Multi-Arterial and Total Arterial Bypass Grafting

Podcast Transcript

Announcer:

Welcome to Love Your Heart, brought to you by Cleveland Clinic's Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute. This podcast will explore disease prevention, testing, medical and surgical treatments, new innovations and more. Enjoy.

Dr. Donna Kimmaliardjuk:

Hi and welcome. Thank you so much for joining us on this podcast episode. I'm Dr. Donna Kimmaliardjuk, and I'm joined today by -

Dr. Faisal Bakaeen:

I'm Dr. Faisal Bakaeen. I'm the Surgical Director of the Coronary Revascularization Center at the Cleveland Clinic. Both Donna and I are very interested in, and our specialty is really coronary artery bypass grafting. Today, we're going to talk about a subject that we both love. Maybe you should start by making a comment or two.

Dr. Donna Kimmaliardjuk:

As Dr. Bakaeen mentioned, we specialize and love coronary artery bypass grafting, but even more so within coronary artery bypass grafting (CABG), we further specialize in what's called multi-arterial bypass grafting or even total arterial bypass grafting at times. What that means is using more than one artery to do bypasses.

So, as we know and as we've talked about on previous podcasts, we're the center, or the place where bypass surgery was created, and really have been the pioneers in using the LIMA (left internal mammary artery) artery, so the artery on the inside of the left chest, to do the bypass to the LAD or the left anterior descending artery. That was really established as the gold standard here. We take it a step further by using even more arteries than that one artery to do other bypasses.

Dr. Faisal Bakaeen:

Right. I mean, it all started here, like Donna said. In 1986, there was a seminal publication in the New England Journal of Medicine showing that using the left internal mammary artery to bypass the left anterior descending artery was associated with better survival of the patients. The reason behind that is that this artery, or the internal mammary artery, is resistant to atherosclerosis and stays open longer than a traditional vein graft.

Years later, also at the Cleveland Clinic, it was demonstrated that using both arteries, meaning the one on the left and the one on the right, was also associated with additional incremental improvement in outcomes. So today, we're going to talk about our philosophy in using those arterial grafts plus the radial artery, which is usually taken from the non-dominant arm to improve outcomes, especially long-term outcomes of CABG.

So, Donna, what are the kinds of patients that you typically would offer multi or total arterial grafting to? For example, what kind of patients would you hesitate, or maybe are not the best candidates for this approach?

Dr. Donna Kimmaliardjuk:

It's a great question. Really, my first thought is I want to offer multi-arterial to every patient that I come across.

Dr. Faisal Bakaeen:

So, that's the default approach.

Dr. Donna Kimmaliardjuk:

That's the default approach, really. And it's more so, what patients do I find that I am hesitant about, or I do not think are a good candidate for it? I'd be curious to see your approach too.

Dr. Faisal Bakaeen:

We'll come to that.

Dr. Donna Kimmaliardjuk:

If a patient has certain risk factors, it makes me pause and think maybe I can't use both arteries from the rib cage, or I can't use an artery from the left arm. So, for example, it becomes very easy if someone has already had previous bypass surgery and they've already had one of their mammary arteries or internal thoracic arteries used. Well, I can't use it again.

It's already been used. Or if it was accidentally damaged from a previous surgery, that makes it easy. So okay, they're not a candidate. Or if someone has a condition called Raynaud's disease, that affects the circulation in their hands, so I can't use the radial artery. Or if it's been used for catheterization in the last 3-6 months, I'm a little more hesitant to use it. Or, of course, if it's their dominant hand, I might not want to use it. So those are a little more clear-cut.

Then there are other things that I look at in terms of the patient themselves and their risk factors. The three big things I look at are if someone has diabetes, but more so if it's diabetes with very high AC1 or very high sugars.

Dr. Faisal Bakaeen:

So, poorly controlled diabetes.

Dr. Donna Kimmaliardjuk:

Poorly controlled diabetes, I'm hesitant to take both arteries from the rib cage. Because, as I say to patients, what do we need to heal after a cut or a surgery? We need blood supply. So, if I'm taking away both that blood supply to put it on the heart, the breastbone and that tissue is going to have a harder time healing. If the sugars are very high, I'm less inclined to take both arteries.

Also, too, if someone is smoking or has a history of severe COPD, because we know too that's another risk factor for infection or poor wound healing at the breastbone, at the sternum. It's something I really have to look at and think about. Then the other thing too that I do have to consider is if someone is very obese. Because I know that with more weight on the chest, it's going to be harder to heal if I take away all that blood supply from that breastbone and that tissue. Again, higher risk of infection.

We've all seen these infections. As I try to explain to patients, it's not just a little bit of redness at the skin, it can be the full incision opening up and spending a lot of time in hospital and on IV antibiotics and going back to the operating room. So, it almost negates, doesn't negate, but almost negates the benefit of bilateral mammaries if you're then in hospital for so long or healing for so long.

Dr. Faisal Bakaeen:

Well, pretty much mine is a similar approach to yours. My go-to approach is multi-arterial. I think of a physiologic risk, as you mentioned, when they have poorly controlled diabetes or obesity or they're smoking. But I also look at the heart, as you do. If they have important target vessels, meaning big target vessels in addition to the LAD, then I feel like this would really make a difference if I put another artery.

But sometimes you find a patient with a hyper dominant LAD that wraps around the heart and smaller other vessels, and those smaller other vessels may be left for veins because they're not going to make any impact on the long-term outcomes. So, we've developed some approaches to minimize the risk when we take the bilateral mammary arteries. For example, we skeletonize them, meaning we minimize any collateral damage. It's a clean harvest, minimal collateral damage. This allows us to do it in higher-risk patients that would otherwise be declined for bilateral mammary artery.

