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A review of hybrid coronary revascularization

  • Michael Owen Kayatta
  • Michael Emanuel HalkosEmail author
Review Article
  • 24 Downloads

Abstract

Purpose

Hybrid coronary revascularization is an emerging treatment strategy for coronary artery disease. We will review the reasons for the development of this strategy, describe surgical techniques, and review outcomes. Finally, we will discuss the future of hybrid revascularization and explain why it will grow as a treatment modality.

Methods

For this review, we conducted an unstructured review of the literature for articles related to hybrid coronary revascularization, bypass surgery, and percutaneous coronary interventions.

Results

Hybrid coronary revascularization has been shown in large series to have excellent results. These include fast recovery time, low mortality and rates of complications, and excellent surgical graft patency. There may be increased need for revascularization over conventional bypass surgery.

Conclusions

The combination improved surgical techniques including a robotic surgery platform, as well as the ever-improving efficacy and durability of coronary stents have made hybrid coronary revascularization an attractive option for many patients. It offers a minimally invasive approach to surgery while avoiding the poor patency of saphenous vein grafts. In appropriately selected patients, this may be an ideal treatment strategy that minimizes risks and maximizes short- and long-term benefits.

Keywords

Hybrid coronary revascularization PCI CABG 

Introduction

Two main modalities exist for the treatment of myocardial ischemia: percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). With PCI, coronary lesions are treated percutaneously with the implantation of drug-eluting stents (DES), while with CABG arterial and vein conduits are used to bypass lesions. While PCI is much less invasive, CABG provides more long-term relief of angina and improves survival in patients with advanced coronary artery disease (CAD) but at the expense of a longer hospital stay with larger up-front risks.

A third option has developed to maximize the benefits while limiting the downsides of PCI and CABG: hybrid coronary revascularization (HCR). While varying definitions of HCR exist, for this review, we will define HCR as an up-front decision to perform both CABG and PCI on the same patient to treat their CAD. These can include not only patients with angina, but also in patients presenting with an acute coronary syndrome (ACS).

While standard PCI techniques are used during HCR, to reduce the invasiveness of coronary surgery, minimally invasive cardiac surgery-CABG (MICS-CABG) techniques are typically used for the surgical component. By doing this, a sternotomy can be avoided. Additionally, postoperative complications, length of stay, and full recovery can potentially be minimized. In this review, we will discuss the evolution of HCR, various surgical techniques used, results with the technique, as well as upcoming evidence and future directions.

Rationale for CABG and PCI

In CABG, various conduits are used to bypass ischemic regions of the myocardium. These most common include the internal mammary arteries (IMAs), greater saphenous vein grafts (SVGs), and radial arteries, though additional sources are also used in a small minority of cases. In PCI, conversely, DES are used to treat open stenotic lesions of coronary vessels to improve myocardial blood flow and reduce ischemia.

Benefits of CABG

With CABG, the first 2/3 of coronary vessels are bypasses, and unless the bypass grafts occlude, further development of CAD in this proximal segment of the artery will be silent as it, along with the index lesions, has already been bypassed. CABG is thus not lesion-specific, but rather treats the entire vessel. In PCI, lesion characteristics are very important. Lesions with excessive angulation, length, bifurcations, and tortuosity, for example, may reduce the safety and effectiveness of PCI.

Critical to success is maintaining patency of the bypass grafts. The LAD, which is the most important coronary artery, supplies 50% of the myocardial mass and can collateralize to protect even more of the heart from ischemia. It is thus not surprising that the LIMA is used in almost all CABG operations to bypass this vessel. This LIMA is remarkably free of atherosclerosis, and, when anastomosed, the LAD has 10- to15-year patency of greater 95% [1]. Furthermore, it appears that as long as the anastomosis is technically successful, it is likely to remain open for the remainder of the patient’s life [2]. When used instead of a SVG, it improves overall survival, MI, hospitalization, and cardiac complications in general [1].

