Despite all advances in prevention and diagnostics, as well as general awareness for cardiovascular disease in the elderly, our patient collective with young patients below 50 years of age often present in urgent or emergency settings. We have to assume that especially in these young patients with multiple risk factors; diagnosis of a coronary artery disease is delayed because of inadequate awareness. Clinical presentation of our patients collective was rather heterogeonus which makes a direct, propensity matched comparison very difficult. Especially the high frequency of extra hospital reanimated patients and patients with iatrogenic complications during PCI, makes a comparison to previous published studies for CABG difficult.
Although the recent long-term results from the SYNTAX [1], ASCERT [9], and FREEDOM [10] trials showed significantly better survival rates after CABG than after PCI, CABG rates are declining over the past years, while PCI rates increase accordingly [11]. Nonetheless, CABG remains the Gold Standard for patients with coronary artery disease including those with diabetes and/or complex left main or three-vessel disease [1,9].
The technique of CABG has not changed significantly over the past years. However, the use of bypass material remains under intense discussion. The use of one internal thoracic artery as graft, most often the LITA anastomosed to the LAD combined with venous conduits represents the standard therapy for patients undergoing CABG [12].
Failure rates of up to 12% of saphenous vein grafts within the first week after operation have been described. Therefore alternative grafts such as bilateral internal thoracic artery or radial artery grafts are more frequently used.
The long-term results from recent trials suggest favorable radial artery graft patency rates over saphenous vein grafts [13,14]. Accordingly, several large observational studies have confirmed excellent graft patency and have reported superior long-term survival rates, [15] also after applying propensity matching [4,16] for patients receiving the radial artery as bypass grafts. However, concerns regarding vessel spasm, graft atherosclerosis, and unfavorable results from a number of studies exist. We do however; believe in the use of the radial artery as our standard graft in patients with no contraindications against this approach.
While these young patients would benefit most from a total arterial revascularization given its superior long term patency rates [4,13-16], this approach is frequently not possible. In our series, 57% of urgent and 17% of emergency cases received a TAR in the subgroup analysis.
In our case series, 12% of patients present with a left ventricular ejection fraction of 35% or lower. This underlines the fact that especially this patient collective is administered to the hospital in a later stage of their disease.
However, the possible long-term advantage of a TAR is diminished by the fact that the life expectancy of these ill patients is severely diminished. Although, the options for a patient requiring CABG are small (TAR, venous and arterial revascularization, venous revascularization only) the decision making process is rather complex (see Figure 2). In general we agree that absolute contraindications for a TAR are: cardiogenic shock, expected high doses of postoperative catecholamines and a life expectancy of less then 10 years. Graft availability is sometimes limited, too. Especially patients requiring dialysis prior to operation or patients that will require dialysis in the future might, the use of the LITA or RITA is forbidden for sake a cimino fistula. Chronic obstructive lung disease, if severe, might lead to the use of venous grafts only to keep the pleura closed. None the less, we are less concerned about the age of the patient since the use of radial artery grafts for revascularization not only leads to better graft patency rates, however graft harvesting site related complications are also quite rare, and less frequent then with the use of saphenous vein grafts.
Emergency operations, as well as an impaired left ventricular function (below 35% LV-EF) are relative contraindications for a total arterial revascularization. Urgent cases with stable haemodynamics might or might not receive TAR. The usage of TAR in cases of left main coronary artery stenosis (LMCA) is currently under discussion. However, LMCA stenosis is only a relative contraindication for TAR at our department and underlies the surgeon’s discretion.
We also found these patients to be prone for complications, and re-operation rates were relatively high, especially those for removal of sternal cerclages. This could be in fact due to a more active lifestyle of this patient collective. None of these were secondary operations were due to sternal wound infections. In fact, the wound complication rate in this collective was very low. This might be due to the low rate of diabetics, a disease primarily of the elderly patient.
In general our low postoperative mortality rate is similar to that reported by Khawaja et al. [17]. Available data about the postoperative morbidity of young CABG patients report 94% of patients aged <50 years undergoing CABG recovering without any major events and 96% of patients being discharged to home [8].
