Off-Pump All Arterial Coronary Artery Bypass Grafting

T here is growing acceptance of the long-term durability of using coronary artery bypass grafting (CABG) for the treatment of coronary artery disease (CAD). The idea is to give an antegrade flow to the coronary artery circulation, thereby relieving angina. CABG as used in clinical practice since the 1960s, is arguably the most intensively studied surgical procedure ever, while percutaneous coronary intervention (PCI), used for over three decades, has been subjected to more randomized clinical trials (RCTs) than any other interventional procedure. In comparison with CABG, PCI unfortunately has a higher rate of reintervention. In 2009, the American College of Cardiology (ACC), Society for Cardiovascular Angiography and Interventions (SCAI), Society of Thoracic Surgeons (STS), American Association for Thoracic Surgery (AATS), American Heart Association (AHA), and the American Society of Nuclear Cardiology (ASNC) jointly launched appropriateness criteria for revascularization.1 Appropriateness criteria are based on current understanding of the technical capabilities and potential patient benefits of the procedures examined. Coronary revascularization is appropriate when the expected benefits, in terms of survival or health outcomes (symptoms, functional status, and/or quality of life) exceed the expected negative consequences of the procedure. The methods of revascularization depend mainly on symptoms, clinical presentations and coronary artery anatomy. Generally, surgery is mostly appropriate except for certain situations, for example, prior bypass surgery with native triple vessel disease, and failure of multiple bypass grafts with patent left internal thoracic artery (LITA) to the native coronary artery, depressed left ventricular ejection fraction. Percutaneous coronary intervention (PCI) has many uncertainties and may be inappropriate in the following conditions: left main (LM) coronary artery disease; multivessel coronary artery disease associated with diabetes, and depressed left ventricular function.