Conversely, PCI has been shown to be no better than optimum medical therapy in patients with stable angina [3], including the ORBITA trial from 2017 which was sham controlled to medical therapy and showed no advantage with PCI [4]. With CABG, complete revascularization is more often achieved, which improves rates of death, MI, and repeat revascularization [5].

In contrast to the excellent patency of the LIMA-LAD anastomosis over time, SVG patency has been shown to have much lower. The data and definitions of patency vary considerably, however. For example, one group found 1-year SVG patency of 95% [6], while other groups have shown 20% occlusion rates within 6-months [7]. The well-conducted PREVENT-IV trial found that 40% of SVGs had at least a 75% stenosis by 1 year [8].

Due to poor SVG patency, great interest developed in multiple arterial grafting. This typically includes the use of bilateral IMAs and a radial artery. Due to improved patency of these grafts over SVGs and observational studies showing improved graft patency and survival [9], the Society of Thoracic Surgeons (STS) currently recommends using multiple arterial conduits when possible [10]. Despite this, just 7% of surgeries performed in the USA use more than one arterial graft [10]. The increased rate of mediastinitis [11] with bilateral IMA usage, increased complexity of the operation, and lack of randomized trials all contribute to this low percentage. In fact, the best current data from the ART trial which compares bilateral vs single IMA usage in CABG has demonstrated no advantage to two IMAs at 5 years, but did show significantly higher rates of sternal wound infections when both IMAs were used. Ten-year data is forthcoming, but, for now, there is no strong evidence to support adding a second arterial graft in most patients.

The benefits of CABG over PCI have been rigorously examined in multiple large, well-conducted clinical trials, and the guidelines support CABG as the best procedure for patients with multivessel CAD [12]. In the SYNTAX trial, CABG was compared to PCI in patients with three-vessel disease and left main disease, and CABG was found to have superior freedom from major adverse cardiac and cerebrovascular events (MACCE) [13]. Similarly, the BEST trial also found CABG superior to PCI (with a third-generation DES) in patients with multivessel disease [14]. In patients with diabetes and CAD, the benefits of CABG over PCI have been particularly evident, as examined in the FREEDOM trial [15]. For patients with isolated left main disease, CABG was also found to have superior freedom from MACCE over PCI in the NOBLE trial [16], a finding which however was not replicated in the EXCEL trial which showed noninferiority with PCI [17]. There has been much debate about the divergent outcomes of these two left main disease trials, and the major differences relate to early complications after surgery (e.g., myocardial infarction and blood transfusion). Both trials do show similar improvements with CABG in longer term follow-up.

Benefits of PCI

PCI has the natural advantage of being a completely percutaneous procedure; a single arteriotomy is the only access site in most cases. Numerous advances have occurred in the field: since balloon angioplasty there have been several generations of stents with increased efficacy and safety. Procedural characteristics and lesion selection with fractional flow reserve/intravascular ultrasound have also reduced the risk of treating unnecessary lesions [18]. Hospital length of stay is typically significantly shorter than after CABG, typically just 1 day if performed in an elective fashion [19].

Post-procedure morbidity is significantly improved over CABG. Stroke and neurocognitive dysfunction are much lower with PCI [20]. Arrhythmias [21] and blood transfusion [22] are also much higher after CABG. Finally, wound infections (including deep sternal wound infections) are much more common with CABG, and their complications can greatly increase both morbidity and mortality [13].

While much of the evidence in the preceding section highlighted the superiority of CABG over PCI, this evidence applied to a subgroup of patients with CAD: those with severe multivessel disease. Many patients, however, present with angina without proximal LAD disease. In these patients, PCI is recommended over CABG [12]. Even in patients with left main disease, PCI may also be appropriate given anatomic criteria are met [17].