We also, both of us actually, extend the mammaries using a radial artery or sometimes a vein. I call it EZ BITA CABG. EZ stands for “Extended Zone Bilateral Internal Thoracic Artery” CABG. Internal mammary and internal thoracic artery are being used interchangeably here.

We at the Cleveland Clinic are very experienced in finding ways to optimize and maximize the use of multi-arterial grafting because again, it is associated in many patients with improved survival. Now, we could do the surgery using the heart-lung machine. Donna prefers to do it without using the heart-lung machine. Maybe you could shed some light on that.

Dr. Donna Kimmaliardjuk:

Sure, sure. That's again, another technique within the world of bypass surgery that some surgeons like to do. I've developed a passion for it in my training. It has its own pros and, at times, cons. It does not necessarily affect if I'm going to do multi-arterial grafting or not. So, I can still do what I call beating heart or off-pump bypass surgery without multi-arterial grafting or with multi-arterial grafting.

There are a lot of patients I meet where I tell them, the important thing for you here is that you get multi-arterial grafting as opposed to on or off-pump. There are some patients where I do feel it's more important they be off-pump because of certain risk factors they may have. But for most patients I meet, I say, really if I put you on-pump, it will not make any difference for you. The difference will be if I use both mammary arteries or a mammary artery and radial artery as opposed to just one mammary artery and veins.

Dr. Faisal Bakaeen:

Yeah. That's the beautiful thing about Cleveland Clinic is that we have a wide range of expertise, and you tailor the operation to the patient. We can handle patients with really diffuse disease, with really bad targets, even with the presence of multiple stents, such as a metal jacket. We do endarterectomies, stentectomies. Patients with really sick hearts, low ejection fractions, we use temporary mechanical support such as the Impella.

We can handle the whole spectrum of coronary artery disease. Those patients who would benefit from the multi-arterial approach, we can certainly cater to that. Because what we need to achieve is immediate excellent outcomes, but also long-term. What I mean by long-term is not a year, two or five. My father had CABG and he's 30 years out because his mammary is open. So that's what we aim for, a lifelong treatment, if you'd like.

Which brings me to the topic of optimal medical management, because that's key to ensure long-term good outcomes as well. We have a multidisciplinary team of cardiologists that follow those patients and put them on those guidelines directed medical therapies. Would you like to shed some light perhaps?

Dr. Donna Kimmaliardjuk:

Dr. Bakaeen's absolutely right. We tell patients, the success of the surgery relies, yes, on excellent bypass grafts, but also on the medications. They've come such a long way over the last 20, 30 years. I also tell patients, unfortunately with bypass surgery, I don't get to get you off medications. You'll still be on a lot of them because they help keep the bypasses open.

But one thing that's been proven to work, and we keep patients on it lifelong, is baby aspirin. Some of us will also put patients on a second blood thinner like Plavix for a period of time in those early months after surgery. The same sort of things that you would talk about for primary prevention, for preventing blockages, I talk about after bypass surgery. So, ensuring you have good blood pressure, good blood pressure control. You might have to be on blood pressure medications. Managing your cholesterol, so a statin is, again, another lifelong medication if it can be tolerated. That's going to help prevent new blockages from forming in the early period after surgery. And if you can tolerate too, a beta blocker. We like to keep that heart rate nice and slow, so the heart doesn't have to be so stressed and working so hard.

Then, there are some new medications. Going back to statins, injectables are really helping lower triglycerides and cholesterol for patients who can't tolerate a statin. Then, of course too, if you have diabetes, managing your blood sugars with diabetic medications.

Dr. Faisal Bakaeen:

These are excellent points. That's exactly what I tell my patients. What I tell patients that are remote that reach out to us at the Cleveland Clinic, I'll say, I'd be happy for you to come over here and receive your CABG. If, however, you decide to go somewhere else because of convenience, because of insurance, et cetera, just make sure you go to the best possible place. Because at Cleveland Clinic, we have the lowest mortality and complication rate amongst centers of excellence within the United States.

You've got to make sure that they're top-rated. You've got to make sure that their surgeons are high volume, comfortable with complex procedures such as poor targets, low ejection fractions and high volume multi-arterial grafting surgeons. Some rarer conditions of the coronary arteries such as aneurysms and aberrant coronaries, meaning you're born with a different track or different pathway of the artery that could be compromised. We are also very skilled in dealing with that.

So, make sure that your surgeon is experienced and comfortable and is able to share the short-term and long-term results because that's what really counts. It's a lifelong therapy that starts from day one of surgery, but extends throughout the lifetime. Any closing comments from you, Donna?

Dr. Donna Kimmaliardjuk:

No, I think I agree with that. Choose your surgeon carefully and choose a surgeon who is comfortable with bilateral mammaries or multi-arterial. This is not just for the immediate relief in those first few months or a year or so. This is lifelong treatment and lifelong therapy, so you want the best shot at it.

Dr. Faisal Bakaeen:

If you don't come here for the first operation, we're very skilled in multiple re-operations.

Thank you very much. I enjoyed our discussions today about a favorite subject for both of us. I just want to tell our listeners and viewers that we're here to help them, and I'm sure you'll be happy to hear from them.

Dr. Donna Kimmaliardjuk:

Oh, yes. As I say, we're always here.

Dr. Faisal Bakaeen:

We're always here.

Dr. Donna Kimmaliardjuk:

Thank you so much for joining us on this podcast.

Dr. Faisal Bakaeen:

Thank you. It's been a pleasure.

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