-14 mo100909.6Lee, 2004 57Lee M.S. Wilentz J.R. Makkar R.R. et al.Hybrid revascularization using percutaneous coronary intervention and robotically assisted minimally invasive direct coronary artery bypass surgery.J Invasive Cardiol. 2004; 16: 419-425PubMed Google Scholar6BMS (100)MIDCAB000—6 (4–7)12 mo100—16Gilard, 2007 44Gilard M. Bezon E. Cornily J.C. et al.Same-day combined percutaneous coronary intervention and coronary artery surgery.Cardiology. 2007; 108: 363-367Crossref PubMed Scopus (52) Google Scholar70BMS (100)On-pump CABG1.400100—33 mo98.6962.3Staged HCR: CAB followed by PCIIsomura, 2000 58Isomura T. Suma H. Horii T. et al.Minimally invasive coronary artery revascularization: off-pump bypass grafting and the hybrid procedure.Ann Thorac Surg. 2000; 70: 2017-2022Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar37PTCA (100)MIDCAB00—100—0-24 mo97.3928.1Wittwer, 2000 59Wittwer T. Cremer J. Boonstra P. et al.Myocardial "hybrid" revascularisation with minimally invasive direct coronary artery bypass grafting combined with coronary angioplasty: preliminary results of a multicentre study.Heart. 2000; 83: 58-63Crossref PubMed Scopus (65) Google Scholar35PTCA (70), BMS (30)MIDCAB0001007.5 ± 4.1————Cisowksi, 2002 41Cisowski M. Morawski W. Drzewiecki J. et al.Integrated minimally invasive direct coronary artery bypass grafting and angioplasty for coronary artery revascularization.Eur J Cardiothorac Surg. 2002; 22: 261-265Crossref PubMed Scopus (56) Google Scholar50PTCA (22), BMS (78)Endo-ACAB002.81004.4 ± 1.712 mo1008810Riess, 2002 39Riess F.C. Bader R. Kremer P. et al.Coronary hybrid revascularization from January 1997 to January 2001: a clinical follow-up.Ann Thorac Surg. 2002; 73: 1849-1855Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar57PTCA (7), BMS (93)MIDCAB000985.7 ± 1.824 mo98.29814Gao, 2009 35Gao C. Yang M. Wu Y. et al.Hybrid coronary revascularization by endoscopic robotic coronary artery bypass grafting on beating heart and stent placement.Ann Thorac Surg. 2009; 87: 737-741Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar10BMS (67), DES (33)Endo-ACAB (6), TECAB (4)000100—5 mo1001000Delhaye, 2010 46Delhaye C. Sudre A. Lemesle G. et al.Hybrid revascularization, comprising coronary artery bypass graft with exclusive arterial conduits followed by early drug-eluting stent implantation, in multivessel coronary artery disease.Arch Cardiovasc Dis. 2010; 103: 502-511Crossref PubMed Scopus (26) Google Scholar18DES (100)OPCAB (5), On-pump CABG (13)00010010 (10-11.2)12 mo1008912BMS = bare-metal stents; CABG = coronary artery bypass grafting; CAD = coronary artery disease; DES = drug-eluting stent; Endo-ACAB = endoscopic atraumatic coronary artery bypass; F/U = follow-up; HCR = hybrid coronary revascularization; LIMA = left internal mammary artery; MACCE = major adverse cardiac and cerebrovascular events; MIDCAB = minimally invasive direct coronary artery bypass; mo = months; OPCAB = off pump coronary artery bypass; PCI = percutaneous coronary intervention; PTCA = percutaneous transluminal coronary angioplasty; TLR = target lesion revascularization.a In the case series of Lewis et al 56Lewis B.S. Porat E. Halon D.A. et al.Same-day combined coronary angioplasty and minimally invasive coronary surgery.Am J Cardiol. 1999; 84: 1246-1247Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar, PCI and MIDCAB occurred within 1 day, but took place in 2 stages. Open table in a new tab One-Stage HCRThe advent of hybrid operating suites allowed for complete revascularization at the same sitting, the ability to perform routine imaging of the LIMA-LAD, a safety net when PCI fails which also allows the performance of PCI in more challenging lesions such as bifurcation and left main lesions [17Kon Z.N. Brown E.N. Tran R. et al.Simultaneous hybrid coronary revascularization reduces postoperative morbidity compared with results from conventional off-pump coronary artery bypass.J Thorac Cardiovasc Surg. 2008; 135: 367-375Abstract Full Text Full Text PDF PubMed Scopus (144) Google Scholar, 18Zenati M. Cohen H.A. Griffith B.P. Alternative approach to multivessel coronary disease with integrated coronary revascularization.J Thorac Cardiovasc Surg. 1999; 117: 439-444Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar]. Additionally, the simultaneous approach reduces waste and duplication of resources and is likely to result in a shorter length of stay compared with other approaches of HCR. However, some investigators do not favor the use of a 1-staged approach due to concerns about bleeding because of the use of dual antiplatelet therapy and incomplete heparin reversal, as well as the concern for acute stent thrombosis due to the pro-inflammatory milieu directly after surgery [19Bonatti J. Schachner T. Bonaros N. et al.Technical challenges in totally endoscopic robotic coronary artery bypass grafting.J Thorac Cardiovasc Surg. 2006; 131: 146-153Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar]. Other challenges that limit the applicability of 1-staged HCR in general practice are increased costs, need for a hybrid operating suite with trained personnel, inadequate hospital reimbursement, and the logistical difficulties of coordinating 2 different teams in the same operating room at different times.Two-Stage: PCI Followed by CABGAlthough performing PCI of non-LAD lesions prior to CABG has several advantages, it is currently reserved for patients with acute coronary syndrome with a non-LAD culprit. In cases where DES is used, this approach may complicate the surgical procedure because of bleeding risks associated with the need for continued use of dual antiplatelet therapy [20Berger P.B. Kleiman N.S. Pencina M.J. et al.Frequency of major noncardiac surgery and subsequent adverse events in the year after drug-eluting stent placement results from the EVENT (Evaluation of Drug-Eluting Stents and Ischemic Events) Registry.JACC Cardiovasc Interv. 2010; 3: 920-927Abstract Full Text Full Text PDF PubMed Scopus (127) Google Scholar, 21Kim J.H. Newby L.K. Clare R.M. et al.Clopidogrel use and bleeding after coronary artery bypass graft surgery.Am Heart J. 2008; 156: 886-892Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar]. Newer antiplatelet agents may lower bleeding rates compared with clopidogrel, but further study is required [22Varenhorst C. Alstrom U. Scirica B.M. et al.Factors contributing to the lower mortality with ticagrelor compared with clopidogrel in patients undergoing coronary artery bypass surgery.J Am Coll Cardiol. 2012; 60: 1623-1630Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar, 23Kohli P. Wallentin L. Reyes E. et al.Reduction in First and Recurrent Cardiovascular Events with Ticagrelor Compared with Clopidogrel in the PLATO Study.Circulation. 2013; 127: 673-680Crossref PubMed Scopus (64) Google Scholar]. Also, compared with other HCR approaches, PCI followed by CABG does not allow routine assessment of the patency of the LIMA-LAD graft.Two-Stage: CABG Followed by PCIThe LIMA-LAD grafting and PCI-DES for non-LAD lesions is currently the most adopted HCR strategy. Unlike the other strategies, dual antiplatelet therapy can be freely given postoperatively without concern for intraoperative bleeding. Similar to 1-stage HCR, the patency of LIMA-LAD can be confirmed with angiography at the time of PCI. Although performing PCI after the CABG avoids operating on patients who have taken antiplatelet age
Referência(s)