Why PCI is more common than CABG

Despite the improved survival of patients with multivessel CAD with CABG, there has been a continual shift of patients away from this proven modality to PCI. In fact, there are currently only about 350,000 CABG operations performed annually in the USA, but over 1.2 million PCIs, and the trend away from CABG toward PCI continues [23]. Part of this shift can certainly be attributed to advances in PCI. The newest generation of DES is better than not only balloon angioplasty, but also significantly better than bare metal and earlier DES [24]. Other catheterization lab advances such as improved imaging, equipment, and protocols have also contributed to the improved success with PCI.

Patient and provider perceptions also contribute to the rise of PCI. As PCI is much less invasive than CABG, it is understandable to prefer the least invasive approach. However, in many cases, PCI and CABG are not equally efficacious, and sometimes perceptions different greatly from our current understanding of the evidence. For example, the vast majority of patients believes that a major goal of PCI is to reduce the risk of heart attack and death, and just 1% believes that relief of angina is the only benefit [25]. Patients’ preference for quick recovery can also lead them to favor faster return to activity over long-term outcomes. For example, in a hypothetical scenario, patients preferred PCI over CABG even when told the long-term risk was double [26]. Cardiologists are also much more likely to refer patients for PCI in scenarios when both CABG and PCI are indicated [27]. Table 1 highlights the strengths and weaknesses of CABG and PCI.
Table 1

Relative strengths and weaknesses of CABG and PCI

Approach

Strengths

Weaknesses

CABG

• Completeness of revascularization

• Improved freedom from death, MI, and angina in patients with complex disease

• Decreased need for repeat interventions

• Invasiveness of surgery

• Postoperative recovery

• Surgical complications

• Negative patient perceptions

PCI

• Truly percutaneous approach

• Rapid recovery and return to function

• Few procedural complications

• Patient preference

• Difficult to apply to complex disease

• In-stent stenosis and thrombosis

• High LAD reintervention rate

• Need for DAPT

Combining both approaches: HCR

In an effort to combine the benefits of CABG and PCI while limiting the drawbacks of each approach, HCR has been developed over the past two decades. CABG benefits mostly from the LIMA-LAD anastomosis with its excellent long-term patency. It is much more invasive than PCI, and short-term morbidity is much higher, which leads many patients and providers to view this as a last resort. While SVGs are most commonly used to complete revascularization, their poor long-term patency calls into questions their utility. While still not well studied, appropriately targeted PCI of non-LAD targets may offer similar if not greater efficacy than SVG anastomoses. However, this does not appear to be the same with PCI of the LAD. Both because excellent LIMA-LAD patency as well as complexity of LAD PCI, CABG of the LAD has consistently shown superior patency and freedom from reintervention than PCI [28, 29]. HCR was first described in 1996 [30], and there have since been thousands of procedures in the literature [31], though the technique still remains a small percentage of all CABG volume.

Reducing the invasiveness of CABG

Perhaps the most important drawback of CABG from the patient’s perspective is the invasiveness of surgery and postoperative recovery. In order to reduce this, several techniques have been developed. Off-pump CABG (OPCAB) is used in many minimally invasive techniques and seeks to decrease invasiveness by avoiding cardiopulmonary bypass. Small incision techniques like minimally invasive direct CABG (MIDCAB) and robotic techniques piggyback off this approach to improve pain, make smaller incisions, and help patients recover more quickly.

OPCAB was originally described in the 1970s, with the goal of eliminating the negative effects of CPB by reducing inflammation, reducing blood transfusions, improving neurological outcomes, and preserving kidney function [32, 33, 34].While decreased in popularity over the last decade due to concerns for inferior outcomes, it remains a commonly employed technique. Difficulty positioning for non-LAD grafts may have contributed to inferior results seen in the ROOBY trial [35].

OPCAB is typically performed via a full sternotomy. A sternotomy provides excellent exposure to the heart and great vessels, but it also has significant downsides. Healing from a sternotomy takes weeks to months, during which time patients are advised not to perform any movements that could jeopardize the healing bone. Superficial and more importantly deep sternal wound infections are a dreaded complication of a sternotomy which can greatly increase the morbidity and mortality of heart surgery. Finally, the cosmesis and perceived ‘splitting of the chest’ should also be considered.

