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Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, GRB425, Boston, MA 02114
(Email: hott{at}partners.org).
"What if it was your [left anterior descending artery] LAD?" With the advent of drug-eluting stents (DES), the common answer to this question has changed. In the last decade, the number of bypass surgeries in the United States has fallen to about 365,000 per year. Meanwhile, the number of patients receiving stents has soared to nearly a million in 2006. Clinical evidence in support of this shift is lagging behind. In a recent single center study, DES did not reproduce the short-term and intermediate-term benefits of bare metal stents over coronary artery bypass grafting (CABG) in multivessel disease [1], and despite the lack of long-term data, the majority of DES in the United States is implanted off-label, leading to a higher rate of adverse outcomes and lower long-term effectiveness [2, 3]. On the other hand, grafting of the left internal mammary artery (LIMA) to the left anterior descending coronary artery achieved similar short-term outcomes as with DES implantation, but provided superior mid-term outcomes such as freedom from reintervention and angina with known excellent long-term outcomes [4].
Aside from the industry, healthcare providers, and interventional cardiologists, patients themselves propelled the move toward percutaneous intervention based on an understandable aversion to major surgery. Similar to other surgical specialties, we face the increasing demand for minimal invasive techniques, shorter hospital stays, and faster recovery times. Robotic surgery has provided the required technical platform to open the field for endoscopic coronary artery bypass grafting, allowing for safe surgical coronary revascularization without the need for sternotomy [5] and cardiac arrest [6]. However, even with the use of stabilizing devices, adapted instrumentation, and suture material, endoscopic performance of coronary anastomoses remains to be a technical challenge.
As an alternative to sutured anastomoses and connection devices, Jacobs and colleagues [7] propose a catheter-based endoscopic bypass grafting technique [7]. Combining endovascular and endoscopic techniques, LIMA to LAD anastomoses were successfully performed through the application of tissue adhesive while protecting the anastomotic site using an angioplasty balloon. Although this technique omits endoscopic suturing or use of a connection device, it does require fluoroscopy capability and a surgeon trained in endovascular techniques. Given the advantage of intraoperative quality control and the advent of integrated revascularization strategies for multivessel coronary artery disease [8], this combined skill set may become reality sooner rather than later. Coupled advanced surgical and endovascular techniques achieve promising results and given prudent clinical evaluation may enable us to offer well-balanced revascularization solutions for optimal long-term outcome.
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