Surgical approaches in HCR

With all minimally invasive approaches to CABG, the excellent results of open CABG need to be maintained. The minimally invasive nature of these approaches can limit complications and improve recovery from surgery. Table 2 lists many important goals with any minimally invasive bypass technique.
Table 2

Goals of minimally invasive CABG

• Maintain equivalent LIMA-LAD patency to traditional CABG

• Avoid sternotomy

• Avoid cardiopulmonary bypass

• Avoid manipulation of aorta

• Decrease ventilator time, ICU LOS, and hospital length of stay

• Minimize postoperative complications including stroke, renal failure, AFIB, and transfusion

• Speed return to full function

• Decrease pain

• Improve patient perception of surgery

• Improve cosmesis

MIDCAB

The MIDCAB technique was developed to perform CABG through a sternum-sparing incision [36]. While this most commonly involves a small anterior thoracotomy in the fourth or fifth intercostal space, an alternative is a partial inferior J-sternotomy. After making a thoracotomy and isolating the left lung, a retractor is placed that both spreads the ribs but also lifts the cranial ribs to allow exposure of the LIMA. This lift is typically done with a sterile table-mounted cable. Under direct visualization, the LIMA is then freed from the chest wall using either a skeletonized or pedicled approach according to surgeon preference. The pericardium is then opened and the LAD exposed. A stabilizer is introduced through a stab incision which assists with completion of the anastomosis. Multivessel bypass is technically possible though more challenging, and requires an apical stabilizer placed through a subxiphoid stab incision (MICS-CABG) [37].

Robotic CABG

The daVinci robotic surgical platform (Intuitive Surgical, Sunnyvale, CA, USA) represented a major improvement in both instrumentation and visualization. The system uses a three-dimensional, × 10 magnified high definition camera with excellent clarity. The robotic instruments offer greatly improved dexterity due to the 7 degrees of freedom. Using these two advances combined allows for safe harvest of the LIMA from the chest wall. Several centers also use the platform to endoscopically complete the anastomosis.

The left lung is isolated and the chest entered in the fourth intercostal space at the anterior axillary line for the camera port. Robotic instrument ports are then introduced into the second and sixth interspaces. Skeletonized and pedicled harvest of the IMA is then performed according to surgeon preference. Cautery alone or endoscopic clips can be used to divide branches. After completions, the pericardial fat is stripped laterally, then, the pericardium opened anteriorly to expose the LAD. Great care must be taken as diagonal branches can easily be misidentified as the LAD.

When a robotic-assisted approach is used, a precision anterior thoracotomy is then made directly over the planned anastomosis site [38]. A soft tissue retract is used and no rib spreading is required. The anastomosis is then performed with traditional techniques. Figure 1 demonstrates the critical steps of the procedure.
Fig. 1

Selected steps in robotic-assisted CABG. a LIMA harvest. b Pericardiotomy and identification of LAD. c Precision thoracotomy exposure. d LIMA-LAD grafting

In total endoscopic CABG (TECAB), selected centers perform the LIMA-LAD anastomosis endoscopically [39]. After LIMA harvest and exposing the LAD, a commercial robotic stabilizer is introduced through a separate stab incision. Using a running polypropylene suture, the anastomosis is then carried out. As no assistant is able to retract, a modification of a surgeon’s typical technique for anastomosis will likely be required. Using TECAB, multivessel bypass is also possible, and requires a separate port for an apical positioner. Peripheral CPB may be required, especially with multivessel bypass.

Timing of procedures in HCR

Three options for timing CABG and PCI are available in HCR: PCI first, CABG first, or one-setting. All three approaches are commonly used in practice today as each has relative strengths and weaknesses [40]. A principle is to treat the most urgent lesion first.

PCI is commonly performed first in patients presenting with myocardial infarction in which the culprit lesion is not the LAD. After recovery from the procedure and in consultation with the minimally invasive surgeon, the CABG can then be performed on a less urgent basis. This can occur during a separate admission which may be advantageous in avoiding the potential for increased bleeding while on DAPT.

Performing minimally invasive CABG before PCI may be advantageous in patients without emergent need for revascularization. In fact, this sequence is the most common in the literature [41]. There are several possible advantages to this. First, there are minimized concerns for bleeding due to the avoidance of DAPT during the procedure. Second, with protection from the LIMA-LAD, subsequent PCI can be performed with less concern for ischemic complications. Finally, interrogation of the bypass will be performed during the PCI, and any issues can either be addressed then or with a return trip to the operating room before adhesions have formed.

CABG and PCI performed in one setting is an attractive option with several caveats. Immediate interrogation of the LIMA-LAD anastomosis will be performed, and any possible issues can be addressed without the need for another operation. Also, complete revascularization will be performed, and thus limit the possibility of demand ischemia during recovery from CABG. DAPT is required, but is generally not started until after completion of the surgical portion of the case. Finally, there are important logistical challenges like the need for a hybrid operating room and coordination of two providers and their teams.

Patient selection for HCR

Choosing which patients to offer HCR is an evolving process that depends on surgeon and interventional cardiologist experience, center results, referral patterns, and technology. High-risk or frail surgical candidates may be excellent candidates for HCR due to the reduced morbidity of minimally invasive CABG, but these patients are probably not the best patients to start a program with. However, low-risk patients will do excellent with conventional surgery, so an early mortality or failed graft in one of these patients may quickly decrease the appeal of the program.

Several surgical and angiographic factors make HCR more or less favorable, regardless of a patient’s overall risk profile. For example, successful PCI depends on low complexity of non-LAD disease. However, high complexity of the LAD lesion favors HCR as this may be best approached with a LIMA-LAD. A calcified, small, or intramyocardial LAD may not be appropriate for minimally invasive grafting where exposure is somewhat limited. Previous cardiac or left chest surgeries are also contraindications as chest adhesions may be prohibitive. Table 3 summarizes important indications and contraindications for HCR.
Table 3

Indications and contraindications for HCR

Indications

Contraindications

• Low-SYNTAX non-LAD disease

• No previous chest surgery

• Poor RCA or LCx targets for surgery, but amenable to PCI

• ACS with non-culprit but significant LAD lesion

• Contraindications for multivessel CABG (e.g., porcelain aorta)

• Previous chest surgery

• Morbid obesity

• High complexity of non-LAD disease

• Patient instability

• Poor LAD target for grafting (calcified, intramyocardial, small, etc.)

Results with HCR

Observational data

There have been numerous case series presented in the literature over the last decade which demonstrate excellent LIMA-LAD patency, quick recovery, and acceptable reintervention rate. Table 4 highlights several recent large series of HCR.
Table 4

Recent outcomes with HCR

Publication

Patients (n)

Technique

Survival (%)

Stroke (%)

LIMA patency (%)

Conversion to Sternotomy (%)

Revision for bleeding (%)

AFIB (%)

Blood transfusion (%)

Ventilator Time (hours)

Hospital LOS (days)

MACCE (%)

Hu et al. 2011 [42]

104

MIDCAB

100

0

100

1

3.8

11.5

28.8

11.6

8.2

1 (18 month)

Bonatti et al. 2012 [43]

140

TECAB

100

0.7

97.3

9.7

3.6

17.1

NR

9

6

20 (5 year)

Repossini et al. 2013 [44]

166

MIDCAB

98.8

NR

100

2.4

0

21.7

26.5

9.6

6.5

17 (5 year)

Adams et al. 2014 [45]

96

Robotic assist

100

1.1

94

2.1

4.3

NR

7.4

NR

4

21 (5 year)

Halkos et al. 2014 [46]

300

Robotic assist

98.7

1

97.6

2

2

20.7

31.7

1.9

5

NR

Modrau et al. 2015 [47, 48]

100

MIDCAB

100

1

98

0

6

NR

9

NR

8

20 (1 year)

LOS length of stay, AFIB atrial fibrillation, NR not recorded

These series represented centers with relatively high volumes of HCR, and showed encouraging results. Mortality was very low with 99% survival among all series. LIMA-LAD patency varied from 94 to 100%, which was no different from conventional LIMA-LAD grafting [49]. Postoperative morbidity was low, and length of stay was lower than typically seen with conventional bypass. MACCE into the medium term was encouraging though higher than open CABG [50], and varied considerably among centers. Most reinterventions across these series were non-LAD reinterventions, and were either re-treating previous PCI targets or new lesions that developed. Recent advances in DES have continued to make HCR more attractive due to considerably lower rates of reintervention [51]. Wound infections are uncommon with minimally invasive techniques (2–3%), and their sequelae are much less severe than infections after sternotomy [46, 48]. Quality of life after surgery may also be better with minimally invasive CABG techniques [52].

Randomized trials

Two important randomized trials have been completed which provide robust evidence of the effectiveness of HCR in the short term. The POL-MIDES study compared HCR to conventional CABG in 200 patients [53]. It found equivalent LIMA-LAD patency (94% vs 93%) and similar MACCE at 1 year (11% vs 8%). The rate of conversion to conventional CABG was 6.1%.

The HREVS trial, which was presented at TCT in October 2017 compared MIDCAB HCR to both PCI and conventional CABG [54]. They noted less postoperative bleeding with HCR compared to conventional CABG, with a 10% conversion rate to sternotomy. At 30 days and 1 year, there was no difference in residual myocardial ischemia among the three groups. These two trials demonstrate that HCR appears effective in the short term. Mid- to long-term freedom from repeat revascularization will need to be carefully monitored.

Learning curve

Minimally invasive CABG techniques have a higher complexity than conventional CABG, and there is a significant learning curve to each approach. However, as evidenced by the excellent results in the recent series, similar LIMA-LAD patency is achievable with improved postoperative recovery. Estimates of learning curve case requirements vary, but typically are estimated at 30–50 cases [55, 56]. Some surgeons may have unacceptable outcomes through the learning curve; minimally invasive CABG may not be for everyone. Even after achieving mastery, continued case volume is essential to maintain outcomes [55]. Long operating times [57] and conversion to sternotomy [56] may be more common early in a surgeon’s experience, and may be associated with longer ICU stay.

Future directions

A multicenter observational trial comparing HCR to PCI has recently been completed in the USA. This trial found similar rates of MACCE between groups in the short term (14% vs 12 at 1 year) [58]. Based on this, a multicenter randomized trial is now recruiting patient to compare HCR to PCI [59]. As many patients now referred for HCR would previously be treated with PCI along, a positive result in this trial should increase the demand for HCR in the future. Cardiologists are more likely to favor HCR than surgeons today, and the majority believes that HCR will expand over the next decade [60]. Training future surgeons to be comfortable with minimally invasive techniques will be essential to meet the increased demand.

Notes

Compliance with ethical standards

Conflict of interest

Dr. Michael Halkos is a consultant for Medtronic. No funds were received by any of the authors for this review and as such, there are no conflicts of interest. Dr. Kayatta has no potential conflicts of interest.

Ethical approval/ethics statement

The review details a technique, and no patient-specific details are mentioned and as a result, formal ethical approval was not required.

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Copyright information

© Indian Association of Cardiovascular-Thoracic Surgeons 2018

Authors and Affiliations

  • Michael Owen Kayatta
    • 1
  • Michael Emanuel Halkos
    • 1
    Email author
  1. 1.Division of Cardiothoracic SurgeryEmory University School of MedicineAtlantaUSA

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